THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES THE STUDENT'S GUIDE DISEASES OF THE EYE. STUDENT'S GUIDE BY EDWARD NETTLESHIP, F.R.C.S. OPHTHALMIC SURGEON TO ST. THOMAS' HOSPITAL, AND TO THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET. SECOND AMERICAN FROM THE SECOND REVISED AND ENLARGED ENGLISH EDITION. WITH A CHAPTER ON EXAMINATION FOR COLOR PERCEPTION, BY WILLIAM THOMSON, M.D., PROFESSOR OF OPHTHALHOLOGY IN THE JEFFERSON MEDICAL COLLEGE. PHILADELPHIA: HENRY C. LEA'S SON & CO. 1883. Entered according to Act of Congress in the year 1883, by HENKY C. LEA'S SON & CO., in the Office of the Librarian of Congress. All rights reserved. PORN AN, PRINTKR. TO JONATHAN HUTCHINSON, CONSULTING SURGEON TO THE MOORFIELDS OPHTHALMIC HOSPITAL, .SKNIOR SURGEON TO THE LONDON HOSPITAL, ETC., THIS BOOK IS DEDICATED IN GRATEFUL ADMIRATION OF HIS EMINENT QUALITIES AS A ri.INICAL TEACHER AND INVESTIGATOR. AMERICAN PUBLISHER'S PREFACE. IN presenting to the medical profession the second American edition of Dr. Nettleship's " Guide to Diseases of the Eye," the publishers desire to state that no pains have been spared to place it in every particular upon a level with the latest developments of the specialty of which it treats. In addition to a most thorough and careful revision by the author, comprising many important changes and additions, there has been inserted a chapter upon the Detection of Color-blindness from the pen of Dr. William Thomson, whose painstaking investigations upon this subject are widely known. In the matter of illustrations, several engravings from the previous edition have been omitted, as deficient in perspicuity, and new ones, to about the number of fifty, inserted. Every care has been taken with the typog- raphy, and in all respects the publishers feel assured that the work will be found to merit in an increased degree the confidence awarded by the profession to the previous edition. PHILADELPHIA, 1883. (vii) PREFACE TO THE SECOND EDITION. THE first Edition has been out of print for more than six months, but I have been unable sooner to prepare a new one. Every page of the book has been carefully revised, much new matter incorporated, and many faulty and needless passages struck out. The book contains about twenty-two pages more than it did. The following are the most important changes and addi- tions : Chapter I., on Symptoms, in the first Edition has been replaced by a chapter on "Optical Outlines," which, I believe, will be more useful to students. The " Functional " Disorders of Sight have been placed in a separate chapter (XV.), instead of being divided, as in the first Edition, between Diseases of the Optic Nerve and Diseases of the Retina. X PREFACE. New woodcuts to the number of forty-eight have been added, and several of the old ones, which were too large for a book of this size, have been recut on a smaller scale ; one or two have been omitted. I have to thank Mr. J. B. Lawford and Mr. E. C. Green for much help in seeing the book through the press. June, 1882. CONTENTS. PAKT I MEANS OF DIAGNOSIS. PAGB LIST OF ABBREVIATIONS, 13 CHAPTEK I. OPTICAL OUTLINES. Lenses and prisms ; Refraction of the eye ; Numeration of spectacle lenses ; Table showing the equivalent numbers of lenses made by the inch scale and metrical scale re- spectively, 13-29 CHAPTER II. EXTERNAL EXAMINATION OF THE EYE. Examination of: (1) Surface of cornea; (2) Tension of eye; (3) Mobility of eye; (4) Squint or strabismus; (5) Di- plopia; (G) Protrusion and enlargement of eye ; (7) Ex- ternal bloodvessels of eye; (8) Color of iris; (9) Pupils; (10) Field of vision; (11) Acuteness of sight; (12) Ac- commodation; (13) Apparent size of objects; (14) Color- perception ; (15) The uses of prisms, . . . 30-46 [CHAPTER III. EXAMINATION FOR COLOR-PERCEPTION. Instructions for examination of railway employes as to vision, color-blindness, and hearing : Acuteness of vision ; Range of vision ; Field of vision ; Color-sense ; Hearing ; Ex- planations, 47-59] CHAPTER IY. EXAMINATION OF THE EYE BY ARTIFICIAL LIGHT. (1) Focal or "oblique" illumination. (2) Ophthalmoscopic examination : Indirect examination; Di- rect examination ; Use of the ophthalmoscope. (xi) xii CONTENTS. PAGE Appearances of Optic Disk; scleral ring, physiological pit, lamina cribrosa: of choroid : of retina: vessels, yellow spot,/ot>e') are restored to their original FIG. 1. Refraction by a medium with parallel sides. direction (6), and if the- medium be thin very nearly to their original path. FIG. 2. Refraction by a prism. 5. But if, as in a prism, the sides of m form an angle (Fig. 2, a) the angles of incidence and emergence (a; and y), OPTICAL OUTLINES. 15 still being equal, b' must also form an angle with b. The angle a is the ''refracting angle" or edge; the opposite side is the " base." The figure shows that light is always devi- ated towards the base. Crown glass prisms cause a deviation FIG. 3. Apparent displacement of object by a prism. (represented by the angle d) equal to about half the re- fracting angle of the prism. The relative direction of the rays is not changed by a prism ; if parallel or divergent before incidence, they are parallel or similarly divergent after emergence (Fig. 3). FIG. 4. Refraction the same for different angles of incidence. 6. Every object seems to lie, or is "projected," in the di- rection of the rays as they enter the eye; ob (Fig. 3), seen 16 OPTICAL OUTLINES. by an eye at a' or b', seems to be at ob', where it would be if the rays a' b' came from it without deviation. 7. For very thin prisms the deviation (a and p, Fig. 4) remains the same for varying angles of incidence. For thin lenses this is expressed by saying that the angle d, Fig. 5, Refraction by a lens the same for all rays incident at same distance from axis. is the same for the rays a a', b b', and c c' , incident at differ- ent angles, but at the same distance from the axis. 8. An ordinary lens is a segment of a sphere (plano-con- FIG. 6. Prismatic elements of a convex lens. vex or plano-concave), or of two spheres whose centres are joined by the axis of the lens (biconvex or biconcave). 9. A lens is regarded as formed of an infinite number of minute prisms, each with a different refracting angle. Fig. 6 shows two such elements of a convex lens, in which the OPTICAL OUTLINES. 17 angle (a) of the prism at the edge of the lens is larger than the angle (/?) of the prism nearer the axis. Hence, of the two parallel rays (a and b~), a will (see 5) be more refracted than b, and the rays will after emergence converge and meet at /. Fig. 7 shows the corresponding facts for a concave lens, by which parallel rays are made divergent. FIG. 7. Prismatic elements of a concave lens. 10. The only ray not refracted by a lens is the one pass- ing through the centre of each surface (compare 2), which is the principal axis (ax, Fig. 8). Secondary axes are FIG. 8. Axes of a lens. rays (such as s. ax) entering and emerging at points on the lens parallel to each other, and hence (see 4) hardly altered in course ; in practice they are all rays (except the principal axis) which pass through the central point oi the lens. 11. The principal focus (/, Fig. 9) of a lens is the point 2* 18 OPTICAL OUTLINES. to which rays parallel before incidence (a a) converge after refraction, the deviation of each ray varying directly with its distance from the principal axis (Fig. 6). If par- allel rays are incident from the side towards/, they will be focussed at /', at the same distance from the lens as/; hence every lens has two principal foci anterior and. posterior. 12. The path of a ray passing from one point to another is the same, whatever its direction; the path of the ray bb' FIG. 9. Foci of a convex len?. is the same, whether it pass from cf to c'f, or in the oppo- site direction. 13. From 7 it follows that in Fig. 9 the angles a and FIG. 10. Foci of a concave lens. a are equal, and hence the ray b, diverging from cf, will not meet the axis at/, but at c'f', cf and c'f are conjugate points, and each is the conjugate focus of the other. The OPTICAL OUTLINES. 19 angle a or a' remaining the same, then if c/"be further from the lens c'f will approach it. A ray (c) converging to the axis will be focussed at c"f", because a" = a ; no real point conjugate to c"f" exists; but if the ray start from c"f" it will, on taking the direction c, appear to come from vf, which is the virtual focus of c"f" (see 6). 14. Concave lenses have only virtual foci. In Fig. 10, a, parallel to the axis, is made divergent (see Fig. 7), and has its virtual focus at /, and cf is similarly the virtual con- jugate focus of 6. 15. In equally biconvex or biconcave lenses of crown glass the principal focus is at the centre of curvature of either surface of the lens. 16. Images. The image formed by a lens consists of foci, each of which corresponds to a point on the object. Given the foci of the boundary points of an object, we have the position and size of its image. In Fig. 11 the object a b lies beyond the focus/. From FIG. 11. Real inverted image formed by a convex lens. the terminal point a take two rays a and a, the former a secondary axis, and therefore unrefracted; the other parallel to the principal axis, and therefore passing after refraction through the principal focus/'. These two rays (and all others which pass through the lens from the point a) will meet at A, the conjugate focus of a. Similarly the 20 OPTICAL OUTLINES. focus of the other end of a b is found, and the real inverted conjugate image of a b is formed at A B. The relative sizes of a b and A B vary as their distances from the lens. If a 6 be so far off that its rays are virtually parallel on reaching the lens, its image A B will be at/', and very small. If a b be at / its rays will be parallel after refrac- tion ( 12), and no image be formed. If a b lie between / (or/') and the lens, the rays will diverge after refraction, and again no image be formed (see Fig. 9, c'/"). But in the two last cases a virtual image is seen by an eye so placed as to receive the rays. In Fig. 12 two rays from a take after refraction the course shown by o and a', virtually meeting at A (see Fig. 9, vf ) ; and an eye at x will see at A B a virtual, magnified, erect image of a b. The enlargement is greater the nearer a b is to /, and greatest when it is at/. But, as A B has no real existence, FIG. 12. Virtual erect image formed Vr a CODTCZ lens. its apparent size varies with the. known or estimated dis- tance of the surface against which it is projected. A uni- form distance of projection of about 12" (30 cm.) is taken in comparing the magnifying power of different lenses. When a b is at/ it will be found on trial that the image A B can be seen well only by bringing the eye close up to the lens. At a greater distance only part of the object will be seen, and it will be less brightly lighted, facts which are OPTICAL OUTLINES. 21 important in direct ophthalmoscopic examination (p. 75 In Fig. 13 an eye placed anywhere between the lens and x Fro. 13. Virtual image; result of observer varying distance of bis eye from the lens. will receive rays from every part of a b, and therefor^ the whole image. But if the observer be at y, his eye will receive rays only from the central part of a b, and will therefore not see the ends of the object. By similar constructions it is easily shown that the images formed by concave lenses are always virtual, erect, and diminished, whatever the distance of the object (Tig. 14 i. (Compare Fig. 10.) Fie. 14. Image formed by a concave lens. 17. The size of the image (whether real or virtual) varies with (1) the focal length of the lens, and (2) the distance of the object from the principal focus. (1) The shorter the focus of the lens, the greater is its effect or the " stronger " it is ; the refractive power of a lens varies inversely as its focal length. 22 OPTICAL OUTLINES. (2) For a convex lens, the image (whether real or vir- tual) is larger (i. e.,the effect greater) the nearer the object is to the principal focus (whether within or beyond it). For a concave lens the image is smaller (i. e., the effect greater) the further the object is from the lens (whether within or beyond the focus). 18. Prisms. An object appears displaced towards the edge of a prism through Avhich it is seen, and to a degree which varies directly as the size of the refracting angle ( 5 and 6). The observer, looking through the prism, directs his eye to the object in its apparent position ( G), and this fact may be utilized for several purposes : 1. To lessen the convergence of the visual lines without removing FIG. 15. Effect of prisms in lesesnlng convergence. the object further from the eyes. In Fig. 15 the eyes, R and L, are looking at the object (06) with a convergence of the visual lines represented by the angle a. If prisms be now added with their bases towards the nose they de- OPTICAL OUTLINES. 23 fleet the light, so that it enters the eyes under the smaller angle (3, as if it had come from (06'), and towards this point the eyes will be directed, though the object still remains at ob. The same effect is given by a single prism of twice the strength before one eye, though the actual movement is then limited to the eye in question. If spectacle lenses be placed so that the visual lines do not pass through their centres, they act as prisms, though the strength of the prismatic action varies with the power of the lens and the amount of this " decentration " (see 9, Figs. 6 and 7). In Fig. 16 the visual lines pass outside the centres of the FIG. 16. Lenses acting as prisms. convex lenses (a) and inside those of the concave lenses (6). Each pair, therefore, acts as a prism with its base in- wards. 2. To remove double vision caused by slight degrees of strabismus. The prism so alters the direction of the rays as to compensate for the abnormal direction of the visual line. In Fig. 17, R is directed towards x instead of towards 24 OPTICAL OUTLINES. ob, and two images of ob are seen. The prism (p) deflects the rays on to y, the yellow spot, and singular binocular vision is the result 3. To te$t the strength of the ocular muscles. In Fig. 18 the prism at first causes diplopia by displacing the rays from the yellow spot (y) of the eye (R) Fra. 17. Diplopia removed by prism. Prism used for testing strength of muscle. (_Chap. XXI.). By a compensating rotation of the eye (cornea) outwards, shown in the figure by the change of the transverse axis from 1 to 2, y is brought inwards to the situation of tin, the images are fused and single vision re- stored ; the effect of the prism is overcome by the action of the external rectus. This "fusion power" of the several pairs of muscles may be expressed by the strongest prism that each pair can overcome. The fusion power of the two external recti is represented by a prism of about 8 ; that of the two internals by 25 to 35, or more ; that of the superior and inferior recti, acting against each other by OPTICAL OUTLINES. 25 only about 3. 4. Feigned blindness of one eye may often be exposed by means of the diplopia (unexpected by the pa- tient) produced by a prism. The prism should be stronger than can be overcome by any effort, e. g., 8 or 10, base upwards or downwards. The patient is often best thrown off his guard by holding the prism before the sound eye. If he now exclaims that he sees double, he must of course be seeing with both eyes. 19. Refraction of the eye. The eye presents three re- fracting surfaces : the front of the cornea, 1 the front of the FIG. 19. Visual angle. Size of retinal image in H. (curved line nearest to ti), in E. (middle thin line), and M. (line furthest from n). lens, and the front of the vitreous ; and in the normally formed or emmetropic eye, with the accommodation re- laxed, the principal focus ( 11) of these combined diop- tric media falls exactly upon the layer of rods and cones of the retina, i. e., the eye in a state of accommodative rest is adapted for parallel rays. The point at which the sec- ondary axial rays (see 10, Fig. 8) cross the "posterior nodal point" (n, Fig. 19) lies in the normally formed eye at 15 mm. in front of the yellow spot of the retina, and 1 The posterior surface of the cornea being parallel with the anterior, causes no deviation ; and the refractive power of the aqueous is the same as that of the cornea. Hence the refractive effect of the cornea and aqueous is the same as if the corneal tissue extended from the front of the cornea to the front of the lens. 3 26 OPTICAL OUTLINES. very nearly coincides with the posterior pole of the crys- talline lens. The angle included between the lines joining n with the extremities of the object (06) is the visual angle (v). If the distance (d), from n to the retina, remain the same, the size of Im will depend on the size of the angle v, which will depend on the size and distance of ob. But if the distance (d) alters (v remaining the game), the size of the retinal image (Im) is altered without any change in v. Now the length of d varies with the length of the posterior segment of the eye; it is increased in myopia (M.) and diminished in hypermetropia (H.), and hence the retinal image of an object at a given distance is larger in myopia and smaller in hypermetropia than in the normally formed eye. The length of d depends also upon the position of n, and this is influenced by the positions and curvatures of the several refractive surfaces, n is advanced very slightly by the increased convexity of the lens during accommoda- tion, but much more so if the same change of refraction is induced by a convex lens held in front of the cornea; hence, convex lenses, by lengthening d, increase the size of the retinal images. Concave lenses put n further back, and by thus shortening d lessen the size of the images. If the lens, which corrects any optical error of the eye, be placed at the " anterior focus " of the eye, 1 13 mm., or half an inch in front of the cornea, n moves to its normal distance (15 mm.) from the retina, and the images are therefore re- duced or enlarged to the same size as in the normal eye. The length of the visual axis, a line drawn from the yel- low spot to the cornea in the direction of the object looked at, is about 23 mm. The centre of rotation of the eye is rather behind the centre of this axis, and 6 mm. behind the back of the lens. It may here be mentioned that the 1 The anterior focus is the point where rays, which were parallel in the vitreous, are focussed in front of the cornea. OPTICAL OUTLINES. 27 focal length of the cornea is 31 mm., and that of the crys- talline lens from 43 mm. with accommodation relaxed, to 33 mm. during strong accommodation. The optical conditions of clear sight are as follows : (1) The image must be formed exactly on the retina i. e., the retina must lie exactly at the focus of the dioptric media for the object looked at. (2) The image must be formed at the centre of the yellow spot (see Acuteness of sight). (3) The image must have a certain size, and this is expressed by the size of the corresponding visual angle (v, Fig. 19) ; with average light v must be equal to at least five minutes (^ of a degree) in order to the perception of the form of the image ; an object subtending any smaller angle (down to about one minute) is still visible, though only as a point of light. Influence of the pupil. Other things being equal, the larger the pupil the worse is the sight, the clearness of the images being lessened by the spherical aberration caused by the marginal part of the lens. For the same reason troublesome distortion of the images is often caused by the operation of iridectomy. Numeration of spectacle lenses. Some system of num- bering is required which shall indicate the refractive power of the lenses used for spectacles. Two systems are current: In the first system, which was till lately universal, the unit of strength was a lens of 1" focal length. As all the lenses used are weaker than this, their relative strengths can be expressed only by using fractions. Thus, a lens of 2" focus is half as strong as the unit, and is, therefore, ex- pressed as ^; a lens of 10" focus is ^; of 20" focus $; and so on. The inconvenience of using fractions in prac- tice is considerable, and, moreover, the intervals between the successive numbers are very unequal. Then the length of the inch is not the same in all countries, so that a glass of the same number has a somewhat different focal length according as it is made by the Paris, English, or German 28 OPTICAL OUTLINES. inch. In the second system, which is fast displacing the old one, the metrical scale is used ; the unit is a weak lens of 1 metre (100 cm.) focal length, and known as a dioptre (D); and the lenses differ by equal refractive intervals. A lens of double the strength of the unit, or half a metre (50 cm.) focal length, is 2 dioptres (2 D), a lens of ten times the strength, or one-tenth of a metre focus (10 cm.), is 10 D, and so on. The weakest lenses are .25, .5, and .75 D, and intermediate numbers differing by .5 or .25 D are also introduced between the whole numbers. A slight inconvenience of the metrical dioptric system is that the number of the lens does not express its focal length. But this can be obtained by dividing 100 by the number of the lens in D; thus the focal length of 4 D = if^ = 25 cm. If it is desired to convert one system into the other, this can be done, provided that we know what inch was used in making the lens whose equivalent is required in D. The metre is equal to about 37 Paris and 39 English or German inches; a lens of 36 Paris inches (No. 36 or ^ old scale), or of 40 English or German inches (No. 40 or -fa), is very nearly the equivalent of 1 D. A lens of 6 Paris inches ( = ^ 6 g-) will therefore be equal to 6 D ; a lens of 18 Paris inches (-fa = -fo) = 2 D, etc.; a lens of 4 D = -g -g-, i. e., a lens of 9 Paris inches, etc. The following lenses are used for spectacles, and are, therefore, necessary in a complete set of trial glasses. The first column gives the number in D, the second the focal length in metres, the third the approximate numbers on the Paris inch scale, the denominator of each fraction showing the focal length in Paris inches. In some cases there are no equivalent lenses made on the inch system. In this table, and throughout the work, convex lenses are indicated, according to custom, by the -(- sign; concave lenses by the sign. OPTICAL PRINCIPLES. 29 1. 2. 3. 1. 2. 3. No. in D. Focal No. and Fo- No. in D. Focal No. and Fo- + (convex) or Length in cm. cal Length in Paris inches. -+ (convex) or Length in cm. cal Length in Paris inches. (concave). (concave). 0.25 4.00 5. 0.20 J 0.5 2.00 T2 5.5 0.18 0.75 1.33 "sV 6. 0.16 i 1. 1.00 1 "ST 7. 0.14 k 1.25 0.80 A 8. 0.125 1.5 0.66 ih 9. 0.111 i* 1.75 0.57 10. 0.10 * 2. 0.50 Y TS 11. 0.09 2.25 0.44 12. 0.083 i 2.5 0.40 T? 13. 0.077 2.75 0.36 TV 14. 0.07 } N 3. 0.33 TV 15. 0.067 J M 3.5 0.28 16. 0.062 J., 4. 0.25 18. 0.055 I 4.5 0.22 I 20. 0.05 3* 30 EXTERNAL EXAMINATION OF THE EYE. CHAPTER II. EXTERNAL EXAMINATION OF THE EYE. (1) To detect irregularity of the corneal surface : whilst the patient follows with his eyes some object, e. g., the uplifted finger, moved slowly in different directions, watch the reflection of the window from the cornea ; it will be suddenly broken by any irregularity, such as an abrasion or ulcer. (2) To estimate the tension of the eyeball (T.) : the patient looks steadily down, and gently closes the eyelids ; the observer then makes light alternate pressure on the globe through the upper lid with one finger of each hand, as in trying for fluctuation, but much more delicately. The finger-tips are placed very near together, and as far back over the sclerotic as possible. The pressure must be gentle and be directed vertically dmvnwards, not backwards. It is best for each observer to keep to one pair of fingers, not to use the index at one time and the middle finger at another. Patient and observer should always be in the same relative position, and it is best for both to stand and face one another. Always compare the tension of the two eyes. Be sure that the eye does not roll upwards during exami- nation, for if this occur a wrong estimate of the tension may be formed. Some test both eyes at once with two fin- gers of each hand. Normal tension is expressed by T. n. The degrees of increase and decrease are indicated by the -(-or sign, followed by the figure 1, 2, or 3. Thus T. -f- 1 means decided increase ; T. -f- 2, greater increase, but sclerotic can still be indented ; T. -f- 3, eye very hard, EXTERNAL EXAMINATION OF THE EYE. 31 cannot be indented by moderate pressure ; T. 1, 2, 3, indicate successive degrees of lowered tension. A note of interrogation (T. ? -f- or ? ) for doubtful cases, and T. n. for the normal, give nine degrees, which may be usefully distinguished. Equally good observers often differ in re- gard to the minor changes of tension. Apart from varia- tions in delicacy of touch, it is to be remembered that eyes deeply set in the orbits are more difficult to test, and that T. in a few cases really does change at short intervals, e. g. t within half an hour. Increased rigidity of the sclerotic, which occurs naturally in old age and sometimes from dis- ease, alters the apparent tension, though the internal pres- sure may be normal or even too low. When a blind eye contains bone, it feels like wood covered with washleather. (3) The mobility of the eyeball may be impaired in any or every direction, and in any degree up to absolute fixity. Commonly only one eye is affected. First direct the patient with both eyes open to look strongly, or follow some upheld object moved in each of the four cardinal directions (up, down, right, left) ; and next to look at an object (finger or pencil) held vertically in the middle line, rather below the horizontal, and gradually approached from 2' to about 6", to test the convergence power. In each position we must notice both eyes ; thus, when the patient looks to his right we have to note the outward movement of his right and the inward movement of his left. The fixed marks for the inward and outward movements are the inner and outer cauthi, and as the apparent range of movement judged in this way varies a little in different people, the corresponding movements of the two eyes should always be compared. In looking strongly outwards, the corneal margin often does not quite reach the outer can- thus, but always fully reaches the inner canthus during in- ward rotation. In children and stupid people the move- ments are often defective from inattention rather than want 32 EXTERNAL EXAMINATION OF THE EYE. of power. In very myopic eyes the movements are some- what defective in all directions. Upward movement may be estimated by noting the position of the cornea in rela- tion to the border of the lower lid ; the border of the upper lid is less trustworthy, since there may be some ptosis or other cause of inequality between the two sides. (4) Squint or strabismus exists if the visual axes are not both directed to the same object. A squint may be the result either of overactiou or of weakness or paralysis of a muscle: the internal rectus by excessive contraction often causes convergent squint ; most other forms, as well as some convergent cases, result from actual defect of nervous or muscular power. When a squint is well marked there is no difficulty in identifying the squinting eye as the one which is not di- rected towards an object held up to the patient's attention: in most cases the patient always squints with the same eye, but in a few he will squint with either indifferently (alter- nating squint). Nor is there often any doubt as to whether the squint is internal (convergent) or external (divergent), i. e., whether the axis of the squinting eye crosses that of its fellow between the patient and the object he looks at, or crosses it beyond this object, or even positively diverges from it ; upward or downward squint, though less common, is almost as evident. But to prove beyond doubt which is the squinting eye, direct the patient to look at a pencil held up in the middle line at about 18" from his face, and with a card or piece of ground glass cover the apparently sound, or "working" eye; the squinting eye will at once move so as to look at or "fix" the pencil, proving that it had pre- viously been misdirected. If the sound eye be watched behind the screen it will be seen to squint as soon as the affected eye "fixes" the object; this is known as the secondary squint, and its direction is the same as that of the original or primary squint. Thus, if the primary squint is EXTERNAL EXAMINATION OF THE EYE. 33 convergent, the secondary will also be convergent. In squint from overaction or from mere disuse of one muscle, the secondary and primary deviations are equal, but in paralytic squint the secondary often exceeds the primary. The term concomitant is used for any case in which the squinting eye has full range of movement, i. e., moves in companionship with its fellow in all directions, and it is complementary to paralytic; hence, in every case of squint, it is necessary to test the mobility of the eyes. It is also important to note whether the squint is constant or only occasional (periodic.') 1 (5) Diplopia (double sight) is almost always a result of squint, but the most troublesome diplopia is often caused by a deviation too slight to be perceptible. Diplopia is almost always binocular, disappearing when one eye is covered. Uniocular diplopia (double sight with one eye), however, occurs in commencing cataract, and is occasion- ally seen in cases of cerebral tumor. In the former it has a physical cause in the crystalline lens; in the latter it must depend upon some cerebral change, and its existence should be accepted with great caution. To find out what defect of movement is causing binocu- lar diplopia, take the patient into a dark-room, and, stand- ing at a distance of 6'-8', ask him to follow with his eyes 1 It is necessary to be aware that an apparent squint, either ex- ternal or internal, is sometimes met with. The optic axis of the ej'e passes from a point rather to the inner side of the y. s. through the centre of the cornea, and forms a small angle ("angle a") with the visual axis, which joins the y. s. with the object looked at and commonly cuts the cornea rather within its centre. As we judge of the apparent direction of a person's eyes by the centres of his cornese (i. e.) by the optic axes), a slight apparent outward squint will be produced if the angle a be (as in many hyperme- tropic eyes) larger than usual, and an apparent convergent squint if, as in myopia, it be smaller. Apparent squint is always slight, and the screen test described in the text gives a negative result. 34 EXTERNAL EXAMINATION OF THE EYE. a candle moved successively into different positions, and to describe the relative places of the double images in each position. Ascertain which of the two images belongs to each eye by placing before one eye a strongly colored glass, or by covering one eye and asking which image disappears. In many cases the image formed in the squinting eye (the "false" image) is less bright or distinct, and this difference gives a valuable means of distinguishing the sound from the affected eye ; but the patient does not always notice such a difference between the two images, and it may then be difficult to be sure which eye is at fault. The patient's replies should be recorded on a diagram (see Chapter XXI.) ; the radii there shown may of course be increased for intermediate positions. The false image is marked by the dotted line, the true one by the unbroken line. We have thus a graphic representation of the candle as it ap- pears to the patient, and can deduce from the apparent position of the false image what movements of the corre- sponding eye are at fault, and, consequently, which muscle or muscles are defective. It is essential that the patient should not move his head during the examination, and that he remain throughout at the same distance from the candle. Remember that, in the extreme lateral movements, the nose interferes, and eclipses one image. When the double images are very wide apart, the patient sometimes fails to notice the false image. For the diagnosis of a case of diplopia it is often sufficient to ask in which directions the double sight is most trouble- some, and how the images appear in respect to height, lateral separation, and apparent distance from the patient (see Chapter XXI). (6) Protrusion (proptosis) and enlargement of the eye. Unequal prominence of the two eyes is best ascertained by seating the patient in a chair, standing behind him, and comparing the summits of the two cornese with each EXTERNAL EXAMINATION OF THE EYE. 35 other, and Avith the bridge of the nose, or the line of the eyebrows. The appearance of prominence or recession, as seen from the front, depends very much on the quantity of sclerotic exposed ; thus, slight ptosis gives a sunken appear- ance to the eyes, and in slight cases of Graves' disease the proptosis seems to increase when the upper lids are spas- modically raised. It is to be remembered that real promi- nence of the eye may depend on enlargement of the eyeball (myopia, staphyloma, intra-ocular tumor), as well as on its protrusion, and that if only one eye be myopic, the appear- ance will be unsymmetrical. Decided proptosis may follow tenotomy or paralysis of one or more orbital muscles. In hypermetropia, in which the eyeball is too short, and in the rare cases of paralysis of the cervical sympathetic, the eye often looks sunken. (7) Information derived from the bloodvessels visible on the surface of the eyeball. Three systems of vessels have to be considered in disease; all, however, owing to their small size, are but imperfectly visible in health. (1) The vessels proper to the conjunctiva (posterior conjunctival vessels"), in which it is not important to distinguish between arteries and veins (Fig. 20, Post. Cory'., and Fig. 21). (2) The anterior ciliary vessels, lying in the subconjunctival tissue, and which, by their perforating branches, supply the sclerotic, iris, and ciliary body, and receive blood from Schlemm's canal and the ciliary body; the perforating branches of the arteries (Fig. 20, A) are seen in health as several rather large tortuous vessels, which stop short about T y or -|" from the corneal margin (Fig. 22) ; their epi- scleral non-perforating branches are very small and numer- ous, invisible in health, but when distended forming a pink zone of fine, nearly straight, very closely-set vessels round the cornea (Fig. 20, A, and Fig. 23) (" ciliary congestion," " circum-corneal zone," see Iritis and Diseases of Cornea) ; the perforating veins are very small, but more numerous 36 EXTERNAL EXAMINATION OF THE EYE. than the perforating arteries (Fig. 20, v), and their episcleral twigs form a closely-meshed network (Fig. 24). (3) The vessels proper to the margin of the cornea and immediately FIG. 20. Pcstting Vessels of the front of the eyeball, c. m. Ciliary muscle. Ch. Choroid. Scl. Sclerotic. V. V. Vena vorticosa. /. Marginal loop-plexus of cornea. Ant. and Post. Conj. Anterior and posterior conjunctival vessels. Ant. Oil. A. and V. Anterior ciliary arteries and veins. (Simplified and al- tered from Leber.) adjacent zone of conjunctiva (anterior conjunctival vessels, and their loop-plexus on the corneal border, Fig. 20, /, and EXTERNAL EXAMINATION OF THE EYE. 37 Fis. 21. Conjunctival congestion (engorgement of the posterior conjunctiva! arteries and veins). (After Guthrie.) FIG. 22. The perforating branches of the anterior ciliary arteries. The dusky spots at the seats of perforation are often seen in dark-complexioned per- sons. (Dalrymple). FIG. 23. FIG. 24. "Ciliary congestion" (engorge- ment of episcleral twigs of anterior ciliary arteries). (After Dalrymple.) Congestion of anterior ciliary veins (episcleral venous plexus).' (After Dalrymple.) 38 EXTERNAL EXAMINATION OF THE EYE. Fig. 46) ; by these numerous minute branches, which are offshoots of the anterior ciliary vessels, Systems 1 and 2 anastomose. Speaking generally, congestion composed of tortuous, bright (brick-red) vessels (System 1) moving with the con- junctiva when it is slid over the globe, and which is least intense just around the cornea (Fig. 21), indicates a pure conjunctivitis (ophthalmia), and will usually be accompa- nied by muco-purulent or purulent discharge. (2) A zone of pink congestion surrounding the cornea, and formed by small, straight, parallel vessels, closely set, radiating from the cornea, and not moving with the conjunctiva (anterior ciliary arterial twigs, Fig. 23), points to irritation or in- flammation of the cornea, or iris. A more scanty zone of dark or dusky color (Fig. 24), which, when severe, is finely reticulated (episcleral venous plexus), often points to glau- coma, but may accompany other diseases, especially in old people. Congestion in the same region, more deeply seated, and of a peculiar lilac tint, especially if unequal in differ- ent parts of the zone, shows cyclitis (anterior choroiditis). (3) Congestion in the same zone, and also composed of small vessels, but superficially placed, bright red, and often encroaching a little on the cornea (anterior conjunctival ves- sels and loop-plexus of cornea, Fig. 46), shows a tendency to a severe form of superficial corneal inflammation. Local- ized or fasciculated congestion generally points to phlyc- tenular disease (Figs. 39 and 40). Although in the severe forms of any acute disease of the front of the eye these types of congestion are often mixed and but imperfectly distinguishable, much information may often be derived from attention to the leading forms described. (8) Note the color of the iris, and compare it with that of the fellow eye. In some persons the irides, although healthy, are of different colors, one blue or gray, the other brown or greenish; and sometimes one iris shows large EXTERNAL EXAMINATION OF THE EYE. 39 patches of lighter or darker color than its fellow (piebald). But if the iris of an inflamed eye is greenish Avhile its fellow is blue, we should suspect iritis ; and if the iris of a defective eye be different from its fellow some morbid change should be suspected. (9) The pupils are to be examined as to (1) equality, (2) size in ordinary light, (3) mobility, (4) shape. The pupils are often large and inactive, and sometimes oval in amaurotic patients, in glaucoma, and in paralysis of the circular fibres of the iris (supplied by the third nerve). They may be too large but still active in myopia and in conditions of defective nerve-tone. Wide dilatation of one or both pupils, with dimness of sight of a few days' dura- tion, and without ophthalmoscopic signs of disease, is usually traceable to atropine or belladonna, used by acci- dent or design, causing paralysis of accommodation. When very small, the pupil is seldom quite round. The pupils in health lie slightly to the inner side of the centre of the cornea ; they should be round, and, when equally lighted, equal in size. When one eye is shaded its pupil should dilate considerably, and on exposure contract quickly to its former size (" direct reflex action ") : during this trial the other pupil will act, but to a less extent (" in- direct reflex action"}. The pupils contract when the gaze is directed to a near object (say 6" off), i. e., during accom- modation and convergence, and dilate in looking at a dis- tant object; but the range of this "associated action" is much less than of the reflex action. The pupils may be motionless to light and shade from iritic adhesions, or from atrophy of the iris in glaucoma or other local dis- ease; and such conditions should be carefully noted or ex- cluded. Reflex action is lost when the eyes are blind from disease of optic nerves or retinse ; if only one eye be blind, the direct action of its pupil will be lost, but (unless there be disease of its third nerve also) the indirect action will 40 EXTERNAL EXAMINATION OF THE EYE. be much greater than in health. When one eye is blind its pupil is often rather larger than the other. Reflex action may also be lost without any affection of sight, and without loss of associated action (see Chapter XXIII.). The dilatation effected by atropine is often less in old than in young people. Marked inequality of pupils is rare, except from disease or widely different refraction in the two eyes. When very active pupils are suddenly ex- posed after being shaded, they often oscillate for a few seconds before settling, and finally remain a little larger than at the first moment of exposure. Considerable differ- ences, both in range and rapidity of action of the pupils, are compatible with health; in general, however, the pupils become smaller and lose both in range and rapidity with advancing years. Marked inactivity, with small size, al- ways leads to suspicion of spinal or cerebral disease. The pupils are smaller whenever the iris is congested, whether this be a merely local condition (e. g., in abrasion of cor- nea), or form part of a more general congestion, as in typhus fever 1 and in plethoric states, or be caused by venous obstruction, as in mitral regurgitation and bron- chitis. They are large in ansemia, and in cases where the systemic arteries are badly filled, such as aortic insuffi- ciency, 2 and during rigors. (10) The field of vision is the entire surface from which, at a given distance, light reaches the retina, 3 the eye being 1 The small pupil of typhus and the frequently large pupil of typhoid are ascribed by Murchison to the differences in the vascu- larity of the iris (as a part of the whole eyeball) in the two dis- eases. 'Continued Fevers, 541. 2 See an article on " The Indications Afforded by the Pupil," 'Medical Examiner,' March 2, 1879. 8 Strictly "the percipient part of the retina." It now seems established that the most peripheral zone of the retina is not sen- sitive to light. (Landolt.) EXTERNAL EXAMINATION OF THE EYE. 41 stationary (Fig. 25). If each part of the field is equidistant from the part of the retina to which it corresponds, the field will form part of a hemisphere, with its inner or concave surface towards the eye ; it may, however, be projected on to a flat surface, and for many clinical purposes this is quite accurate enough. For roughly testing the field, e. g., in a case of chronic glaucoma, or of atrophy of optic nerve, or of hemianopsia, the following is generally enough. Place the patient with his back to the window ; let him FIG. 25. Field of vision with radius of 12", projected up to 45 on to a flat surface two feet square. F, fixation spot. cover one eye, and look steadily at the centre of your face or nose at a distance of 18" or 2'. Then hold up your hands with the fingers spread out in a plane with your face, and ascertain the greatest distance from the central point at which they are visible in various directions up, down, in, out, and diagonally. It is essential that the pa- tient should look steadily at the face, and not allow his eye to wander after the moving fingers. A more accurate method is to make the patient gaze, 4* 42 EXTERNAL EXAMINATION OF THE EYE. with one eye closed, at a white mark (the " fixation spot") on a large black board at a distance of 12" or 18", and to move a piece of white chalk set in a long black handle from various parts of the periphery towards the fixation spot, until the patient exclaims that he sees something white. If a mark be made on the board at each of about eight such peripheral points, a line joining them will give with fair accuracy the boundary of the visual field if it be FIG. 26. Field of vision of right eye. w, boundary for white. B, for blue. R, for red. G, for green. (Landolt.) not larger than 45 in any direction; but beyond that angle the object, if on a flat surface, will be much too far from the eye to make the test accurate (see Fig. 25). Hence a true map, unless the field be much contracted, can be EXTERNAL EXAMINATION OF THE EYE. 43 made only by means of an instrument, the perimeter, which consists essentially of an arc marked in degrees, and mova- ble around a central pivot on which the patient fixes his gaze. The visual field is not circular, but somewhat oval, with its smaller end upwards and inwards (Fig. 26). From the fixation point it extends 90 or more in the outward direction, but only about 65 or rather less inwards, up- wards, and downwards. (11) Testing the acuteness of sight. By acuteness of sight (V. or S.) is meant the power of distinguishing form, and as commonly used the term refers only to the centre of the visual field, the peripheral parts of the retina having a very imperfect power of distinguishing form and size. V. varies considerably in different persons whose eyes are normal. It is said to diminish somewhat in old age, with- out disease of the eyes (Bonders). The standard taken as normal is the power of distinguishing square letters that subtend an angle of five minutes, the limbs of which are of uniform thickness, each limb subtending an angle of one minute (Snellen's Test-types). Rays forming so small an angle are very nearly parallel, and may be considered as coming from an object at an infinite distance. The types are made of various sizes, each being numbered according to the distance (in feet or metres), at which it subtends a visual angle of 5 minutes. Thus, No. XX. subtends this angle at 20' (= No. 6 at 6 m.), No. X. at 10' (= No. 3 at 3 m.), No. II. at 2' (= No. .6 at .6 m.). Numerically, acute- ness of vision is expresed by a fraction, of which the de- nominator is the number of the type, and the numerator the greatest distance at which it can be read; if No. 6 is read at 6 m. V = f- or 1, i. e., normal; if only No. 18 can be read at 6 m. V = T 6 ^ ; if only 60, then V = 6 7 . Any distance greater than about 3 m. may be selected for this test, i. e., No. 3 read at 3 m., or No. 5 at 5 m., generally show the same acuteness as 6 read at 6 in. But at shorter 44 EXTERNAL EXAMINATION OF THE EYE. distances the accommodation comes into play, and the illumination is often brighter, hence No. 1 at 1 m. ( T ) does not practically show the same state of sight as 6 at 6 m. (). It is, therefore, best to record the fractions unreduced, so that the distance at which the test was used may be known. For testing near vision, Snellen's types are thought by many to be practically inferior to those of Jaeger and others, in which the letters have the form and proportions found in ordinary type. (See Appendix.) If V. be very bad (less than y^), it may be generally ex- pressed accurately enough by noting the distance at which the outspread fingers can be counted when exposed to a good light and against a dark background. Below this point we can still distinguish good from bad or uncertain perception of light and shade (jo. L), by alternately expos- ing and shading the eye with the hand without touching the face. (12) Accommodation (A.) is tested clinically by meas- uring the nearest point (punctum proximum, p.~) at which the smallest readable type (Snellen's 5 or Jaeger's 1) can be clearly seen. The region of accommodation is the space in which it is available (see Chapter XX.). The ampli- tude, power, or range of A. is expressed in terms of the convex lens, whose focal length is = the distance from the cornea to p., this being the lens which adapts V. in an eye without A. from the farthest point of distinct vision (punc- tum remotum, r.) to p. : thus, if p. be at 10 cm. and A. be subsequently relaxed, i. e., the eye adapted for parallel rays, V. will again be clear at 10 cm. if a lens of 10 cm. focus ( = 10 D., see p. 28) be held close to the cornea ; because rays from that point will be made parallel before entering the eye ( 10 and 11). The convergence of the visual axes upon a point at any given distance is always naturally associated with accom- modation for the same distance. The two functions can, EXTERNAL EXAMINATION OF THE EYE. 45 however, be partially disassociated to a degree which varies with age and in different persons; i. e., the accommodation can be either relaxed a little or increased a little, without changing any given position of the visual axes ; this inde- pendent portion is known as the relative accommodation. (13) The apparent size of an object depends, in the first place, on the size of its retinal image, and this, as already shown ( 19, p. 26), depends upon (a) the size of the visual angle, and (6) the distance of the retina from the nodal point. It is clear that in Fig. 19 a smaller object placed nearer to the eye or a larger one placed further off might subtend the same angle as ob, and therefore have a retinal image of the same size. There are, however, other factors contributing to our estimate of the size of objects, especially contrast of size and shade, estimation of distance, and effort of accommodation. A white object on a black ground looks larger than a black object of the same size on a white ground. The further off an object is judged to be, the larger does it look. The greater the accommodative effort used, whatever may be the distance of the object, the smaller does it ap- pear ; thus, patients whose eyes are partly under the in- fluence of atropine, and presbyopic persons whose glasses are too weak, complain that near objects if looked at in- tently for a short time get much smaller ; whilst when one eye is under the action of eserine (causing spasm of the accommodation) objects appear larger than if held at the same distance from the other eye. Prisms with their bases towards the temples seem to diminish objects seen through them by necessitating excessive convergence of the eyes. (Compare Fig. 15.) (14) Color perception is best examined by testing the power of discriminating between various colors without naming them. The best test-objects are a series of skeins of colored wool, or, for pocket use, smaller strips of colored 46 EXTERNAL EXAMINATION OF THE EYE. paper, or colored stuffs. A color-blind person will expose his defect by placing side by side as similar, certain colors, usually mixed tints, which to the normal eye appear quite different. The set of wools generally used was introduced by Professor Holmgren, of Upsala. 1 In acquired color- blindness (from atrophy of the optic nerves), the patient, if well trained in colors, may be asked to name them, and his defect will generally in this way be correctly found. But in congenital color-blindness the confusion test, with- out naming the colors, is far safer; because, in the first place, such persons often learn to distinguish correctly be- tween many common-colored objects by differences of shade (i. e., differences in the quantity of white light which they reflect, and hence may escape detection unless tested with a large series of different colors, amongst which some, con- taining equal quantities of white, will look exactly alike ; and secondly, though such persons often use the names for colors freely, the words do not to them convey the same meaning as to those with normal color-sense, and hopeless confusion results from an examination so made. For de- tails, see Chapters III. and XVI. (15) The uses of prisms have been explained at p. 22. 1 ' De la Cecite des Couleurs,' etc., 1877. EXAMINATION OF RAILWAY EMPLOYES. 47 [CHAPTER III. THE PRACTICAL EXAMINATION OP RAILWAY EMPLOYES AS TO COLOR-BLINDNESS, ACUTENESS OF VISION AND HEARING. BY WILLIAM THOMSON, M.D. IN accordance with a wish expressed many months ago, that I should suggest some practical method for the exami- nation of the employes of the Pennsylvania Railroad, as to their ability to see the colored signals by day and night used in the service, I devoted much time to the subject, in an effort to overcome the following difficulties : 1. To ascertain whether each man possesses sight enough to see form at the average distance ; and range of vision to enable him to see near objects well enough to read written or printed orders and instructions. 2. To learn if each man has color-sense sufficient to judge promptly, by day or night, between the colors in use for signals. 3. To de- termine the ability of each man to hear distinctly. The difficulties to be overcome were found in the magni- tude of the task, involving the examination of thousands of men now in the service, with the necessity of extending it to all who may be hereafter employed, distributed over thousands of miles of road ; and in the absence of pro- fessional experts in sufficient number, possessing enough special training to fit them to decide with precision the points at issue. It soon became apparent that some system would be needed that could be put in force by each division super- intendent, acting through an intelligent employe^ under the general supervision of one or more ophthalmic sur- 48 EXAMINATION OF RAILWAY EMPLOYES. geons of recognized skill, to whom all information collected could be transmitted, and who would be able to decide all doubtful cases, and thus protect the road from any danger arising from incapable employes, and save good and faith- ful men from the evil of being discharged from the com- pany's service, or prevented from being employed on other roads on insufficient grounds. It was believed that the facts could be collected by non- professional persons, and could be so clearly presented to the division superintendent and to the professional expert, as to enable a perfectly correct decision to be made in every case ; and that men fit for service would be recog- nized, whilst those deficient in sight, color-sense, or hearing, could be referred to the expert if they so desired, or trans- ferred to places in the service where their defects, if not remediable by treatment, could do no harm either to the road or to the public. Such a system was submitted to the general manager of the Pennsylvania Railroad, and has been perfected by the labors of a special committee of the Society of Transportation Officers in conjunction with the writer. The entire method has furthermore been submitted to a practical experimental test extending over nearly two thousand men, employed as conductors, engineers, firemen, and brakemen, and the results have satisfied the committee and myself that our object has been fully attained, and that the system proposed may now be put in force with confidence in its practical utility. As an evidence of this, I may cite two complete detailed reports, including 1383 men in all. The blanks upon which the original entries were made have all been submitted to me, and they satisfy me that the results in the summary of each of these ex- cellent reports may be confidently accepted, and thus we have become acquainted with the fact that there were in the service of the Pennsylvania Railroad, of the 1383 men EXAMINATION OF RAILWAY EMPLOYES. 49 examined, 246 men deficient in the full acutenessof vision, 55 absolutely color-blind, and 21 defective in hearing. In one of the reports, an examination, not included in the instructions from the committee, was made with colored flags and colored lights by night, and 13 men failed to be able to recognize them from a total of 24, who were color- blind to the test used for its detection, but I have little doubt whatever that the eatire number of color-blind, viz., 55, would also fail under a carefully devised system of tests by the usual railroad signals. The entire number reported as defective in color-sense, 4^ per cent., is up to the average as reported by the best authorities in. its percentage , but those absolutely color, blind, and hence unable to distinguish between a soiled white or gray and green, or a green and red flag, are fully 4 per cent. ; and this proves that the instrument employed in this part of the examination has met our expectations fully. As this was the point about which I had most doubt, a word or two of explanation may be proper, more especially as many good authorities declare that no examination for color-blindness should be accepted, unless made by pro- fessional specialists. The examination for color-blindness now generally ac- cepted and proposed by Prof. Holmgren, consists in testing the power of a person to match various colors, which are most conveniently used in the form of colored yarns. Usually about 150 tints are employed, in a confused mixture, and three test colors, viz., light-green, rose or purple, and red, are placed in the foregoing order before the person ex- amined, who is directed to select similar colors from the mass. The examiner sits then in judgment, and decides whether the color-sense is perfect from the selections made, or from those not made, or from them both, and from the prompt or hesitating manner of the examined. It has 5 50 EXAMINATION OF RAILWAY EMPLOYES. been our effort to render this more simple, and to so ar- range the colors that they may be identified by some num- ber, so that an expert, although absent from the scene, would know by these numbers the exact tints selected, and thus be fully competent to declare from them the color- perception of any person whose record had been properly made. From theory based upon scientific knowledge, and from much experience, I was 9,ble to arrange an instru- ment that would have the real colors, and those usually confounded with them, " confusion colors," placed in such relations to each other, and so designated by numbers, as to make an examination for color-blindness possible by a non- professional person, who could conduct the testing, record it properly, and transmit it to an expert capable of decid- ing upon the written results. Hence there is no departure from the system of matching tints already established, the only novelty being in reducing the number of colors to those similar to the test colors, and to those usually chosen by color-blind persons, and so identifying them as to enable an absent expert or superintendent to know precisely what colors had been selected to match the test colors. The theory of the instrument (consisting of a stick with the yarns attached, see Fig. 27), is that color-blindness is most promptly detected by using the light-green test-skein, and asking that it be matched in color from the yarns on the stick, which are arranged to be alternately green and confusion colors, and are numbered from one to twenty, the person being directed to select ten tints, and the examiner being required to note the numbers of the tints chosen. It will be understood that the odd numbers are the green, and the even ones the confusion colors, and that, if a person has a good color-sense, his record will exhibit none but odd num- bers ; whilst, if he be color-blind, the mingling of even num- bers betrays his defect at a glance to the supervising expert or superintendent. EXAMINATION OF RAILWAY EMPLOYES. 51 52 EXAMINATION OF RAILWAY EMPLOYES. There are forty tints on the stick, and the first twenty are given to the detection of color-blindness, using the green-test, and if the color-sense is deficient, it will surely be revealed. To distinguish, however, between green-blindness and red-blindness, the rose-test is used, and those color-blind will select indifferently, either the blues intermingled with the rose, between figures 20 and 30, or perhaps the blue-green or grays from 1 to 20, and thus reveal their defect, and es- tablish either green- or red-blindness. Finally, the red-test corroborates these results, and satis- fies the most sceptical of color defect, when the " confusion tints " or even numbers between 30 and 40 are selected. On a suitable blank these figures are placed in the order of examination, and a glance of the eye reveals the color- sense of the person examined; since, if anything but odd numbers are chosen, there is a defect ; or if, with test one, anything beyond 20 is chosen ; or if, with test two, any- thing but odd numbers between 20 and 30 ; or, with test three, anything but odd numbers between 30 and 40. The colors can readily be changed on the instrument, if it should be found desirable. It is theoretically and practically a fact, that the tints as arranged in the three sets on the instrument look quite the same in color to color-blind persons, and that those having a perfect color-sense can thus form an idea of this infirmity. If, then, green and gray are indistinguishable, and green and red, when of the same depth of color, seem to be entirely the same to the color-blind, it needs no opinion from a scien- tific expert to convince the manager of a railroad that it would be most dangerous to place the lives of people under the guidance of an engineer who could not distinguish, if green-blind, between a soiled white and a green flag, or be- tween a green and red flag, or other signal of these colors. It is a fact that some of the color-blind promptly give EXAMINATION OF RAILWAY EMPLOYES. 53 the proper names to the flags, and answer correctly, when asked what they would do in presence of such signals, but it must be remembered that they may see form perfectly, and have always had some perception of these colors, and do give them their conventional names, perhaps, but that they are unable to distinguish them at once and infallibly, and that it will only require a further extension of our method of testing to demonstrate the inability of persons color- blind to our examination to recognize the signals, by day or night, which are now depended upon to prevent acci- dents of the gravest character. This must be done by de- manding that the signals be matched, and not named, and this is incorporated in the instructions herewith submitted, so that the tints which color-blind men select with the rail- road signals from the instrument may hereafter be known and recorded. My conclusions from a study of the subject in connection with the railway service are : 1. That there are many employes who have defective sight, caused either by optical defects, which are, perhaps, congenital, and which might be corrected with proper glasses, or due to the results of injuries or diseases of the eyes, remediable or not, by medical or surgical treatment. 2. That one man in twenty-five will be found color-blind to a degree to render him unfit for service where prompt recognition of signals is needed, inasmuch as color-blindness for red and green renders signals of these colors indistin- guishable. It is a fact in physiological optics, however, that yellow and blue are seen by those color-blind for red and green, and that yellow-violet blindness is so rare that it might lead to the use of these yellow and blue colors, in preference to red and green, wherever possible. 3. That color-blindness, although mainly congenital and incurable, is sometimes caused by disease or injury, and that precautions might be needed to have either periodical 54 EXAMINATION OF RAILWAY EMPLOYES. examinations or to insist upon it in cases where men have suffered from severe illness or injury, or -when they have been addicted to the abuse of tobacco or alcohol. 4. That the method, when adopted, will enable the authorities to know exactly how many of their employes are "satisfactory in every particular" as to sight and hear- ing; and that the examination will have the further value of making the division superintendents acquainted with the general aptitude of the men in their divisions as to gen- eral intelligence. 5. That the entire examinations can be made at the rate of at least six men an hour; whilst that for color-sense alone can be done in a very few minutes for each man by an intelligent employe. 6. That to secure the confidence of the employes, and of competent scientific critics, as well as of the public gener- ally, it is advisable to have some official professional specialist to whom all doubtful questions could be referred, and who should be held responsible for the accuracy of the instruments, test-cards, etc., to be put in use, and who should have a general supervision of the entire subject of sight, color-sense, and hearing. 7. That from the impossibility of subjecting the immense number of employes on our large railways to the inspection of the few medical experts available, and to secure the ex- amination of those hereafter to be employed, some system of testing by the railway superintendents has become a necessity, and it is believed that the one proposed will an- swer the purpose. EXAMINATION OF RAILWAY EMPLOYES. 55 PENNSYLVANIA RAILROAD COMPANY'S INSTRUCTIONS FOR EXAMINATION OF EMPLOYES AS TO VISION, COLOR- BLINDNESS, AND HEARING. Instructions for examination as to vision, color-blind- ness, and hearing. The examination will be made as to vision, color-sense, and hearing, and the following appa- ratus will be used: 1. A card or disk of large letters for testing distant sight. 2. A book or card of print for testing sight at a short distance. 3. An adjustable frame for supporting the print to be read, with a graduated rod attached for meas- uring the distance from the eye while reading. 4. A spec- tacle frame for obstructing the vision of either eye while testing the other. 5. An assortment of colored yarns for testing the sense of color. 6. A watch with a loud tick for testing the hearing. 7. A book or set of blanks for record- ing the observations. 8. A copy of an approved work on " Color-blindness." Acuteness of vision. For distant vision, place the test- disk or card in a good light twenty feet distant, and ascer- tain for each eye separately the smallest letters that can be read distinctly, and record the same by the number of that series on the card. Range of vision. For near vision, ascertain the least number of inches at which type D = 0.5 or 1 , can be read with each eye, and record the result. Field of vision. Let the examiner stand in front of the examined, at a distance of three feet, and directing the ex- amined to fix his eyes on the right eye of the examiner, and keep them so fixed, let the examiner extend his arm later- ally, and opening and shutting his hands, let him by ques- tions satisfy himself that his hands are seen by the examined 56 EXAMINATION OF RAILWAY EMPLOYES. without changing the direction of the eyes ; recording the result as good or defective, as the case may be. Color-sense. Three test-skeins A, light-green ; B, rose ; C, red will be used with the colored yarns attached to the stick ; of the latter there are forty tints, numbered from 1 to 40, and arranged in three sets a, b, and c of which the odd numbers correspond to the colors of the test-skeins, whilst the even numbers are different or " confusion colors." The first set is to test for color-blindness; the second to determine whether it be red or green blindness, and the third to confirm the opinion formed from the first or second test. Place the test-skein A at a distance of not less than three feet, and, without naming the color, direct the person ex- amined to name the color, and to select from the first twenty tints, or set (a), of the yarns on the stick, ten tints of the same color as skein A, stating that they do not match, but are different shades of the same color. Record the number of the tints so selected. Do the same with skeins B and C, using for B the tints from 21 to 30, and for C the tints from 31 to 40. If the odd numbers are selected read- ily, the examination may be gone over very quickly. When color-blindness is detected, any one of the even numbers or " confusion colors " may be used as a test-skein, and the man may be directed to select similar tints, when he will most probably choose odd numbers, which should be recorded, stating the number on the stick of the " con- fusion color" used for a test, and then giving the numbers chosen to match it. Then a soiled white flag should be shown, and the man be directed to select tints to match it, which should be re- corded ; next a green, and finally a red flag. All of the particulars are to be recorded as the examina- tion proceeds, not leaving it to memory. Use the numbers in recording. The letters indicating the set need not be EXAMINATION OF RAILWAY EMPLOYES. 57 used. Note whether the selection is prompt or hesitating by a distinct mark after the proper word on the blank form. When deficient color-sense is discovered, and varia- tions in the mode of testing are made by the examiner or examined, they should be noted under remarks, or on a separate sheet to be referred to, if the blank has not room enough. Hearing. Note the number of feet or inches distant from each ear at which a watch, having a tick loud enough to be heard at five feet, is heard distinctly, using a watch without a tick, or a stop watch, to detect any supposed deception; and the number of feet at which ordinary conversation is heard. Explanations. The test-card contains letters, numbered from 20 (xx), or D = 6, to 200 (cc), or D = 60. Those measuring three-eighths of an inch, and numbered 20 (xx) or D = 6, are such as a good eye of ordinary power sees dis- tinctly twenty feet or six metres distant. If a man sees distinctly only those marked C (or 100), his acuteness of vision, V., is equal to T 2 7 or %. If he sees to XX (or 20), then V. is equal to f $ or 1, and his sight is up to the full standard. This mode of statement indicates the relative value of the sight examined, and should be used in the records. If one eye is -|$ or 1, and the other not less than f-g- or Y, with or without glasses, the sight may be con- sidered satisfactory. The power of discerning small objects at the reading distance is tested by the small print, and good sight may be assumed if one eye can see at twenty inches the matter marked 1 2 or D = 0.5, whilst the other distinguishes not less than 4J or D= 1.5. The small print should then be brought to the point of nearest vision for each eye, and that point mentioned in inches. A good eye should be able to read No. 1 J at twenty inches, and have a range of vision up to ten inches. 58 EXAMINATION OF RAILWAY EMPLOYES. The color-test will indicate whether the man is deficient in color sense. The colors are arranged in three sets, one of 20 and two of 10 each the odd numbers are the colors similar to the test-skeins, and the even, numbers are the " confusion colors," or those which the color-blind will be likely to select to match the sample skeins or colors shown him. The first 20 (a), numbered from 1 to 20, have green tints for the odd numbers or test-colors. In the second (6), 21 to 30, the test-colors are rose or purple, a combina- tion of red and blue ; and in the third (c), 31 to 40, they are red. Ordinarily the test will be with each set separately, but the whole 40 may be employed on any test-skein. Any- thing but green matched with green indicates a defect in the color sense, for which use set (a). The test with the second set indicates whether red or green blindness exists. The odd numbers from 21 to 30 are purple. If either of these is matched with test-skein B, nothing is indicated, as they must appear alike to a color-blind person ; but if blue is chosen, red-blindness is indicated, and if green, then green-blindness is established. The third set (c) is scarcely needed, but may be used in confirmation of, or in connection with, the last, as to red or green defect. When the numbers of the tints selected are recorded in the proper blank, color-blindness will be indicated in those instances where even numbers appear, and suspicions will arise where numbers beyond 20 are used with test-skein A, and under 21 or beyond 30 with B, and below 31 with C. Further tests should be made of those found to be color- blind with the usual signal flags, requesting them to name each color, shown singly, and to match the colors of them from the tints on the stick, and with colored lamps ; and finally to state what they understand them to mean as signals. It will be well not to dwell on the examination of a man EXAMINATION OF IIAILWAY EMPLOYES. 59 found to be defective in color-sense or in vision, but to pass over each examination with the same general care, and afterwards send for those giving indications of defects, to come in singly for fuller examination. The examination should be private as far as practicable, especially excluding persons who are to be subsequently examined. Inability to name color accurately, or to distinguish nicely as to difference in tint, is not to be taken as an evi- dence of color-blindness. In testing as to hearing, if the watch used can be heard at five feet distant, and the person examined hears it only at one foot, his hearing would be 1-5, and may be so recorded in fractions. Conversation in an ordinary tone should be heard at ten feet. It should be understood that all employes examined, failing to come up to the requirements of the above stand- ard, shall be accorded the benefit of a professional ex- amination. When acuteness of vision is below the standard adopted, it may be possible to restore full vision by proper glasses, when it is due to optical defects, known as near- sight, far-sight, or astigmatism, or by other medical or surgical treatment, and useful men may then be retained in the company's service. These rules and regulations, having been approved by the Board of Managers, have been put into effect on the Pennsylvania Railroad, under the general supervision of the writer, and give entire satisfaction,] 60 FOCAL ILLUMINATION. CHAPTER IY. EXAMINATION OF THE EYE BY ARTIFICIAL LIGHT. THIS includes (1) examination by focal or oblique light; (2) examination by the ophthalmoscope. (1) In using focal or oblique illumination the anterior parts of the eye are examined with the light of a lamp concentrated by means of a convex lens. It is used for the examination of opacities of the cornea, changes in the appearance of the iris, alterations in the outline and area of the pupil from iritis, and opacities of the lens. Such an examination is to be made by routine in every case before using the ophthalmoscope. We require a somewhat dark- ened room, a convex lens of two or three inches focal length (one of the large ophthalmoscope lenses), and a bright, naked lamp-flame. The patient is seated with his face towards the light, which is at about 2' distance. The lens, held between the finger and thumb, is used like a burning-glass, being placed at about its own focal length from the patient's cornea and in the line of the light, so as to throw a bright pencil of light on the front of the eye at an angle with the observer's line of sight. Thus all the superficial media and structures of the eye can be successively examined under strong illu- mination, the distance of the lens being varied a little, ac- cording as its focus is required to fall on the cornea, the iris, or the anterior or posterior surface of the crystalline lens (Fig. 28). By varying the position of the light and of the patient's eye, making him look up, down, and to each side, we can examine all parts of the corneal surface, of the iris, FOCAL ILLUMINATION. 61 FIG. 28. of the pupillary area (i. e., the anterior capsule of the lens), and of the lens-substance. If the light be thrown at a very acute angle on the cornea or lens, opaci- ties are much more visible than if it fall almost perpendicularly. For complete exploration of all parts of the crystalline lens the pupil must be dilated with atropine, but careful exam- ination without atropine will generally enable us to detect opacities lying in or near the axis of the lens even if quite deeply seated. In examining the pos- terior pole of the lens the light must be thrown almost perpendicularly into the pupil, and the observer must place his eye as nearly in the same di- rection as is possible without intercepting the incident light. Opacities of the cor- nea and anterior lay- ers of the lens appear whitish; deep opacities in the lens, especially in old people, look yellowish by focal light. Tumors and large opacities in the vitreous, hemorrhagic or other, may be seen by this method if seated close behind the lens. Minute foreign bodies in the cornea will often be seen by focal light when invisible, because covered by hazy epithe- lium, in daylight. By habitually magnifying the illumin- ated parts by a second lens held in the other hand, much additional information can be gained. Focal illumination. 62 OPHTHALMOSCOPIC EXAMINATION. (2) OPHTHALMOSCOPIC EXAMINATION. The ophthalmoscope enables us to see the parts of the eye behind the crystalline lens by making the observer's eye virtually the object by which the observed eye is lighted up. Rays of light entering the pupil in a given direction are partly reflected back by the choroid and retina, and on emerging from the pupil take the same or very nearly the same course that they had on entering ( 12, p. 18). Hence the eye of the observer, if so placed as to receive these re- turning rays, must also be so placed as to cut off the enter- ing rays; as, therefore, no light can enter in this direction, none can return to the observer's eye. This is why the pu- pil generally looks black. Although with a large pupil, especially in a hypermetropic or myopic eye, the observer receives some of the returning rays (because he does not intercept all the entering light), and in this way sees the pupil of a fiery red instead of black, still for any useful examination the observer's eye must, as already stated, be in the central path of the entering (and emerging) rays. This end is gained by looking through a small hole in a mirror, by which light is reflected into the patient's pupil, and this perforated mirror is the ophthalmoscope. There are two ways of seeing the deep parts of the eyeball by its means. A. The indirect method of examination, by which a clear, real, inverted image of the fundus, somewhat magnified, is formed in the air between the patient and the observer. The following simple experiment will show how this is effected : Take two convex lenses of about 2" focal length each. (1) Hold one in the left hand, at about 2" from this print ; (2) take the second lens in the right hand, and, moving your head a few inches back, hold the second lens at about its focal length in front of the first ; you will then OPHTHALMOSCOPIC EXAMINATION. 63 see an inverted image of the print slightly magnified, a. Observe that in order to see this image clearly you have to make an effort, and that you cannot see the image and the print on the page itself, clearly at the same moment ; this is because the inverted image (im, Fig. 29 ) lies in the air between the eye and the second lens, and more accommo- dation is necessary for seeing it clearly than for the object (ob}. The fundus of the eye seen on this principle is mag- FIG. 29. <'b is the object, a. The first lens. /. The second lens. im. The magnified inverted image of ob viewed by the observer, obi. nified about four diameters, if the eye be normal. The image is larger in H and smaller in M. b. Notice that if the observer's head be moved slightly from side to side the image will appear to move in the opposite direction. B. The direct method of examination by which (except when the eye is myopic) a virtual, erect image is seen more magnified than in the former method and behind the pa- tient's eye. The conditions are the same as those under which a magnified image of any object is seen through a convex lens (Fig. 12), as in the following experiment: (1) Hold a con- vex lens, of say 3" focal length, at any distance from this 64 OPHTHALMOSCOPIC EXAMINATION. page not greater than 3", and place your eye close to the lens. The print will be magnified and seen in its true position, i. e., " erect." a. The enlargement will be more the greater the distance of the lens from the page up to 3" ( 16 and 17, p. 19). If the distance be further increased the print will not be seen clearly. The image is a " virtual " one, because it is the image which would be formed if the rays which enter the eye in a diverging direction could be prolonged backwards until they met behind the lens (Figs. 12 and 32). b. If the lens be placed just at its focal length from the paper the image will be seen clearly only during complete relaxation of the accommodation, c. If it be nearer to the page, either accommodation must be used according to the distance, or the observer must withdraw his head further from the lens. d. If, keeping the lens quite still, the observer withdraw his head, the field of view will be lessened (Fig. 13), whilst the image will appear to increase in size (without really doing so), and these changes will be greater the nearer the lens is to its focal distance from the paper ; if it be almost exactly at its principal focal distance, only a very small part of the print will be seen when the head is withdrawn, e. If the head be moved a little from side to side, the image will appear to move in the same direction. The emmetropic eye, with the accommodation fully re- laxed, being adjusted for distant objects, i. e., parallel rays, receives a clear image of such objects on the layer of rods and cones of the retina (p. 25). A clear image of the/tm- dus of the eye, i. e., the retina, optic disk, and choroid, can be obtained in such an eye (as in the second experiment above described, when the distance of the lens from the paper was equal to or less than its focal length) ; on con- dition that the eyes, both of patient and observer, be ad- justed for infinite distance, i. e., for parallel rays ; in other OPHTHALMOSCOPIC EXAMINATION. 65 words, that the accommodation of both be relaxed. The fundus so seen is magnified about 15 diameters. In order to use the ophthalmoscope 1 it is first necessary to learn to manage the mirror and light. (1) Seat the pa- tient in a darkened room and place a lamp with a large steady flame on a level with his eyes, a few inches from his head, and about in a line with his ear. The lamp may be on either side, but is usually placed on his left, and it is better to keep to the same side until practice has given steadiness to the various combined movements which are necessary. (2) Sit down in front of the patient with his face fronting your own, feature to feature. It is most con- venient for the observer's face to be a little higher than that of the patient. (3) Take the mirror of the ophthal- moscope (without any lens behind, and without the large lens) in your left hand for examining the patient's left eye (and vice versd for his right eye) ; hold it, mirror towards the patient, close to your own eye, and with the sight-hole placed so that (with your other eye closed) you see the pa- tient through it. Now rotate the mirror slightly towards the lamp until the light reflected from the flame is thrown into the patient's pupil, and open your other eye. (4) You will so far have seen nothing except the front of the eye, unless the patient's eye is under atropine ; for he will have looked at the centre of the mirror, and his pupil, strongly contracted, will look either black or very dull red. (5) Now tell him to look steadily a little to one side into va- cancy, or at an object on the other side of the room. The pupil will now become red bright fiery red, if it be rather large ; a duller red if it be small, or the patient be of dark complexion. In one position, when the eye under exam- ination looks a little inwards, the red will change to a yellowish or whitish color, and this indicates the position 1 For choice of instruments, see Appendix. 6* 66 OPHTHALMOSCOPIC EXAMINATION. of the optic disk. (6) Learn to keep the light steadily on the pupil during slow movements backwards and forwards and from side to side (taking care that the patient keeps his eye all the time in the same position, and does not fol- low the movements of the mirror) ; the test of steadiness will be that the pupil remains of a good red color in all positions. Up to this point the examination may be made without atropine; and so far only a uniform red glare will have been seen, no details of the fundus being visible unless the patient be either myopic or considerably hyper- metropic. In order to see the details of the fundus it is best to be- gin by learning the Indirect Method (Fig. 30), for, though rather less easy than the direct, it is more generally useful. Having learned to keep the light reflected steadily into the patient's pupil, take the mirror without any lens behind it (unless you are either hypermetropic or myopic, in which case you should either wear the glasses you commonly use for reading, or place a lens of the same strength in the disk behind the mirror) in one hand, and one of the large convex " objective" lenses in the other. Always, if possi- ble, have the pupil dilated with atropine, for by this means you learn to see the fundus much more quickly and easily. In examining the patient's right eye, apply the mirror with your right hand to your right eye, holding the lens in your left hand; it is best to reverse everything for his left eye, but the position of the light need not be changed. The hand which carries the lens should be steadied by resting the little or ring finger against the patient's eyebrow or temple. It is best to begin by looking for the optic disk, which is one of the most important and easily seen parts. To bring it into view the patient must look a little inwards with the eye under examination, e. g., if his right eye is under ex- amination he must direct it to the observer's right ear, or OPHTHALMOSCOPIC EXAMINATION. 67 68 OPHTHALMOSCOPIC EXAMINATION. look at the little finger of his mirror's hand. Take care that the patient turns his eye, not his head, in the required direction. The lens should be held about 2"-3", and the observer be about 18" from the patient's eye; the image of the fundus being formed in the air 2" or 3" in front of the lens, will thus be situated about 12" from the observer. The bright red glare (from the choroid) will be obvious enough ; but most beginners find some difficulty in avoid- ing the reflection of the mirror from the cornea, and in ad- justing the accommodation and the distance of the head so as to see the image clearly. The head must be slowly moved a little further from or nearer to the patient, and at the same time an attempt made to adjust the eyes (both being kept open) for a point between the observer and the lens. Several sittings are sometimes necessary before the image of the optic disk, or retinal vessels, can be clearly seen. The optic disk ending of the optic nerve in the eye above the lamina cribrosa, optic papilla (Figs. 31 and 33) is seen as a round object, of much lighter color than the fiery red of the surrounding fundus, and with numerous bloodvessels radiating from its centre chiefly in an upward and downward direction. As soon as the disk can be easily seen, the student must pass on to the study of the most im- portant details of this part itself and of the other parts of the fundus, some of which will be given here and others will be found in the chapters on the Diseases of the Choroid and Retina, and on the Errors of Refraction. The disk, as a whole, is of a grayish-pink, with admix- ture of yellow. It is nearly circular, but seldom perfectly so, being often apparently oval or slightly irregular. Two differently colored parts are noticeable a central patch, whiter than the rest, and into which most of the blood- vessels dip ; and a surrounding part of pink or grayish- pink. In many eyes, especially in old persons, the appar- OPHTHALMOSCOPIC EXAMINATION. 69 ent boundary of the disk is formed by a narrow line of lighter color, which represents the border of the sclerotic (scleral ring). The bloodvessels consist of several large trunks and a varying number of small twigs; the large trunks emerge from the central white part of the disk, and often bifurcate once or twice on its area ; the small twigs may emerge separately from various parts of the disk, or form branches of the large trunks. Variations. The color of the disk appears paler or darker according to the color of the surrounding choroid, the brightness of the light used, and the patient's age and state of health. A curved line of dark pigment often bounds a part of the circumference of the disk and has no pathological meaning. The central white patch varies greatly in size, position, and distinctness ; it may be so small as hardly to be perceptible, or very large ; may shade off gradually or be abruptly denned ; may be central or eccentric ; when large it generally shows a grayish stippling or mottling. The white patch itself represents a depression of corresponding position and size, the physiological cup or pit (compare Figs. 33 and 34) formed by the nerve-fibres radiating from the centre of the disk on all sides towards the retina, like the tentacles of an open sea-anemone, and through it the chief bloodvessels pass on their way between the nerve and the retina. This depression is generally shaped like a funnel or a dimple with gradually sloping sides (Fig. 34) ; but sometimes the sides are steep, or even over-hanging ; in other eyes it is wide or shallow, and en- larged towards the outer side of the disk. The physiolog- ical pit is whiter than the rest of the disk, because the grayish-pink nerve-fibres are absent at this part, and we can therefore see down to the opaque, white, fibrous tissue which, under the name of lamina cribrosa, forms the floor of the whole disk (Fig. 34). The stippled appearance often noticed in the pit is caused by the holes in this lamina, 70 OPHTHALMOSCOPIC EXAMINATION. through which the bundles of nerve-fibres pass on their way to the retina, the holes appearing darker because -filled by non-medullated nerve-fibres, which reflect but little light. The other parts of the fundus. The groundwork is of a bright fiery red (the choroid, not the retina), which iu average eyes is nearly uniform, but in persons of very light or very dark complexion shows a pattern of closely- set tortuous red bands (vessels), separated by interspaces either of darker or of lighter color (Fig. 31). (For fur- ther details, see Diseases of Choroid.) Upon this red ground the vessels of the retina divide FIG. 31. Opbthalmoscopic appearance of healthy fundus in a person of very fair complexion. (Wecker and Jaeger.) and subdivide dichotomously. It will be noticed that the principal trunks pass almost vertically upwards and down- wards, but that no large branches go to the part apparently inwards from the disk ; that the whole number of visible retinal vessels is comparatively small, large spaces inter- OPHTHALMOSCOPIC EXAMINATION. 71 vening between them ; that they become progressively smaller as they recede from the optic disk ; and that they never anastomose with each other. Special attention must be given to the part, apparently to the inner (nasal) side of the optic disk (really to its outer temporal side), which is the region of most accurate vision, the yellow spot (y. s., macula lutea, or shortly " macula "). This region is skirted by large vessels from which numerous twigs are given off to it. The y. s. is seen when the patient looks straight at the ophthalmoscope ; it will be noticed that the choroidal red is darker at this part, and that no retinal vessels pass across its centre, but that numerous fine twigs radiate to and from it (see Chap. XIV.). In many eyes nothing but these in- definite characters mark the y. s. ; but in some, especially in dark eyes and young patients, a minute bright dot oc- cupies its centre, and is encircled by an ill-bounded dark area, round which again a characteristic shifting white halo is seen. The minute dot is the fo vea centralis, the thinnest part of the retina. The neighborhood of the disk and y. s. form the central region of the fundus. The pe- ripheral parts are explored by telling the patient to look successively up, down, and to each side without moving his head. To see the extreme periphery the observer must move his head as well as the patient his eye. Towards the periphery the choroidal trunk-vessels are often plainly visi- ble when none were distinguishable at the more central parts. The vessels of the retina (see Chap. XIV.) are easily distinguished from those of the choroid by their course and mode of branching, and by the small size of all except the main trunks ; but especially by their greater sharpness of outline and clearness of tint, and by the presence of a light streak along the centre of each (Fig. 31), which gives them an appearance of roundness, very different from the flat band-like look of the choroidal vessels. They are di- 72 OPHTHALMOSCOPIC EXAMINATION. visible into two sets a darker, larger, somewhat tortuous set the veins ; and a lighter, brighter red, smaller, and usually straighter set the arteries, the diameter of cor- responding branches being about as 3 to 2. The arteries and veins run pretty accurately in pairs. Pressure on the eyeball, through the upper lid, causes visible pulsation of the arteries on the disk. The indirect method of examination is most generally useful, because it gives a large field of view, under a com- paratively low magnifying power (about three to five diameters). The general character and distribution of any morbid changes are better appreciated than if we begin with the direct method, in which the field of view is smaller and the magnifying power much greater. It has also the great advantage of being equally applicable in all states of refraction in the patient, whereas in myopia the fundus cannot be examined by the direct method with- out the aid of a suitable concave lens, found experiment- ally, placed behind the mirror (p. 76). In the inverted image the inversion is such that what appears to be upper is lower, and what appears to be R. is L. The Direct Method, i. e., examination by the mirror alone, or with the addition of a lens in the clip or disk behind it, but without the intervention of the large lens. By this method the parts (unless the eye be myopic) are seen in their true position (Fig. 32), the upper part of the image corresponding to the upper part of the fundus, the right to the right, etc., it is therefore often called the method of the "erect" or "upright" image; though, as will be seen below, these terms are not strictly convertible with "direct examination." It is used (1) to detect opaci- ties in the vitreous humor and detachments of the retina ; (2) To ascertain the condition of the patient's refraction, i. e., the relation of his retina to the focus of his lens-sys- OPHTHALMOSCOPIC EXAMINATION. 73 tern ; (3) For the minute examination of the fundus by the highly magnified, virtual erect image (Fig. 33). (1) To examine the vitreous humor. The patient is to move his eye freely in different directions whilst the light is reflected into the eye from a distance of a foot or more (for details, see Diseases of Vitreous) ; detachments of the retina are seen in the same way. Opacities in the vitreous and folds of detached retina, being situated far within the focal length of the refractive media, are seen in the erect position under the conditions mentioned at p. 64, c.,the observer being at a considerable distance from the eye. (2) To ascertain the kind of refraction. If when using the mirror alone, at a distance of 18" or more from the pa- tient's eye, we see some of the retinal vessels clearly and easily, the eye is either myopic or hypermetropic. If, when the observer's head is moved slightly from side to side, the vessels seem to move in the same direction, the image seen is a virtual one and the eye hypermetropic. The eye is myopic if the vessels seem to move in the contrary direc- tion ; the image in myopia is, indeed, formed and seen in the same way as the inverted image seen by the " indirect" method of examination, but except in the highest degrees of myopia it is too large and too far from the patient to be available for detailed examination. In low degrees of M. this inverted image is formed so far in front of the patient's eye as to be visible only when the observer is distant per- haps 3' or 4' ; whilst in E. and in lower degrees of H. the erect image will not be easily seen at a greater distance than 12" or 18" (p. 64, d., and Fig. 13). If, therefore, in order to get a clear image by the direct method, the ob- server has to go either very close to, or a long way from, the patient, no great error of refraction can be present. The above tests only reveal qualitatively the presence of either M. or H., but by a modification of the method, the exact quantity of any error of refraction, e. g., H., can be 7 74 OPHTHALMOSCOPIC EXAMINATION. OPHTHALMOSCOPIC EXAMINATION. 75 determined with great accuracy (determination of the refrac- tion by the ophthalmoscope). In E., as already stated at pp. 64, 65, the erect image can be seen only if the observer be near to the patient, and also completely relax his accom- modation ; for, in experiment d. there described, when the head was withdrawn from the lens the magnifying power appeared to increase, whilst the field of view and illumina- tion rapidly diminished. The same occurs with the eye, but in a much greater degree, and hence in E. no useful view can be gained except near to the eye. In H., where the retina is within the focus of the lens- system, the erect image is seen when close to the patient's eye only by an effort of accommodation in the observer, just as in the same experiment when the lens was within its focal length from the page (p. 64, c.). And as in that experiment the print was also seen easily, even when the head was withdrawn, so in H. the erect image is seen at a distance as well as close to the patient. If now the observer, instead of increasing the convexity of his crystalline, place a convex lens of equivalent power behind his ophthalmoscope mirror, this lens will be a measure of the patient's H., i. e., it will be the lens which, when the patient's accommodation is in abeyance, will be needed to bring parallel rays to a focus on his retina. If a higher lens be used, the result will be the same as when in the experiment the convex lens was removed beyond its focal length from the print ; the fundus will be more or less blurred. Hence to measure H. : (1) the accommodation of both patient and observer must be fully relaxed (usually by atropine in the patient and by voluntary effort in the ob- server) ; (2) The observer must go as close as possible to the patient; (3) he must then place convex lenses behind his mirror, beginning at the weakest and increasing the strength till the highest is reached with which the details 76 OPHTHALMOSCOPIC EXAMINATION. of the optic disk can be seen with perfect clearness. By practice the distance between the cornese of patient and observer may be reduced to about J". The light must be on the same side as the eye under examination, so as to avoid much rotation of the mirror. The right eye must examine the right, and vice versa. In the same way, though with less accuracy in the high degrees, M. can be measured by means of concave lenses ; the lowest lens with which an erect image is obtained being the measure of the M. Astigmatism (As.) may also be measured by this method, the refraction being estimated first in one and then in the other of the two chief meridians by means of correspond- ing retinal vessels (see Astigmatism). FIG. 33. Ophthalmoscopio appearance of healthy disk, as seen in the erect image. Dark vessels, veins; double contoured vessels, arteries. X 15 diameters (after Jaeger). This application of the direct method needs much prac- tice, and for convenience the lenses, of which there are twenty or more, are placed in a thin metal disk, which can be revolved behind the mirror so as to bring each lens in succession opposite the sight-hole. There are many forms of these "refraction ophthalmoscopes," varying in minor details of construction (see Appendix). OPHTHALMOSCOPIC EXAMINATION. 77 (3) The erect image is very valuable, on account of the high magnifying power (about 15 diameters in the E. eye) for the examination of the finer details of the fuudus. The disk looks less sharply defined because more magnified than when seen by the indirect method ; both the disk and the FIG. 34. Vertical section of healthy optic disk, etc. X about 15. 7?. Retina, outer layers shaded vertically, nerve-fibre layer shaded longitudinally. Ch. Choroid. Set. Sclerotic. L, Or. Lamina cribrosa. S. V. Subvaginal space between outer and inner sheath of optic nerve. The central vein and a main division of the central artery are seen in the nerve and disk. retina often show a faint radiating striation (the nerve- fibres) ; the lamina cribrosa is often more brilliantly white; and the pigment epithelium of the choroid can be recog- nized as a fine uniform dark stippling. If the refraction be E. or H., no lens is needed behind the mirror ; if M., a concave lens must be placed in the clip behind the mirror, of sufficient strength to give a good, clear, erect image. The observer must come as near as possible to the patient. By reference to Fig. 32 it will be seen that only those rays are useful which strike near the centre of the mirror, none others entering the patient's pupil ; hence, if the aper- ture in the mirror be too large, the fundus will not be well 7* 78 OPHTHALMOSCOPIC EXAMINATION. lighted. It should not be larger than 3 mm., whilst if much smaller than that the image has a fictitious clearness which in some cases would be misleading. KETINOSCOPY (KERATOSCOPY). If the fundus be lit up by the ophthalmoscope mirror from a distance, slight rotation of the mirror between the finger and thumb causes a dark shadow to pass across the red field. The edge of the shadow has the same direction as the axis on which the mirror is turned. In emmetropia, hypermetropia, and very low myopia, the shadow moves in a direction opposite to that in which the mirror is rotated ; in myopia of 1 D. and more it moves in the same direction as the mirror. The higher the degree of H. or M. the fainter is the illu- mination, the more crescentic the shadow, and the slower its movement; the lower the defect the brighter is the lighted area, the more linear the shadow, and the quicker its motion. By placing trial lenses in front of the patient's eye ( if the shadow move with the mirror, showing de- cided M. ; -j- if it move against the mirror, generally show- ing decided H.) we can estimate the degree of M. or H. In M. we find experimentally the weakest lens, which makes the shadoAV move against the mirror ; and since this movement is still compatible with very slight M., we say that the M. is greater by (.5 D.) than the chosen lens indi- cates. In H. we find the weakest -f- lens, which makes the shadow move with the mirror ; and as this movement shows at least 1 D. of M., the H. is less by 1 D. than the lens in- dicates. The chief meridians in astigmatism may be ascer- tained by observing that when one meridian is as nearly as possible corrected by a spherical lens, the shadow shows by its characters a decided error of refraction in the opposite meridian ; and the degree of As. is shown by the cylindri- OPHTHALMOSCOPIC EXAMINATION. 79 cal lens (-)- or ), which, with its axis parallel to the border of this shadow, corrects the error. For retinoscopy a concave mirror of 9" (22 cm.) focus is to be used, at a distance of 4' (120 cm.) from the patient, and the pupil is to be dilated by atropine. The light is to be thrown as nearly as possible in the direction of the visual axis. The method is useful, especially for children, and is said after a little practice to be both quick and accurate ; though I have not yet tried it largely, I have several times found it useful. For further details the reader is referred to Mr. Morton's excellent little work, which contains the best account of the subject in our language. 1 1 A. Stanford Morton, Kefraction of the Eye, its Diagnosis, etc., 1881, chap. ix. PART II. CLINICAL DIVISION. CHAPTER V. DISEASES OF THE EYELIDS. THE border of the lid, which contains the Meibomian glands, the follicles of the eyelashes, and certain modified sweat-glands and sebaceous glands, is often the seat of troublesome disease. Being half skin and half mucous membrane, it is moist and more susceptible than the skin itself to irritation by external causes ; being a free border, its circulation is terminal, and therefore especially liable to stagnation. Its numerous and deeply-reaching glandular structures, therefore, furnish an apt seat for chronic inflam- matory changes. Blepharitis (ophthalmia tarsi, tinea tarsi, sycosis tarsi) includes all cases in which the border of the eyelid is the seat of subacute or chronic inflammation. There are sev- eral types. The skin is not much altered, but chronic thickening of the conjunctiva near the border of the lid is generally observed. The disease may affect both lids or only one, and the whole length or only a part. In the commonest and most troublesome form the glands and eyelash-follicles are the principal seats of the disease. The symptoms are firm thickening and dusky congestion of the border region, with exudation of sticky secretion from (81) 82 DISEASES OF THE EYELIDS. its edge, gluing the lashes together into little pencils. Very mild cases present merely overgrowth of lashes and excess of Meibomian secretion. But generally the disease pro- gresses ; little excoriations and ulcers covered by scab form along the free border, and often minute pustules appear; the thickening and vascularity increase; the lashes are loosened, and free bleeding occurs when they are pulled out. After months or years of varying activity some or all of the hair-follicles become altered in size and direction, or quite obliterated ; and stunted, misplaced, or deficient lashes, are the result; as the thickening gradually disappears, little lines, or thin seams, of scar are seen just within the edge of the lid, slight eversion being often the result. The re- sulting exposure of the marginal conjunctiva, together with the deficiency of lashes, causes the disagreeably raw and bald appearance termed lippitudo. Epiphora, from ever- sion, tumefaction, or narrowing of the puncta, is a common result in these bad cases. Often, however, the disease leads to nothing w r orse than the permanent loss of a certain num- ber of the lashes. In another type the changes are quite superficial mar- ginal eczema ; the patient is liable, perhaps through life, to soreness and redness of the borders of the lids, little crusts and scales, and sometimes pustules, form at the roots of the lashes, whose growth, however, is not interfered with. In such people the eyes look weak or tender ; the condition is made worse by exposure to heat, dust, and wind, and by long spells of work. Ophthalmia tarsi generally begins in childhood, and an attack of measles is the commonest exciting cause. It sel- dom becomes severe or persistent except from neglect of cleanliness combined with a sluggish circulation; the pa- tients are generally ansemic, and often scrofulous, and the condition is then often the result of some previous more acute ophthalmia. In adults severe sycosis of the eyelids DISEASES OF THE EYELIDS. 83 may accompany sycosis of the beard, but, as a rule, no ten- dency to such disease of the skin is observed. TREATMENT. When the inflammatory symptoms are se- vere nothing has such a marked effect as pulling out all the lashes. Cases of a few weeks' standing may be cured by one or two such epilations, together with local remedies, and in old cases it gives great relief in the relapses which are so common. Local applications are always needed (1) for the removal of the scabs, (2) to subdue the inflamma- tory symptoms. A warm alkaline and tar lotion, with which the lids are to be carefully soaked for a quarter of an hour night and morning, followed by a weak mercurial ointment applied along the edges of the lids after each bathing, is an efficient plan if the mother will take pains. In bad cases painting or pencilling the border of the lid with nitrate of silver, either in strong solution, or the di- luted stick, or the use of weak silver lotion is very useful in addition to the ointment. In old cases with much epi- phora the canaliculus is to be slit up. The patients gener- ally need a long course of iron (F. 1, 2, 3; 13, 14; 18, 19, 20). A stye is the result of suppurative inflammation of the connective tissue, or of one of the glands in the margin of the lid. Owing to the close texture of the tarsus and the vascularity of the parts, the pain and swelling are often disproportionately severe and even alarming to the patient. The matter generally points around an eyelash; but if seated in a Meibomian gland, it may point either to its opening on the border of the lid or to the conjunctiva, rarely to the skin. Styes almost always show some derangement of health. Overuse of the eyes, especially if hypermetropic, is the exciting cause in some cases; exposure to cold wind in others. Styes are very apt to occur one after another in successive crops for several weeks. 84 DISEASES OF THE EYELIDS. TREATMENT. A stye may sometimes be cut short if seen quite early, by the vigorous use of an antiphlogistic lotion. A little later the attack may be shortened by thrusting a fine point of nitrate of silver into the orifice of the gland if this can be identified, the corresponding eyelash being first drawn out. But often poulticing gives most relief until the stye points, when it should be opened. The health always needs attending to, and a purgative iron mixture often suiis better than anything else. Some persons are subject to very small pustules or styes much more superficial than the above, and less closely asso- ciated with derangement of health. A Meibomian gland is often the seat of chronic over- growth, a little tumor in the substance of the lid being the result (Meibomian cyst, chalazion). In a few weeks or months the growth becomes as large as a pea, forming a firm, hemispherical, painless swelling beneath the skin. It generally causes thinning of the tissues towards the con- junctiva, and is then recognizable by a dusky patch on the inner surface of the lid. The deeper part of the gland is generally affected, the border of the lid remaining healthy; and even if the tumor happen to be close to the border, it is usually of small size. The skin is freely movable over the tumor, but occasionally the growth pushes forwards and adhesion occurs ; even then it is easily distinguished from a sebaceous cyst by the firmness of its deep attachment. During its course the cyst may inflame and even suppurate, and in the latter case it forms one variety of "stye." The same tumor may inflame several times, and finally suppu- rate and shrink. Like styes, these tumors are apt to con- tinue forming one after another. They are much com- moner in young adults than earlier or later, but they are now and then seen in infants. Patients as often apply for the disfigurement as for any discomfort which these little growths occasion. DISEASES OF THE EYELIDS. 85 TREATMENT. The cyst is to be removed from the inner surface of the lid ; in the rare cases where it points forwards the incision may be in the skin ; it never recurs. The tu- mor generally consists of a soft, pinkish, gelatinous mass, or of a gruelly or puriform fluid ; there is no cyst-wall. (See Operations.) Small yellow dots are sometimes seen on the inner surface of the lids, due to little cheesy collections in the Meibomian glands, and causing irritation by their hardness. They should be picked out with the point of a knife. Warty formations are not very common on the border of the lid, and are of little consequence except in elderly people, when they should be looked upon with suspicion as possible starting-points of rodent cancer. A small fleshy, yellowish-red, flattened growth is sometimes met with just upon the tarsal border, and apparently seated at the mouth of a Meibomian gland. It causes some irritation, and should be pared off. Cutaneous horns are occasionally seen on the skin of the eyelid; small pellucid cysts are also seen on the lid border. Molluscum contagiosum is partly an ophthalmic disease, because so often seated upon the eyelids. One or more lit- tle rounded prominences, showing a small dimpled orifice at the top, usually plugged by dried sebaceous matter, are seen in the skin, varying from the size of a mustard seed to a cherry, but usually not larger than a sweet pea; at first they are hemispherical, but afterwards become con- stricted at the base. The skin is tightly stretched, thinned, and adherent. The larger specimens sometimes inflame } and their true nature may then, without due care, be mis- taken. Each molluscum must be removed, the white lobu- lated, gland-like mass which forms the growth being squeezed out through the incision made by a knife or scis- sors. 8 86 DISEASES OF THE EYELIDS. Xanthelasma palpebrarnm appears as one or more yel- low patches like pieces of washleather in the skin, varying from mere dots to the size of a kidney bean, quite soft in texture, and only a very little raised. They are common- est near the inner canthus, and unless symmetrical are usually on the left side. They occur chiefly in elderly per- sons who have previously been liable to become often very dark around the eyes when out of health. The patches are due to infiltration of the deeper parts of the skin by groups of cells loaded with yellow fat. The frequency of xanthelasma in the eyelids is, perhaps, related to the nor- mal presence of certain peculiar granular cells, some of which contain pigment, in the skin of these parts. The pediculus pubis (crab-louse), if it happens to reach the eyelashes will flourish there. The lice themselves cling close to the border of the lid, and look like little dirty scabs. The eggs are darkish, and may also be mistaken for bits of dirt. The absence of inflammation and the rather peculiar appearances will lead, in cases of doubt, to the use of a magnifying glass, which will settle the question at once. Ulcers on the eyelids may be malignant, or lupous, or syphilitic, and in the last case the sore may be either a chancre or a tertiary ulcer. Rodent cancer (rodent ulcer, flat epithelial cancer) is by far the commonest form of carcinoma affecting the eyelids, although cases are occasionally seen of which both the clinical and pathological characters are those of ordinary epithelioma. The peculiarities of rodent cancer are, that it is very slow, that ulceration almost keeps pace with the new growth, and that it does not cause infection of lym- phatics. It seldom begins before, generally not until con- siderably after, middle life, and its course often extends over many years. Beginning as a "pimple" or "wart," it slowly spreads, but some years may pass before the ulcer DISEASES OF THE EYELIDS. 87 is as large as a sixpence. When first seen we generally find a shallow ulcer involving the border of the lid, and covered by a thin scab. It is bounded by a raised sinuous edge, which is nodular and very hard, but neither inflamed nor tender. Slowly extending both in area and depth, it attacks all tissues alike, finally destroying the eyeball and opening into the nose. In a few very chronic cases the disease remains quite superficial, and cicatrization may occur at some parts of the ulcerated surface. Now and then a considerable nodule of growth forms in the skin before ulceration begins. The diagnosis is generally quite easy. A long-standing ulcer of the eyelids in an adult is nearly certain to be rodent cancer. Tertiary syphilitic ulcers are much less chronic, more inflamed and punched out, and devoid of the very peculiar hard edge of rodent ulcer ; moreover, they are very uncommon. Ltipus seldom occurs so late in life as rodent cancer, presents more inflammation and much less hardness, and is often accompanied by lupus elsewhere on the cutaneous or mucous surfaces. Lupus is seldom difficult to distinguish on the eyelids from tertiary syphilis, the latter being more acute, more dusky, and showing more loss of substance, with none of the little, ill-defined, soft tubercles seen in lupus. When a chancre occurs on the eyelid the induration and swelling are usually very marked ; the surface is abraded and moist, but not much ulcerated ; the glands in front of the ear and behind the jaw become much enlarged. The same glands enlarge, either with or without suppuration, in lupus, and in many inflammatory conditions of the lid. TREATMENT OF RODENT CANCER. Early removal is of great importance, and probably the more so in proportion to the youth of the patient. Chloride of zinc paste or the actual cautery is necessary in addition to the knife in bad cases; scraping may also be employed. The disease is 88 DISEASES OF THE EYELIDS. very apt to return locally. Even in very advanced cases, where complete removal is impossible, the patient may be made much more comfortable, and life probably prolonged, by vigorous and repeated treatment. Congenital ptosis is a not very rare affection. It is com- monly unilateral, is stated to have been present at birth, and its causation is unknown. It sometimes diminishes markedly in the first few years of life, but probably sel- dom disappears. It is customary to remove an elliptical piece of skin from the lid, and improvement is gained, es- pecially in the slighter cases, by this procedure. Other more severe operations have also been devised. Epicanthus is a rare condition, in which a fold of skin stretches across from the inner end of the brow to the side of the nose and hides the inner canthus. If it does not disappear as the child's nose develops, an operation re- moval of a piece of skin from the bridge of the nose (some- times combined with canthoplasty) is indicated. DISEASES OF LACHRYMAL APPARATUS. 89 CHAPTER VI. DISEASES OF THE LACHRYMAL APPARATUS MAY be divided into those which affect the secreting parts the lachrymal gland and its ducts ; and those in which the drainage apparatus is at fault the puncta, canaliculi, lachrymal sac, and nasal duct. In the great majority of cases the fault lies entirely in the drainage system. The flow of tears over the edge of the lid and down the cheek has been called epiphora when due to over-secretion by the gland, and stilliddium lacrymarwn when caused by obstruction to an outflow. No useful purpose is served by keeping the two names, and only the former will be here used. Lachrymation is a convenient term for the increased flow which accompanies superficial inflammation of the eyeball. (1) The lachrymal gland is occasionally the seat of acute or chronic inflammation, and in either case an abscess may form. In chronic cases the enlarged gland is dis- tinctly felt projecting, and can generally be recognized by its well-defined and lobulated border; but the enlargement cannot always be distinguished from that caused by a mor- bid growth in the gland or corresponding part of the orbit. In acute inflammation there are the usual signs local heat, tenderness, and pain with swelling which may obscure the boundaries of the gland. If the enlargement be great, the eyeball is displaced, and the oculo-palpebral fold of conjunctiva in front of the gland is pushed downwards, and projects more or less between the lid and the eye. 8* 90 DISEASES OF LACHRYMAL APPARATUS. When an abscess forms it may sometimes be opened from the conjunctiva, but more often it points to the skin, through which the incision must then be made. If it be allowed to burst spontaneously through the skin a trouble- some fistula may follow. A little abscess sometimes forms in one of the separate anterior lobules, the main body of the gland remaining free. There is limited swelling and tenderness of the lid at the upper outer angle, not passing back beneath the orbital rim ; the abscess points through the conjunctiva, above the outer end of the tarsal cartilage, and is thus dis- tinguished from a suppurating Meibomian cyst. Very rarely cystic distention of one or more of the gland-ducts is seen in the form of a bluish, semi-transparent swelling (Dacryops), just beneath the conjunctiva of the lid at the upper outer part. No change in the lachrymal secretion appears to have been noticed in cases of paralysis of the cervical sympathetic nerve. (2) The drainage system may be at fault in any part from the puncta to the lower end of the nasal duct. The slightest change in the position of the lower punctum causes epiphora. In health the punctum is directed back- wards against the eye ; if it look upwards or forwards the tears do not all reach it, and some will then flow over a lower part of the lid. In paralysis of the facial nerve the patient sometimes comes to us for epiphora ; the symptom is caused partly by loss of the compressing and sucking action effected by winking, partly by a slight falling of the lid away from the eye, and a consequent change in the position of the punctum. These patients sometimes notice the " watery eye " before they discover the other symptoms. The various chronic diseases of the border of the lids (oph- thalmia tarsi), and also granular disease of the conjunctiva (granular lids), are fertile sources of (1) tumefaction with narrowing of the puncta and canaliculi; (2) cicatricial DISEASES OF LACHRYMAL APPARATUS. 91 stricture of the same parts ; and in both cases the puncta are displaced as well as constricted. Narrowing, even to complete obliteration of the puncta, is sometimes seen as the result of former inflammation, of which all traces have long since passed away. Wounds by which the canaliculi are cut across cause their obliteration, and epiphora is the result. In all the above cases the epiphora is accompanied by a visible change in the size or position of the punctum, none of the symptoms of inflammation in the lachrymal sac or stricture in the nasal duct being present ; and simple divis- ion of the canaliculus will cure or much relieve the water- ing eye (see Operations). This measure is, however, seldom necessary in the epiphora of facial paralysis. Epiphora not explained by any of the above changes is in most cases caused by obstruction in the nasal duct, with or without disease of the lachrymal sac. Disease of the sac is rarely primary. It is generally due either to retention of secretion caused by stricture of the duct below, or to the mucous membrane participating in a chronic inflammation of the conjunctiva, or of the Schnei- derian membrane. Obstruction of the nasal duct is usually caused by chronic thickening of the mucous and submucous tissues lining the canal. Dense, hard thickening causes a stricture, often very tight and unyielding, but obstruction is common with the canal of full size or even dilated, and in these excess of mucus seems to be the chief cause. Disease of the duct is commonest after middle life. In some cases the change evidently forms a part of a chronic disease of the neighbor- ing mucous membrane, but in a large number no cause can be assigned. Sometimes stricture is the result of periostitis or of necrosis, and of these conditions syphilis (either acquired or inherited), scarlet fever, and smallpox are the 92 DISEASES OF LACHRYMAL APPARATUS. commonest causes. Injuries to the nose account for a few cases. A stricture may be seated at any part of the duct, but the upper end, where there is often a natural narrowing, is the commonest spot. Obstruction of the nasal duct, by preventing the escape of tears, leads to distention of the lachrymal sac, to chronic thickening of its lining membrane, and increased secretion of mucus. The mucus may be clear or turbid. A point is reached at length when the distention can be seen as a little swelling under the skin at the inner canthus (mucocele or chronic dacryo-cystitis). This swelling can generally be dispersed by pressure with the finger, the mucus and tears either regurgitating through the canaliculus or being forced through the duct down into the nose. In cases of old stand- ing the sac is often much thickened, and may contain polypi, and the swelling cannot then be entirely dispersed by pressure. A mucocele is always very apt to inflame and suppurate, the result being a lachrymal abscess. Most cases of lachrymal abscess, indeed, have been preceded by mucocele. Its formation gives rise to great pain, and to tense, brawny, dusky swelling, which, extending for a considerable dis- tance around the sac, is sometimes mistaken for erysipelas. The matter always points a little below the tendo palpe- brarum; the pus often burrows in front of the sac, forming little pouches in the cellular tissue, and if allowed to open spontaneously a fistula, very troublesome to cure, is likely to follow. If seen early, before there is decided pointing, it is best to open the abscess by slitting the lower canali- culus freely into the sac, and passing a knife down the nasal duct ; anaesthesia is usually necessary. If interfer- ence be delayed, the skin over the sac soon becomes thinned, and the abscess is then best opened through the skin by a free puncture inclined downwards and a little outwards ; DISEASES OF LACHRYMAL APPARATUS. 93 no anaesthetic is necessary, and the resulting scar is insig- nificant. When the thickening has subsided, under the use of warm lead lotion dressing, the stricture of the duct is treated ; but the former condition of mucocele will recur, and another abscess may form at any time unless a free passage can be restored down the nasal duct. TREATMENT OF MUCOCELE AND LACHRYMAL STRICT- URE. The object aimed at is the permanent dilatation of the stricture, but whether this can be gained or not a free opening from the canaliculus into the sac should be main- tained, that the secretions may be often and easily squeezed out. Dilatation by probing (see Operations) is the ordinary and best treatment for all strictures, whether there be mucocele or not, the rule being to use the largest probe that will pass readily. The probing is repeated every few days or less often, according to the duration of its effect, and often needs to be continued for weeks or months. The pa- tient may sometimes learn to use the probe himself. When the stricture is tough and tight it is best at once to divide it by thrusting a strong-backed, narrow knife down the duct, and afterwards to use probes. In cases where the stricture is quite soft, and the obstruction due rather to general thickening of the mucous membrane and over- secretion of mucus than to dense fibrous thickening, the occasional passage of a very large probe, or frequent wash- ing out of the duct with water or weak astringents by means of a lachrymal syringe, is beneficial. The diligent and long use of astringent lotions to the conjunctiva is also useful particularly in soft strictures, as some of the lotion reaches the sac and duct. In cases of long standing, where all other treatment has failed and the lachrymal sac is much thickened, its complete obliteration by the actual cautery gives great relief; extirpation of the lachrymal gland is also occasionally practised. For refractory children and for 94 DISEASES OF LACHRYMAL APPARATUS. patients who cannot be seen often, a style of silver or lead, passed in exactly the same way as a probe, but worn con- stantly for many weeks, is sometimes very useful ; but it may slip into the sac out of reach unless furnished with a bend or head so large as to be somewhat unsightly. As a rule, probing is not to be begun until the inflammatory thickening and tenderness following a lachrymal abscess have subsided. It must be confessed, however, that in a considerable proportion of lachrymal cases, whether the stricture be soft or firm, the final results of all treatment are but palliative, and that the benefit obtained is not always worth the pain and inconvenience. Suppuration of the lachrymal sac, on one or both sides, sometimes takes place in new-born infants without apparent cause ; if there be much redness, the abscess should be opened, but the suppuration is sometimes chronic, and will cease under the use of astringent lotions. The cases of epiphora with contracted punctum, which are sometimes met with in older children, may perhaps be the conse- quences of this infantile suppuration. Cases in which the sac or duct is obliterated by injury can seldom be relieved. DISEASES OF THE CONJUNCTIVA. 95 CHAPTER VII. DISEASES OF THE CONJUNCTIVA MAY be divided into those which from the outset are general and affect the whole membrane, ocular and palpe- bral alike, and of which the various forms 01 contagious ophthalmia are examples ; and those which primarily affect either the ocular or the palpebral part alone. The term "ophthalmia" includes all inflammations of the conjunctiva, and should not be applied to any other diseases. GENERAL DISEASES. The conjunctiva, like the urethra, is subject to purulent inflammation, and, like the respiratory mucous membrane, is liable to the muco-purulent and to the membranous or diphtheritic forms of disease. All cases in which there is yellow discharge are in greater or less degree contagious. The congestion, which forms a part of conjunctivitis, is much influenced by age ; the younger the patient the less is the congestion in proportion to the discharge, a fact to be borne in mind in examining patients at both ends of the scale. Purulent ophthalmia (O. neonatorum, Gonorrhoeal O., Blennorrhrea of the conjunctiva) is generally due to con- tagion from the same disease, or from an acute or chronic discharge from the urethra or vagina, whether gonorrhceal or not. Muco-purulent ophthalmia when quickly passed on from one to another under conditions of health favorable to suppuration (e. g., weakness after acute exanthems) may be intensified into the purulent form. Gonorrhoea has been 96 DISEASES OF THE CONJUNCTIVA. experimentally produced by inoculation with pus from purulent ophthalmia. Some animals are subject to puru- lent ophthalmia, but it is said that the discharge from the human disease, and even from gonorrhoea, gives no result on the conjunctiva of rabbits. Like gonorrhrea, purulent ophthalmia may occur more than once. It varies greatly in severity, but is, on the whole, much milder in babies than in older persons. The quality of the infecting dis- charge no doubt has much influence, severe forms being generally caused by inoculation from a recent or severe case ; but chronic discharge may also give rise to a severe attack. The health of the recipient and the previous con- dition of the eyelids exert an important influence ; if the lids be granular, various slight causes sometimes bring on severe purulent ophthalmia. The disease sets in from twelve to about forty-eight hours after inoculation ; in infants the third day after birth is al- most invariably given as the date when discharge was first noticed. Itchiness and slight redness of conjunctiva soon pass on to intense congestion of conjunctiva with chemosis, tense inflammatory swelling of the lids, great pain, and discharge. The discharge at first is serous, or like turbid whey, but soon becomes more profuse, creamy (purulent), and yellow, or even slightly greenish. Dark, abrupt ecchy- moses are often present. The lids, always swollen, hot and red, in bad cases become very tense and dusky. The upper lid hangs down over the lower, and is often so stiff that it cannot be completely everted. The conjunctiva is succu- lent, and easily bleeds. The disease, if untreated, declines spontaneously, and the discharge almost ceases in about six weeks, the palpe- bral conjunctiva being left thick, relaxed, and more or less granular. Cicatricial changes, identical with, but less se- vere than, those resulting from chronic granular lids, and analogous to what occurs in stricture of the urethra, some- DISEASES OF THE CONJUNCTIVA. 97 times follow; considerable permanent thickening of the ocular conjunctiva may also occur. There is a great risk to the cornea in this disease, partly from strangulation of the vessels, partly from the local influ- ence of the discharge. If within the first two or three days the cornea becomes hazy and dull, like that of a dead fish, there is great risk that total or extensive sloughing will occur. In milder cases, ulcers, often transparent, frequently form near the margin, and rapidly cause perforation. In many of the slighter cases, such as are seen in infants, no corneal damage occurs. Either one or both eyes may be attacked ; in adults one eye often escapes ; in infants, where the inocu- lation occurs during birth, both eyes almost always suffer. TREATMENT. If oaly one eye be affected, and the patient be old enough to obey orders, the sound eye must be cov- ered up with the shield introduced by Dr. Buller; take two pieces of India-rubber plaster, one 4i ", the other 4" square ; cut a round window in the middle of each, and stick them together, with a small watch-glass inserted into the window. The plaster is fixed by its free border and by other strips to the nose, forehead, and cheek, and the patient looks through the glass ; the lower outer angle is left open for ventilation ; particular attention is to be paid to the fasten- ing on the nose. All concerned are to be warned as to the risk of contagion and the means of conveying it. The es- sential curative measures are : (1) Frequent removal of the discharge by the free use of water. Every hour, day and night, or in adults every two hours, the lids are gently opened and the discharge removed with soft bits of moist- ened rag or cotton wool ; or a syringe or irrigation appa- ratus may be used. In adults, where the swelling is often extreme and very brawny, we may increase the congestion and irritability by interfering oftener than every two hours. (2) The frequent anointing of the lids with a simple oint- ment. (3) The use of astringent or antiseptic lotions once 9 98 DISEASES OF THE CONJUNCTIVA. ail hour, or every two or three hours, according to the case and the nature and strength of the solution. The lotion may be alum (eight or ten grains to the ounce), or sulphate of zinc and alum, used very freely every hour or two; or corrosive sublimate (one-eighth or one-quarter of a grain) ; or chloride of zinc (two grains, with just enough dilute hy- drochloric acid to make a clear solution), used freely every two or three hours; or pure carbolic acid, 5 per cent., every hour; or nitrate of silver (two grains), four or six times a day. Many surgeons greatly prefer the last to all others. (4) Strong solutions of nitrate of silver, or the mitigated solid nitrate (F. 1 and 2), are of great service in shortening the attack and lessening the risks, and should be used in all severe cases unless specially contraindicated. A ten- or twenty -grain solution is brushed freely over the conjunctiva of the lids everted as well as possible, and freed from dis- charge. If the mitigated stick is used, more care is needed ; and, to prevent too great ail effect, it is to be washed off with water after waiting about fifteen seconds. These strong applications must be made by the surgeon; the pain caused by them is lessened and the beneficial effect increased by free bathing with cold or iced water after- wards. The application is not to be repeated until the discharge, which will be arkedly lessened for some hours, has begun to increase again ; it is seldom needful or justi- fiable more than once a day. (5) Local cold by iced water or thin ice compresses ; in severe cases to be used almost constantly, in milder cases frequently for periods of half an hour. This plan, but little adopted in our hospital prac- tice, is very highly spoken of as most efficacious, if begun early and carried out well ; but if only half done, it is use- less and disagreeable. Hot fomentations are sometimes better than cold. (6) In the early stage, in adults, several leeches to the temple will give relief; or, if the swelling be very tense, we may divide the outer canthus with scissors DISEASES OF THE CONJUNCTIVA. 99 or knife, and thus botli bleed and relax the parts at the same time. Scarification of the palpebral conjunctiva and radial incisions in the ocular conjunctiva may be tried. Mr. Critchett has, in very bad cases, gone so far as to di- vide the upper lid vertically across, and keep its two halves turned upwards by means of sutures fastened to the forehead. The following additional precautions are important : Strong nitrate of silver applications are unsafe in the ear- liest stage, before free discharge has set in, and also in cases where, even later in the disease, there is much hard, brawny swelling of the ocular conjunctiva, and comparatively little discharge ; cases, in fact, approaching the condition known as diphtheritic ophthalmia. In these, either very cold or very hot applications, leeches, cleanliness, and weak lotions should be chiefly relied upon. Ice and leeches are seldom advisable for infants. It is of extreme importance to begin treatment very early, for the cornea is often irreparably damaged within two or three days. The patients, if adults, are often in feeble health, and need supporting treatment. Ulceration of the cornea does not contraindicate the use of strong nitrate of silver if the discharge is abundant. Treat- ment must be continued so long as there is any discharge, or the conjunctiva of the lids remains fleshy, for a relapse of purulent discharge often takes place if remedies are dis- continued too soon. Muco-purulent ophthalmia. The commonest and best characterized of the acute ophthalmias is the so-called catarrhal ophthalmia. The name is a bad one, for neither does the disease form part of a general catarrh of the re- spiratory tract, nor does it show the tendency to relapse so characteristic of catarrh, nor does it seem to be caused by cold. The disease attains its height very quickly, almost always attacks both eyes, and gets well spontaneously in about a fortnight. There is great congestion, much gritty 100 DISEASES OF THE CONJUNCTIVA. pain, which often prevents sleep, spasm of the lids, free, muco-purulent discharge, and, in many cases, ecchymotic or thrombotic patches in the conjunctiva. The lids are somewhat swollen and red, but never tense, and the cornea seldom suffers. This disease is apparently far more contagious than pur- ulent ophthalmia, for which it is sometimes mistaken. It varies much in severity, even in different members of the same household, who catch it almost at the same time, but attacks all ages indiscriminately. It is, I believe, common- est in warm weather, or perhaps at the change from cold to warm. It is rare to find that the patient has suffered from the disease before. Any mild astringent lotion will cut it short. Troublesome ophthalmia, ivith muco-purulent discharge, is common in children after exanthemata, especially measles. It runs a less definite course than the preceding disease, shows but little tendency to spontaneous cure, rifed s very often complicated with phlyctenular ulcers of the cornea, blepharitis, and eruptions on the face; and the patients are frequently strumous. The discharge is seldom so abundant as in the disease just considered. The treatment is often troublesome, and many changes have to be tried ; weak nitrate of silver lotions (F. 3), with the use of yellow oint- ment (F. 10), or boracic acid ointment, both to the skin and conjunctiva, or calomel dusted into the eye, are the best local means; atropine often increases the irritation. Careful attention to health is necessary. The patient should not be confined to the house, but, with a large shade over both eyes, should take plenty of exercise in fine weather. The eyes should not be bandaged in any form of ophthalmia; and poultices are very seldom suitable. Some forms of acute conjunctivitis, with little or no dis- charge, are seen both in children and adults, which do not conform to the above types, and are of comparatively slight DISEASES OF THE CONJUNCTIVA. 101 importance. Many such appear to depend on changes of weather or exposure to cold, and are complicated with phlyctenulse. A few are distinctly rheumatic. The con- junctiva is involved more or less in herpes zoster of the ophthalmic division of the fifth nerve, in erysipelas of the face, in the early stage of measles, and slightly in eczema of the face. Slight degrees of chronic conjunctivitis are set up by various local irritants, dust, smoke, cold wind, etc., and by the strain attending the use of the eyes without glasses in cases of hypermetropia. Mention must be made of the not very common cases in children, where an oph- thalmia appears to form part of an irnpetiginous or herpetic eruption on the face, with which it is simultaneous. These differ from the ordinary instances in which the lids, cheek, and lining membrane of the nose are irritated into an eruption by tears and discharge from a pre-existing con- junctivitis. Muco-purulent ophthalmia, of any kind, becomes a very important affair if it breaks out in schools or armies, etc., where granular disease of the eyelids is prevalent (p. 105). Membranous and diphtheritic ophthalmia. In a few cases of ophthalmia, either purulent or muco-purulent, the discharge adheres to the conjunctiva in the form of a mem- brane (membranous or croupoiis ophthalmia). Still more rarely, in addition to the membrane on the surface, the whole depth of the conjunctiva is stiffened by solid exuda- tion, which much impairs the mobility of both the lids and eyeball, and, by compressing the vessels, prevents the formation of free discharge, and places the nutrition of the cornea in great peril. It is to the latter cases that the term diphtheritic is limited by most authors ; but we find many connecting links between the two types above defined, and between each of them and the ordinary purulent and muco- purulent cases. It is of much consequence in practice, both for prognosis 102 DISEASES OF THE CONJUNCTIVA. and treatment, to recognize the presence of membranous discharge and of solid infiltration, in any case of ophthal- mia; for the liability to severe corneal damage is much increased by both these conditions, and especially by the latter. When membrane is present, it may cover the whole inside of the lids, or it may occur in separate or in conflu- ent patches ; it often begins at the border of the lid, and is seldom found on the ocular conjunctiva. It can be peeled off, and the conjunctiva beneath bleeds freely, unless infil- trated and solid ; in the latter case the membrane is more adherent, the conjunctiva is of a palish color, and scarcely bleeds when exposed, and there is little or no purulent dis- charge. In most cases the solid products, whether mem- brane or deep infiltration, pass after some days into a stage of liquefaction, with free purulent secretion. In rare cases the membrane forms and re-forms for months. As regards cause, (1) very rarely the process creeps up to the conjunc- tiva from the nose in cases of primary diphtheria, or is caused by inoculation of the conjunctiva with membrane; Avhilst in a few the ophthalmia forms the first symptom of general diphtheria, or of masked or anomalous scarlet fever. (2) Much more commonly it is part of a diphtheritic type of inflammation following some acute illness. (3) It may be caused by the over-use of caustics in ordinary puru- lent ophthalmia (p. 99). (4) It may be due to contagion, either from a similar case or from a purulent ophthalmia, or a gonorrhea, the membranous or diphtheritic type de- pending on some peculiarity in the health or tissues of the recipient. Membranous and diphtheritic ophthalmia are seen most often in children from two to eight years old, sometimes in young infants, and less commonly in adults. It is commoner in North Germany than in other parts of Europe, but very severe and even fatal cases occur in our own country. In treatment the cardinal point is not to use nitrate of DISEASES OF THE CONJUNCTIVA. 103 silver in any form when there is scanty discharge and much solid infiltration of the conjunctiva. The agents to be re- lied upon are (1) either ice or hot fomentations; ice, if it can be used continuously and well ; fomentations, to encour- age liquid exudation and determination to the skin if the cold treatment cannot be carried out, or fails to make any impression on the case ; (2) leeches, if the patient's state will bear them ; (3) great cleanliness. The presence of membrane is no bar to the use of caustics, provided that the conjunctiva is succulent, red, and bleeds easily. Mr. Tweedy strongly advises quinine lotion used very frequently (F. 21). The local use of atropine sometimes gives rise to a pecu- liar inflammation of the conjunctiva and skin of the lids "atropine irritation." The conjunctiva of the lids becomes vascular, thickened, and even granular, the skin reddened, slightly excoriated, somewhat shining, but lax. This effect of atropine is commonest in old people. Some persons are very susceptible and cannot bear even a drop or two with- out suffering in some degree. Daturine and duboisiu cause less irritation and may be used instead, unless it be safe to disuse all mydriatics for a few days. An ointment con- taining some lead and zinc should be applied to the lids, and zinc or silver lotion to the conjunctiva; in other cases glycerine to the skin suits better than ointment. Eserine sometimes causes identical symptoms. This condition is said to be prevented by adding a very little carbolic acid (. 1 per cent.) to the solutions. Granular ophthalmia (trachoma) is a very important malady, characterized by slowly progressive changes in the conjunctiva of the eyelids, in consequence of which this membrane becomes thickened, vascular, and roughened by firm elevations, instead of being pale, thin, and smooth. The change usually begins in the follicular structures of the conjunctiva of the lower lid, extending to the papilla? 104 DISEASES OF THE CONJUNCTIVA. and the submucous tissue of both lids at a later period, and giving rise to the growth of much organized new tissue in the deep parts of the conjunctiva. This tissue is afterwards partly absorbed and partly converted into a dense tendinous scar, which by very slow shrinking often gives rise to much trouble. It is important to remember that the conjunctiva in this disease does not ulcerate, and that the prominences are not "granulations" in the pathological sense. The disease is first shown by the presence on the lower lid of a number of rounded, pale, semi-transparent bodies like little grains of boiled sago, or sometimes looking like vesicles; the so-called "vesicular," or "sago-grain," or "follicular" granulations (Fig. 35). Some of these appear Pie. 35. Granular lower lid (after Eble). to be lymphatic, others tubular mucous follicles. They are, to a certain degree, normal, and are seen, especially on the lower lids, in many young persons with slight ophthal- mia who never afterwards suffer from true granular lids. Such mild cases in which no parts deeper than the follicles and papillae are affected, and in which recovery takes place without cicatricial changes, are by some distinguished authors placed, under the name of conjunctivitis follicularis, in a separate category from the granular disease. The latter disease is held on this hypothesis to depend on a different morbid process, th'e growths or "granulations" bearing no relation to lymph-follicles. But the frequent coincidence of transition forms in the same case, the fact DISEASES OF THE CONJUNCTIVA. 105 that both follicular conjunctivitis and well-marked granular disease admittedly occur under the same general conditions, and that in a given case the distinctions between " follicles " and " granulations " often cannot be made until it is known whether or not cicatricial changes will occur, certainly much lessen the clinical value of the asserted pathological difference. Granular disease is very important because it greatly in- creases the susceptibility of the conjunctiva to take on acute inflammation and to produce contagious discharge, makes it less amenable to treatment, and very liable to relapses of ophthalmia for many years, and often gives rise to deform- ities of the lid and to serious damage of the cornea. So vulnerable is the granular conjunctiva that it is rare in ordinary practice to see granular lids of long standing without the history of an acute ophthalmia at some pre- vious time, though many such may be seen in crowded schools, etc. Chronic granular disease is the result (1) of prolonged overcrowding, or rather of long residence in badly venti- lated and damp rooms ; it used to be very abundant in the army and navy, and is still seen in great perfection in workhouse schools ; (2) a generally low state of health, no doubt, increases the susceptibility to it ; (3) it is, ccderis paribus, commonest and most quickly produced in children ; (4) certain races are peculiarly liable to suffer, e. g., the Irish, the Jews, and some other Eastern races, and some of the German and French races. The Irish and Jews carry it with them all over the world, and transmit the liability to their descendants wherever they live. Negroes in America are said to be almost exempt ; (5) damp and low-lying climates are more productive of it than others ; thus it is rare in Switzerland. Possibly what are now race tendencies may be the expression of climatal conditions acting on the same race through many generations. When DISEASES OF THE CONJUNCTIVA. accompanied by discharge the disease is contagious, but not otherwise ; and it is generally held that the discharge from a case of trachoma is specific, i. e., that it will give rise by contagion, not only to muco-purulent or purulent ophthal- mia, but to the true granular disease. This point is a very difficult one to decide, but my own experience inclines me to accept the view, at least for some cases. Those who practise in the army, or who have charge of such institutions as pauper schools, will find that in prac- tice the causes of the chronic granular condition are inex- tricably mixed up with all kinds of facilities for contagion, and that it will be necessary to fight against two enemies the causes of spontaneous granular disease, and the sources of contagious discharge. The former is to be com- bated by improved hygienic conditions, especially by free ventilation, dry air, abundant open-air exercise, and im- provement of the general vigor. The sources of contagion are endless, especially since, as has been stated, granular patients are liable to relapses of muco-purulent discharge from almost any slight irritation. Frequent inspection of all the eyes, rigid separation of all who show any discharge or are known as especially subject to relapses; such arrange- ments for washing as will prevent the use of towels and water in common, extreme care against the introduction of contagious cases from without such are the chief pre- ventive measures. Extra precautions will be needed in time of war or famine, or when measles or scarlet fever are prevalent, or during marches through hot, sandy, or windy districts. The curative treatment, when discharge is present, does not differ from that of the acute ophthalmias already given. The use of strong astringents (solid sulphate of copper) or caustics (nitrate of silver in strong solution, or in the miti- gated solid pencil), however, is generally needed in order to make much impression on the granular state of the lids. DISEASES OF THE CONJUNCTIVA. 107 The lids, being thoroughly everted, are touched all over with one or other application, and this is repeated daily, or less often, according to the case. Some practice is re- quired before we can decide on the needful frequency for each case. By careful treatment on this principle, most patients may be kept comfortably free from active symp- toms, many relapses may be prevented, the duration of the disease shortened, and the risks of secondary damage to the cornea much lessened. Do what we will, however, granu- lar disease, when well established, is most tedious, and fas- tens many risks and disabilities on its subjects for years to come. For routine treatment on a large scale, nothing is so effectual as nitrate of silver, either a ten- or twenty-grain solution, or the mitigated solid point (F. 1 and 2). But silver has the disadvantage of sometimes permanently staining the conjunctiva after long use, and in very chronic cases I think either sulphate of copper or the lapis divinus (F. 5) is to be preferred, especially as the patient may sometimes be taught to evert his own lids and use it him- self. The solid mitigated nitrate of silver needs washing off with water at first (p. 98), but in old cases it is often better not to do so. Results of granular disease. Friction by the granula- lations of the upper lid (a, Fig. 36), especially in cases of FIG. 36. Granular upper lid, with scarring. long standing where some scarring is present (&), often causes cloudiness of the cornea, partly from ulceration, but 108 DISEASES OF THE CONJUNCTIVA. mainly from the growth of a layer of new and very vascu- lar tissue, just beneath the epithelium (pannus) (Fig. 37). In later periods the conjunctiva and deeper tissues are shortened and puckered by the scar following absorption of the "granulations." These changes, when severe, often lead to inversion of the border of the lid (entropion*) ; when FIG. 37. Ept. 'Scl. Section showing layer of new and vascular tissue (pannus) between epithelium (Ept.) and cornea ((7.). Scl. sclerotic ; CM. ciliary muscle; Sch. C. Schlemm's canal; /. iris. X about 10 diameters. slighter, some or all of the lashes may be distorted so as to rub against the cornea, without actually turning inwards (distichiasis, trichiasis) ; and these conditions are often combined with pannus. Pannus begins beneath the upper lid, its vessels are superficial and continuous with those of the conjunctiva, and are distributed in relation to the parts covered by the lid, not in reference to the structure of the cornea (Fig. 38). The proper corneal tissue suffers but little except where ulcers occur; but when the vascularity is extreme, it may soften and bulge even without ulcerating. Pannus disappears when the granular lid, or the dis- placement of lashes, is cured. Very severe and universal pannus is sometimes best treated by artificial inoculation with purulent ophthalmia, the inflammation being followed by obliteration of vessels and clearing of the cornea ; but this treatment needs great judgment and caution. Removal of a zone of conjunctiva and subconjunctival tissue (syn- dectomy, peritomy} from around the cornea is free from risk and sometimes very beneficial in old cases which, though DISEASES OF THE CONJUNCTIVA. 109 severe, are not bad enough for inoculation. In old cases of granular disease, even where no complications have arisen, the upper lids often droop from relaxation of the FIG. 38. Pannus affecting upper half of cornea. loose conjunctiva above the tarsal cartilage, and the patient acquires a sleepy look. For the cure of the displaced lashes and incurved eyelid we may (1) repeatedly pull out the lashes with forceps ; (2) extirpate all the lashes by cutting out a narrow strip of the marginal tissues of the lid ; or (3) attempt by opera- tion to restore the parts to their proper positions (see Ope- rations). These operations for restoring the lashes to their normal direction often give only temporary relief, chiefly because the inner surface of the lid continues to shorten, and thus the original state of things is sooner or later reproduced. Chronic conjunctivitis, chiefly of the lower lid, is a com- mon disease, especially in elderly people. There is more or less soreness and smarting, a very little discharge, red- ness and papillary roughness of the inner surface of the lid or of both lids, but no true trachoma granulations. The caruncle is red and fleshy, as it is in all forms of palpebral conjunctivitis, and there is often soreness of the lids at the canthi. Lapis divinus is one of the best applications, and yellow ointment is sometimes useful (F. 5 and 10). 10 110 DISEASES OF TI1E COKNEA, CHAPTER VIII. DISEASES OF THE CORNEA. A. ULCERS AND NON-SPECIFIC INFLAMMATORY DISEASES. INFLAMMATION of the cornea may be circumscribed or diffuse, and, though usually affecting the proper corneal tissue, may be limited to the epithelium on either of its surfaces. It may be a local process leading to formation of pus, or to ulceration ; or the expression of a constitutional disease, such as inherited syphilis ; or it may form part, and perhaps only a minor part, of disease involving also the deeper parts of the eyeball the iris (kerato-iritis), or sclerotic (sclero-keratitis), for example. The different varieties of corneal ulceration and suppura- tive inflammation form a very large and important con- tingent of ophthalmic cases. The fact that the cornea, although a fibrous structure, is further removed from the bloodvessels than almost any other tissue, renders it ex- tremely susceptible to disturbances of nutrition whether from defective supply or bad quality of blood. Lastly, the surface of the cornea is so delicate, and its perfect trans- parency and regularity so important, that slight injuries and irritations are of more moment here than in any other part of the body. When inflamed the cornea always loses its transparency. If only the anterior epithelium is involved, the surface loses its polish and looks like clear glass which has been breathed upon " steamy," or finely pitted. This steami- ness occurs in many states of disease. DIS EASES OF THE CORNEA. Ill Thickening of the epithelium, and, still more, exudation into the corneal tissue, are shown by a white, grayish, or yellowish tint. If the corneal tissue be opalescent, while the surface is at the same time " steamy," the term " ground-glass " gives a good idea of the appearance, though to make the simile correct the glass ought to be milky throughout, as well as ground on the surface. Rapid suppurative inflammation is preceded by a stage of diffused opalescence, and this ap- pearance is therefore a very dangerous sign in such diseases as purulent ophthalmia, severe burns, or paralysis of the fifth nerve. Before describing the most important types of corueal ulcer, it is convenient to mention the principal changes at- tendant on ulceration of the cornea in general. An ulcer of the cornea is preceded by a stage of infiltration, and the inflamed spot is generally a little raised. After the centre of the spot has broken down into an ulcer, some infiltration remains at its base and edges, the quantity and color of which help us to judge of the probable course of the case. When the ulcer heals it leaves a hazy or opaque spot (leucoma if dense, nebula if faint), which is slight and will often disappear entirely if superficial, but will in part be permanent if it result from a deep ulcer. These opacities are likely to clear, cceteris paribus, in proportion to the youth of the patient ; time also is a very important element, nebulae often continuing to clear slowly for years. Local stimulation aids in the removal of the opacities, one of the best applications being the ointment of yellow oxide of mercury (F. 10). Some ulcers have scarcely any infiltra- tion, and these for the most part heal slowly with little or no opacity ; but they often cause permanent loss of sub- stance, and this is shown by the presence of a facet or flat- tened spot at the seat of the former ulcer. Such a facet, even though quite clear, will, if it lies over the pupil, in- 112 DISEASES OE THE CORNEA. terfere \vith sight more than a nebula which occupies the same position, but does not alter the regularity of the corneal curve. During repair bloodvessels often form and pass from the nearest part of the corueal edge to the ulcer, and disappear when healing is complete; phlyctenular ulcers, however, are vascular from the beginning. Corneal opacities are of course most serious when over the pupil. The chief symptoms of corneal ulceration are: (1) photo- phobia, or at least spasm of the orbicularis, blepharospasm (for it is not always clear whether the reflex irritation starts from the retina or from the branches of the fifth nerve in the cornea and conjunctiva); (2) congestion; (3) pain. All three symptoms vary extremely in degree in different cases. As a broad rule, with many exceptions, we may say that intolerance of light is worse in children than in adults, worse with superficial than with deep ulcers, and worse in persons who are strumous and irritable than in those whose tissues are healthy and tone good. Photophobia should always lead to a careful inspection of the cornea, and Ave shall then sometimes be surprised to find how slight a change gives rise to this symptom in its severest form. The degree of congestion varies with the seat and cause of the ulcer and with the patient's age, being usually greatest in adults. The visible congestion is, as in iritis, due espe- cially to distentiou of the subconjunctival twigs of the ciliary zone (Fig. 20, Ant. Cil., and Fig. 23), but there is often congestion of the conjuuctival vessels as well. In some forms of marginal ulcer only those vessels which feed the diseased part are congested. Great pain in and around the eye often attends the earlier stages of corneal abscess, and is common in many acute ulcers ; as a symptom, it of course always needs careful attention ; it is generally re- lieved by those local measures which are best for the dis- ease itself. DISEASES OF THE CORNEA. 113 Types of Corneal Ulceration. (1) One of the simplest forms is the small central ulcer often seen in young children. A little grayish-white spot is seen at or near the centre of the cornea, at first elevated and bluntly conical, afterwards showing a minute shallow crater; the congestion and photophobia varying, but often slight. The ulcer is usually single, but is apt to recur in the same or the other eye. The infiltration in many of these cases extends quite into the corneal tissue, and the residual opacity often remains for a long time if not per- manently. The patients are always badly nourished little children. In most cases the ulcer quickly heals, but now and then the infiltration passes into an abscess or a spread- ing suppurating ulcer. (2) In other cases, less common than the above, one or more central ulcers occur of a much more chronic charac- ter, attended with little or no infiltration. After lasting for months the loss of tissue is only partly repaired, and a shallow depression or a flat facet is left with perhaps scarcely any loss of transparency. Some of the best ex- amples are seen in anaemic or strumous patients, with gran- ular lids of long standing. (3) Phlyctenular ophthalmia and phlyctenular ulcers of cornea (phlyctenulse, herpes cornese, pustular ophthalmia, marginal keratitis). The formation of little papules or pustules on or near the corneal margin is exceedingly com- mon, either independently or as a complication of some existing ophthalmia. Although there are many varieties and degrees of phlyctenular inflammation in respect to the seat, extent, and course of the disease, the following fea- tures are common to all. Phlyctenular affections show a strong tendency to recur during several years ; they are sel- dom seen in very young children, and comparatively seldom 10* 114 DISEASES OF THE CORNEA. after middle life; they occur so often in strumous subjects that we are justified in strongly suspecting scrofulous ten- dencies in all who suffer much from them; ophthalmia tarsi is often seen in the same patients; the first attack often follows closely after an acute exanthem and especially after measles; the cases are much influenced by climate and weather, and their condition often varies extremely from day to day without making either progress or regress. An elevated spot, like a papule, commonly about the size of a small mustard seed, is seen either on the white of the eye near the cornea, or upon, or just within, the cor- neal border. It is preceded and accompanied by localized congestion. Its top sometimes becomes as yellow as that of an acne pustule, but more often when seen it has become abraded, flat, and whitish. Pustules at a little distance from the cornea (Fig. 39), although generally larger than FIG. 39. Phlyctenular ophthalmia, conjunctival form. (Dalrymple.) those seated on the corneal border, occasion less photopho- bia, and are more easily cured. Pustules at the corneal border, though often very small, cause troublesome and even very severe photophobia; they are troublesome in propor- tion rather to their number than their size, and if numer- ous enough to form a ring round the cornea, their cure is often most tedious. DISEASES OF THE CORNEA. 115 A pustu-le is always liable, even ' when it has begun on the conjunctiva, to run as a superficial ulcer on to the cor- nea, though it never extends in the opposite direction over the sclerotic. Such a phlyctenular ulcer, if it do not stop near the corneal border, will make, in an almost radial di- rection, for the centre, carrying with it a leash of vessels which lie upon the track of opacity left in the wake of the ulcer (Fig. 40). Finally, the ulceration stops, the vessels FIG. 40. Phlyctenular ulcer. (Travers.) dwindle and disappear, and the path of opacity clears up more or less. The term recurrent vascular ulcer is used when such ulcers are solitary ; but they are often multiple as well as recurrent, and the cornea may then finally be covered by a thin, irregular network of superficial vessels on a patchy, uneven, hazy surface, the so-called "phlycten- ular pannus." A variety of phlyctenular inflammation, aptly called marginal keratitis ("spring-catarrh" of continental authors), occurs in mild degrees in the form of a slight granular- looking, often vascular, swelling all around the edge of the cornea. If the process continues the cornea is encroached on by a densely vascular superficially ulcerated, and yet somewhat thickened zone. In slight degrees this condition is common enough ; severe cases are rare and very serious, leading finally to implication of perhaps the greater part 116 DISEASES OF THE CORNEA. of the cornea. It often begins crescentically above and below, as in Fig. 46. In another variety a single pustule at the border of the cornea ulcerates deeply, becomes surrounded by swollen and infiltrated tissue, and may perforate ; such cases are seen in weakly women and strumous children. In very rare cases, what appears to be an ordinary con- junctival pustule persists, grows deeply, and may even per- forate the sclerotic in the form of an ulcer; or it may infiltrate the sclerotic and the ciliary body beneath, form- ing a soft, semi-suppurating tumor, whence the inflamma- tion is likely to spread to the vitreous and destroy the eye. Stopping short of these extreme results, such a case forms one type of episcleritis. The corneal changes produced by the friction of granu- lar lids have been considered under that subject. The pan- nus of granular lids can usually be distinguished from the phlyctenular pannus just mentioned, by the greater uni- formity and closeness of its vessels, and by its being worst under the upper lid (Fig. 38) ; any doubt is settled by everting the lid. But it must be borne in mind that ulcer- ation of the cornea often occurs as a complication of tra- chomatous pannus (pp. 107 and 113, 2). (4) A very serious form of disease, commonest in the senile period of life, is the serpiginous ulcer. It is often comparatively chronic, There is much congestion, and often much pain and photophobia. With these symptoms we find either a marginal trough-like or ditch-like ulcer, with crescentic borders, or a more central ulcer, with nearly circular outline and a varying amount of infiltra- tion of its walls. If the ulcer has lasted some little time one of its borders, the outer, if the ulcer be marginal, will be partly healed and bevelled off, the floor of the ulcer sloping downwards to its inner boundary, which will be infiltrated, sharply cut, or even overhanging. DISEASES OF THE COKNEA. 117 Slight cases, taken early, generally give little trouble, especially if the infiltration is insignificant. But such an ulcer, if neglected, is very likely to increase in all dimen- sions, to become complicated with iritis and hypopyon, and to lead to perforation of the cornea ; or to spread slowly over the whole cornea, and leave a dense scar. In either event the eye is much damaged, if not destroyed. (5) Abscess of the cornea and acute suppurating ul- ceration are common diseases. Abscess may occur at any age, but is commonest in elderly or senile people, in whom an abrasion or some slight injury by a foreign body is not an uncommon cause, especially if near the centre of the cornea. The little gray central ulcers of young children (p. 113) sometimes go on to abscess. It will very often be noticed that in cornea! abscess, as well as in the serpiginous ulcera- tion just described, the patients are either senile or under- fed, or if vigorous and full-blooded that they show signs of being damaged by drink. Abscess of the cornea is attended by great pain and congestion, and the case often comes under care pretty early, though often not till the cornea has given way, either in front of or behind the little collection. The spot itself is generally small and circum- scribed ; it usually bursts forwards, and is converted into an ulcer, but it may perforate the posterior surface of the cornea. There is always some haziness of the whole cornea, and the purulent infiltration may, if the case do badly, spread and involve almost its whole extent. Hypopyon signifies a collection of pus or puro-lymph at the lowest part of the anterior chamber ; its upper boundary is usually, but not always, level (Fig. 41). It may occur with any acute ulcer, whether deep or not, if it be accom- panied by purulent infiltration of the surrounding cornea or with corneal abscess ; or with any corneal ulcer, chronic or acute, in which iritis supervenes. The pus may be de- rived either from an abscess breaking through the posterior 118 DISEASES OF THE CORNEA. surface of the cornea, or from suppuration of the epithe- lium covering Descemet's membrane, or from the surface of the iris. Simple iritis now and then gives rise to hypo- pyon (see Rheumatic Iritis). FIG. 41. Hypopyon, seen from the front, and in section, to show that the pus is behind the cornea. In many cases of severe corneal suppuration (a, Fig. 42) the pus sinks clown between the lamellte of the cornea (6). To this condition the term onyx is applied, and should be FIG. 42. a. Abscess. 6. Onyx. limited, though it is sometimes used in other senses. The term, however, may very well be discarded. Onyx and hypopyon often coexist, and then the distinction between DISEASES OF THE CORNEA. 119 them can hardly be made without tapping the anterior chamber. Hypopyon, however, when liquid, will change its position if the patient lies down, but as it is more often gelatinous or fibrinous, this test loses much of its value ; oblique illumination will sometimes show the cornea clear in front of an hypopyon; and as the diameter of the an- terior chamber is a little greater than the apparent diame- ter of the clear cornea, a very small hypopyon is almost hidden behind the overlapping edge of the sclerotic, and may escape detection. Treatment of Ulcers of the Cornea. The general principles of local treatment suitable to the different types of ulceration are : (1) By bandaging the affected eye or by shading both eyes, to prevent movement of the lids, and thus secure rest for the ulcerated surface. (2) To soothe local pain, and diminish congestion, by atro- pine. (3) To relieve the tension of the ulcerated surface, and so favor healing. Atropine has been believed to owe part at least of its good effect in cases of corneal ulcer to a power of lessening the tension of the eye, but this is un- likely, since it certainly increases tension in eyes threat- ened, or affected, with glaucoma. Eserine probably owes much of its beneficial effect in ulcer cases to its undoubted power of lowering tension. But in severe cases some opera- tive measure, which at the same time will let out any pus that may be present in the anterior chamber is best. (4) In suppurating cases, to induce granulation instead of suppuration, and absorption of the pus already effused. Frequent hot fomentations to the eyelids attain this end better than any other means in a large number of cases. (5) Stimulation of the surface of the ulcer when it has begun to heal, especially if it be indolent. The best stimu- lants are calomel, yellow oxide of mercury, and nitrate of silver. (6) Counter-irritation by a seton in the temple is 120 DISEASES OF THE CORNEA. of very great use in chronic irritable ulcers. (7) When ulcers are caused by granular lids, the treatment of the granular disease is more important than that of the ulcera- tion, unless the latter be of threatening character. The choice of one or another of the above plans is easy enough in a large proportion of cases ; in others a good deal of judgment is needed ; while in a certain number it is impossible to say with any certainty what will be found most beneficial. Ulcers of the cornea are so often a sign of bad health that the improvement of the general state should always receive most careful attention. Treating the matter clinically we shall find that local stimulation is best for a large majority of the cases as they first come under notice, including phlyctenular cases, chronic superficial ulcers of various kinds, and even many recent ulcers if not threatening to suppurate. As a general rule, this plan is not suitable when there is much photo- phobia, but exceptions to the rule are found, especially in old-standing cases. The most convenient remedy is the ointment of amorphous yellow oxide of mercury (F. 10 and 11), of which a piece about as large as a hemp-seed is to be put inside the eyelids once or twice a day. If smart- ing continue for more than half an hour, the ointment should be washed out with warm water; and if the eye become more irritable after a few days' use of the ointment it must be weakened or discontinued. The same ointment com- bined with atropine gives excellent results in cases of super- ficial ulcer with much photophobia. Calomel flicked into the eye daily or less often is an admirable remedy in many cases. Kitrate of silver in the form of solid mitigated stick is useful if carefully applied to large conjunctival pustules, and occasionally to indolent corneal ulcers ; its use, how- ever, needs some skill, and is seldom really necessary. Solu- tions of from 5 to 10 grains to the ounce may be cautiously DISEASES OF T1IE CORNEA. 121 used by the surgeon instead of the yellow ointment, and are particularly valuable in old vascular ulcers and when there is conjunctivitis. When in doubt, it is best to depend for a few days on atropinc alone, used just often enough to cause wide dilatation of the pupil. Severe and obstinate photophobia, especially in young children, is best treated by a free division of all the tissues at the outer canthus, which renders spasm impossible for a time, and allows the remedies to be efficiently used. In all cases of corneal disease attended with intolerance of light the patient is to wear a large shade, or, better, a pair of " SSS^ es " ver both eyes ; a little patch over one eye does not relieve photophobia. Many a child is kept within doors to the injury of its health who, with suitable protec- tion, can go out daily without the least detriment to its eyes. In chronic and relapsing cases, with photophobia and irritability, where other methods have had a fair trial, a seton gives the best results, whether or not there be much congestion of the eye. A double thread of thick silk is used, and at least an inch of skin included between the punctures, which are placed amongst the hair of the temple or behind the ear, that the resulting scar may be hidden ; it is to be moved daily, and if acting badly may be dressed with savin ointment. The seton should be worn at least six weeks. Severe inflammation, and even abscess, some- times sets in a few days after the insertion of the thread, and in very rare cases severe secondary bleeding has oc- curred from a branch of the temporal artery. To avoid wounding the artery in inserting the seton in the temple, the skin is to be held well away from the head. Very severe recent phlyctenular cases are occasionally difficult to influence, and remain practically "blind " with spasm of the lids for weeks. There is seldom any risk, provided that we thoroughly examine the cornea at inter- 11 122 DISEASES OF TI1E CORNEA. vals of a few days, and they generally in the end recover well. Calomel dusted on the cornea sometimes helps more than any other local measure, and change of air, especially to the seaside, frequently effects a more rapid cure than any plan. Cases for which the stimulating treatment is suitable seldom need the eye to be bandaged, though, as mentioned, they often need a shade or goggles. The remaining methods of treatment protective ban- daging, atropine, eserine, hot fomentations, and operative measures are reserved for the more serious forms of ulcer- ation, the serpiginous ulcer, acute suppurating ulcers, ab- scesses, and generally for all ulcers with hypopyon, and ulcers which are deep and threaten to perforate. The compress used for this purpose consists of a pad of cotton- wool and a single turn of bandage, tied at the back of the head ; a piece of linen rag should t>e placed next the skin to prevent irritation by the wool ; such a compress is most grateful in the irritation caused by a corneal abrasion, or after a foreign body has been removed (p. 164). Atropine is to be used regularly from three to six times a day, on the ground that iritis, if not present, is very likely to occur ; it also soothes pain and diminishes congestion. Hot fomen- tations are extremely valuable. I generally direct that the compress be removed every two hours, or sometimes every hour, and the lids fomented for fifteen or twenty minutes with a belladonna lotion (one drachm of extract to the pint) made as hot as can be borne. If atropine be properly used, there is no actual need for the belladonna ; hot water or poppy-head fomentation is as good. Many cases of acute suppurating ulcer, of serpiginous ulcer, and of abscess, quickly recover under this treatment, combined with the administration of bark or quinine with ammonia and ether. Even a considerable hypopyon will often be quickly absorbed. DISEASES OF THE CORNEA. 123 But the ulceration may increase, or the hypopyon, if present, enlarge. If so, the hypopyon is to be evacuated by an incision close to the margin of the cornea. Some surgeons prefer at the same time to make an iridectomy, but the effect of removal of iris upon the progress of the inflammation is doubtful. I incline to think that a pam- centesis with a broad needle, repeated if the hypopyon re- form in a few days, is all that is needed. Another method is to evacuate the aqueous by cutting across the whole width of the ulcer, and by opening the wound daily with a probe, to keep the cornea flaccid until healing is well es- tablished ; this method was intended by its author (Sae- misch) especially for the serpiginous ulcers. In corneal abscess a similar incision is often made across the inflamed spot into the anterior chamber. In these operations the hypopyon will usually escape through the incision, and after all of them the anterior chamber will leak for a longer or shorter time, according to the size of the incision. Prob- ably iridectomy is often so beneficial because the incision is too large to close at once, and I have several times seen the best results from a wound made as for iridectomy, but without the removal of any iris. When an acute ulcer without hypopyon is just about to perforate, puncture of its transparent protruding floor, with a needle, will aid the healing. It is well known that atropine does not suit all cases of suppurative inflammation and ulceration of the cornea, particularly if there be decided conjunctivitis with dis- charge. Eserine (F. 29) has come largely into use within the last few years for many cases of suppurative ulcer accompanied by much infiltration, for which atropine was formerly employed. I have used it largely, but hitherto without being able to draw decided conclusions, either as to the cases in which it will be well borne, or as to its effect in favoring absorption. The almost universal custom 124 DISEASES OF THE CORNEA. of using hot applications to the lids renders it difficult to draw trustworthy conclusions as to the effect of eserine. Antiseptic dressings are also being largely used ; a 4 per cent, solution of boracic acid is the most suitable solution for the eye, whether for bathing or continuous application by a pad. I have occasionally seen a good result from the use of cold evaporating lotions in irritable superficial ulcers, with much spasm of lids, which have resisted other treatment. Conical cornea. In this condition the central part of the cornea very slowly bulges forwards, forming a bluntly conical curve. The focal length of the affected part of the cornea is thereby shortened, and the eye becomes myopic, not owing to increase of its length but from increase of re- fractive power. The curvature, however, is not uniform, and hence irregular astigmatism complicates the myopia. The disease, which is rare, occurs chiefly in young adults, especially women, and is often dated from some illness or failure of general health ; and it appears to be due to de- fective nutrition of that part of the cornea which is furth- est from the bloodvessels. In advanced cases the protru. sion of the cornea is very evident, whether viewed from the front or from the side, but slight degrees are less easily dis- tinguished from ordinary myopic astigmatism (see Irregu- lar Astigmatism). In high degrees the apex of the cone often becomes nebulous. The disease may progress to a high degree, or stop before great damage has been done. Concave glasses alone are of little use, but in combination with a screen perforated by a narrow slit or small central hole, which allows the light to pass only through the cen- tre, or through some one meridian, of the cornea, they are sometimes useful. In advanced cases operation is needed. (See Operations.) DISEASES OF THE CORNEA. 125 B. DIFFUSE KERATITIS. Syphilitic, Interstitial, Parenchymatous, or " Strumous" Keratitis. In this disease the cornea in its whole thickness under- goes a chronic inflammation, which shows no tendency either to the formation of pus or to ulceration. After sev eral months the inflammatory products are either wholly or in great part absorbed, and the transparency of the cor- nea restored in proportion. The changes in the cornea are usually preceded for a few days by some ciliary congestion and watering. Then a faint cloudiness is seen in one or more large patches, and the surface, if carefully looked at, is found to be "steamy" (p. 110). These, nebulous areas may lie in any part of the cornea. In from two to about four weeks the whole cornea has usually passed into a condition of white haziness with steamy surface, of which the term " ground glass " gives FIG. 43. Interstitial keratitis. the best idea. Even now, however, careful inspection, especially by focal light, will show that the opacity is by no means uniform, that it shows many whiter spots or large denser " clouds " scattered among the general "mist;" in very severe cases the whole cornea is quite opaque and the iris hidden ; but, as a rule, the iris and pupil can be seen, though very imperfectly (Fig. 43). In many cases iritis takes place, and posterior synechiae are formed. Blood- vessels derived from branches of the ciliary vessels (Fig. 11* 126 DISEASES OF THE CORNEA. 20) are often formed in the layers of the cornea (Fig. 44) ; they are small but thickly set, and in patches ; as they are covered by a certain thickness of hazy cornea, their bright scarlet is toned down to a dull reddish-pink color (" salmon FIG. 44. Thickening of cornea and formation of vessels in its layers in syphilitic keratitis. Subconjunctival tissue thickened. X about 10 diameters. patch" of Hutchinson). The separate vessels are visible only if magnified (p. 61), when we see that the trunks passing in from the border divide at acute angles into very numerous twigs, lying close to each other and taking a FIG. 45. Vessels in interstitial keratitis. nearly straight course towards the centre (Fig. 45). These salmon-patches are of no constant form, but when small are often crescentic, and tend when large to the sector- DISEASES OF THE CORNEA. 127 shape. In another type the vascularity begins as a nar- row fringe of looped vessels which are continuous with the superficial loop-plexus of the corneal margin (Fig. 46, com- pare Fig. 20, 0> au( i gradually extend from above and be- low towards the centre. The vessels in these cases are more superficial, and the corneal tissue in which they lie is always swollen by infiltration. These cases are described as "marginal keratitis" by some authors (compare p. 115); nearly all the examples occur in syphilitic subjects, but I believe that some of the patients are at the same time stru- mous. A similar disease, ending in loss of the eye, some- times from glaucoma, occurs now and then in elderly people. In extreme cases of either type of vascular keratitis the vessels occupy the whole cornea except a small central island. FIB. 46. Marginal vascular keratitis. The degree of congestion and the subjective symptoms in syphilitic keratitis vary very much ; as a general rule there is but moderate photophobia and pain, but when the ciliary congestion is great these symptoms are sometimes very severe and protracted. The attack can be shortened and its severity lessened by treatment ; but the disease is always slow, and from six to twelve months may be taken as a fair average for its dura- tion from beginning to end. Very bad cases Avith exces- 128 DISEASES OF THE CORNEA. sively dense opacity sometimes continue to improve for several years, and reach a very unexpected degree of sight. Perfect recovery of transparency is less common, even in moderate cases, than is sometimes supposed, but the slight degree of haziness which so often remains does not much affect the sight. The epithelium usually becomes smooth before the cornea becomes transparent ; but in severe cases irregularities of surface and straggling superficial vessels may remain and render the diagnosis difficult. Syphilitic keratitis is almost always symmetrical, though an interval of a few weeks commonly separates its onset in the two eyes ; rarely the interval is several months, or even longer. It generally occurs between the ages of 6 and 15; sometimes as early as 2 z or 3 years, and very rarely as late as 35. When it occurs at a very early age the attack is generally mild. Relapses of greater or less severity are common. Not only does iritis occur with tolerable fre- quency, but we occasionally meet with deep-seated inflam- mation in the ciliary region, giving rise either to secondary glaucoma, or to stretching and elongation of the globe in the ciliary zone, or to softening and shrinking of the eye- ball. 1 Dots of opacity may sometimes be seen on the lower part of the back of the cornea before the cornea itself is much altered (p. 130) ; sometimes, too, the interstitial ex- udation is much more dense at thejower part of the cor- nea than elsewhere. Syphilitic keratitis in- strumous children often presents more irritability and photophobia, and more conjunctival congestion, than in others; but it is very seldom that ulceration occurs ; and although in the worst cases the cornea becomes softened and yellowish, and for a time seems likely to give way, actual perforation and % 1 Patches of atrophy after choroiditis are often found after the cornete have cleared. Probably in most of these the active choro- iditis took place long before the keratitis set in. DISEASES OF THE CORNEA. 129 staphylomatous bulging are amongst the rarest events. Pannus from granular disease may coexist with syphilitic keratitis. TREATMENT. A long but rnild course of mercury exerts an undoubtedly good eifect. It is customary to give iodide of potassium also, and it probably has some influence. If, as is often the case, the patients are very ausemic, iron, or the syrup of the iodide of iron, is sometimes more useful than iodide of potassium as an adjunct to the mercury. Locally, the use of atropine is advisable as a routine practice until the disease has reached its height, on the ground that iritis may be present. In cases attended by severe and prolonged photophobia and ciliary conges- tion, setons in the temples sometimes give relief. In similar cases iridectomy is sometimes followed by rapid improve- ment ; but the cases in which this operation is needed or justifiable are not numerous. When all inflammatory symptoms have subsided, the local use of yellow ointment or calomel (F. 9 and 10) appears to aid the absorption of the residual opacity. The form of keratitis above described is caused by in- herited syphilis. In a few very rare cases it has been seen as the result of secondary acquired syphilis. Other cases of diffuse keratitis occur in which syphilis has no share, but they are seldom symmetrical, nor do they occur early in life. That diffuse chronic keratitis affecting both eyes of children and adolescents is, when well characterized, almost invariably the result of hereditary syphilis is proved by abundant evidence. A large proportion of its subjects show some of the other signs of hereditary syphilis in the teeth, skin, ears (deafness\ physiognomy, mouth, or bones. When the patients themselves show no such signs, a history of infantile syphilis in the patient or in some brothers or sisters, or of acquired syphilis in one or other parent, may 130 DISEASES OF THE CORNEA. often be obtained. 1 That this keratitis stands in no causal relation to struma is clear, because the ordinary signs of struma are not found oftener in its victims than in other children, because persons who are decidedly strumous do not suffer from this keratitis more often than others, and because the forms of eye disease which are universally recognized as "strumous" (ophthalmia tarsi, phlyctenular disease, and relapsing ulcers of cornea) very seldom accom- pany this diffuse keratitis. Other forms of Keratitis. Inflammation of the cornea forms a more or less con- spicuous feature in several diseases where the primary or principal seat of mischief is in some other part of the eye. It is important for purposes of diagnosis to compare these secondary or complicating forms of keratitis with the primary diseases of the cornea already described. In cases of iritis the lower half of the cornea often be- comes steamy, and its tissue more or less hazy. In some cases a number of small separate opaque dots are seen on the posterior elastic lamina (Descemet's membrane), often so minute as to need a hand-lens for their detection (p. 61). In other cases a few large dots only are present, or a mix- ture of large and small. They are sharply defined, the large ones looking very like minute drops of cold gravy- fat, the smallest like grains of gray sand; in cases of long standing they may be either very white or highly pig- mented. They are generally arranged in a triangle, with its apex towards the centre and its base at the lower mar- gin of the cornea, and the smallest dots are commonly nearest the centre (Fig. 47), but in some cases (sympathetic 1 I have found other personal evidence of inherited syphilis in 54 per cent, of my cases of interstitial keratitis, and evidence from the family history in 14 per cent, more ; total, 68 per cent. ; and in most of the remaining 32 per cent, there have been strong rea- sons to suspect syphilis. DISEASES OF THE CORNEA. 131 ophthalmitis especially) the dots are scattered over the \vhoie area. They are, of course, difficult to detect in pro- portion as the corneal tissue itself has lost its transparency. The terra keratitis punctata, is used to express this accu- mulation of dots on the back of the cornea, and by some authors is made to include also small spots with hazy out- FIG. 47. Keratitis punctata. lines, which lie in the cornea proper, and are sometimes seen in similar cases. Keratitis punctata is, almost with- out exception, secondary to some disease of the cornea, iris, or choroid and vitreous. But a few cases are seen, chiefly in young adults, where the cornealdots form the principal if not the sole visible change ; the number of these cases diminishes, however, in proportion to the care Avith which other lesions are sought (p. 149). It is now and then difficult to say whether the iritis or keratitis in a mixed case has been the initial change ; but when this doubt arises the cornea has generally been the starting-point; and with care we are seldom at a loss to decide whether the case is one of syphilitic keratitis with iritis, or of sclerotitis with corneal mischief and iritis, or of primary iritis with an unusual degree of corneal haze. (See Ciliary Region and Iritis.) Slight loss of transparency of the cornea occurs in most cases of glaucoma. The earliest change is a fine uniform steaminess of the epithelium. In very severe acute cases the cornea becomes hazy throughout, though not in a high degree. The same haze occurs in chronic cases of long standing, with great increase of tension, but the epithelial "steaminess" often then gives place to a coarser "pitting," 132 DISEASES OF THE CORNEA. with little depressions and elevations (vesicles), especially on the part which is uncovered by the lids. A peculiar and rare form of corneal disease, seen in elderly or prematurely senile persons, is the transverse calcareous film, an elongated patch of light gray opacity, looking when magnified like very fine sand, placed beneath the epithelium and running almost horizontally across the cornea. It consists of minute crystals, chiefly calcareous. Arcus senilis is caused by fatty degeneration of the cor- neal tissue just within its margin (Fig. 48). It generally FIG. 48. Arcus senilis. (Canton.) begins beneath the upper lid, and next appears beneath the lower, forming two narrow, white or yellowish crescents, the horns of which finally meet at the sides of the cornea ; it always begins, and remains most intense, on a line slightly within the sclero-corneal junction, and the degeneration is most marked in the superficial layers of the cornea beneath the anterior elastic lamina; in other words, the change is greatest at the part most influenced by the marginal blood- vessels. It is not found to interfere with the union of a wound carried through it, though the tissue of the arcus is often very tough and hard. Nevertheless, its occurrence chiefly at an advanced age, and its frequent coexistence with fatty degeneration, both in distant parts and in the bloodvessels and muscles of the eyeball, mark it as a truly senile change. DISEASES OF THE CORNEA. 133 Less regular forms of amis are seen as the result of pro- longed or relapsing inflammations near the corneal border, whether ulcerative or not. It is generally easy to dis- tinguish such an arcus, because the opacity is denser, more patchy, and its outlines less regular than in the primary form ; when arcus is seen unusually early in life it is gen- erally of this inflammatory kind, for simple arcus is com- paratively rare below forty. Opacity of a very characteristic kiud is likely to follow the use of a lotion containing lead when the surface of the cornea is abraded. An insoluble, densely opaque and very white film of lead salts is precipitated on the ulcerated surface, and adheres very firmly to it. Such an opacity when once seen can scarcely be mistaken ; it is sharply de- fined, and looks like white paint. If precipitated on a deep and much inflamed ulcer, the film of tissue to which it adheres is often thrown off; but when there is only a superficial abrasion or ulcer, the lead adheres very firmly, and can only be scraped off imperfectly. But even in these cases the layer is probably after a time thrown off or worn off, if we may judge by the fact that nearly all the lead opacities which come under notice are comparatively new. The practical lesson is, never to use a lead lotion for the eye when there is any suspicion that the corneal surface is broken. Powdered acetate of lead rubbed into the con- junctiva (a treatment sometimes used for granular lids), is, I believe, not attended by risk of corneal opacity, even though there be ulceration ; the lead is precipitated at once, and adheres for weeks to the surface of the granular conjunctiva, any superfluous salt being washed away with water immediately after the powder has been applied. The prolonged use of nitrate of silver, whether in a weak or strong form, is sometimes followed by a dull (brownish- green), permanent discoloration of the conjunctiva, and even the cornea may become slightly stained. 12 134 DISEASES OF THE IRIS. CHAPTER IX. DISEASES OF THE IRIS. IRITIS. INFLAMMATION of the iris may be caused by certain specific blood diseases, especially syphilis ; or may be the expression of a tendency to relapses of inflammation in certain tissues under the influence largely of climate and weather rheumatic iritis ; it often occurs in the course of ulcers, and of wounds and other injuries, of the cornea; also with diffuse keratitis and sclerotitis ; iritis forms a very important part of the grave and peculiar disease known as sympathetic ophthalmitis. Acute iritis, from whatever cause, is shown by a change in the color of the iris, by indistinctness or " muddiness " of its texture, by diminution of its mobility, and by the existence of adhesions (posterior synechice) between its pos- terior (uveal) surface and the capsule of the lens ; there is, besides, in most cases, a duluess of the whole iris and pupil, caused partly by slight corneal changes (p. 130), partly by muddiness of the aqueous humor. The eyeball is con- gested and sight is almost always defective. There may or may not be pain, photophobia, and lachrymation. The congestion is often nearly confined to a zone of about one-twelfth or one-eighth of an inch wide, which sur- rounds the cornea, its color being pink (not raw red), the vessels small, radiating, and nearly straight, and lying be- neath the conjunctiva (ciliary or circum-corneal congestion}. These are the episcleral branches of the anterior ciliary DISEASES OF THE IRIS. 135 arteries (p. 38). Quite the same congestion is seen in many other conditions, e. g., corneal ulceration (p. 112) ; whilst on the other hand, in some cases of iritis, the superficial (con- junctival) vessels are congested also, especially in their anterior divisions, which are chiefly offshoots of the ciliary system (Fig. 20). We therefore never diagnose iritis from the character of the congestion alone; but iritis being proved by the other symptoms, the kind and degree of con- gestion help us to judge of its severity. The altered color of the iris is explained by its conges- tion, and by the effusion of lymph and serum into its sub- stance ; a blue or gray iris becomes greenish, whilst a rich brown one is but little changed. The inflammatory swell- ing of the iris also accounts both for the blurring (muddi- ness) of its beautifully reticulated structure, and for the sluggishness of movement, indicating stiffness of its tissue, noticed in the early period. After a few days, lymph is throAvn out at one or more spots on its posterior surface, and still further hampers its movements by adhering to the lens-capsule; and most cases do not come to notice till some such synechise have formed. The quantity of solid exuda- tion, whether on the hinder surface or into the structure of the iris, varies much ; it is usually greatest in syphilitic iritis, when distinct nodules of pink or yellowish color are sometimes seen projecting from the front surface. In rare cases pus is thrown out by the iris into the aqueous, and, sinking down, forms a hypopyon. Firm adhesions to the lens-capsule may be present without much evidence of ex- udation, into the structure of the iris. These exudative changes are most abundant at the inner ring of the iris, where its capillary vessels are far the most numerous (Fig. 49). Apparent discoloration of the iris is also due, in part, to suspension in the aqueous humor of pus or blood-corpuscles, either of which may form a distinct deposit at the lowest 136 DISEASES OF THE IRIS. part of the anterior chamber (hypopyon, hyphseraa). Sometimes the slightly turbid fluid coagulates into a gela- tinous mass, which almost fills the chamber (" spongy exu- dation "). The tension of the eyeball is often a little increased in acute iritis ; rarely it is considerably diminished, and in such cases there are generally other peculiarities. The condition of the pupil alone is diagnostic in all ex- cept very mild or incipient cases of iritis. It is sluggish or FIG. 49. Vessels of human iris artificially injected; capillaries most numerous at pupillary border, and next at ciliary border. quite inactive, and not quite round ; it is also rather smaller than its fellow (supposing the iritis to be one-sided), be- cause the surface of the iris is increased (and the pupil, therefore, encroached on) whenever its vessels are distended (p. 40). Atropine causes it to dilate between the synechise. These synechise, being fixed, appear as angular projections when the iris on each side of them has retracted. If there DISEASES OP THE IKIS. 137 be only one adhesion, it will merely notch the pupil at one spot ; if the adhesions be numerous, the pupil will be cre- nated or irregular (Fig. 50). If the whole pupillary ring, or, still more, if the entire posterior surface of the iris, be adherent, scarcely any dilatation will be effected ; the FIG. 50. Posterior synechiaj causing irregularity of pupil. (Wecker and Jaeger.) former condition is called annular or circular synechise, and its result is " exclusion " of the pupil; the latter is known as total posterior synechia. If the synechise are new and the lymph soft, the repeated use of atropine will cause them to give way, and the pupil will become round, but even then some of the uveal pigment, which is easily sep- arable from the posterior surface of the iris, will often re- main behind, glued to the lens-capsule by a little lymph (Fig. 51) ; and the presence of one or more such spots of FIG. 51. Spots of pigmqnt and lymph at seat of former iritic adhesions. brown pigment on the capsule is always conclusive proof of present or of past iritis. The pupillary area itself is often blurred or even quite obscured by grayish or yellow- ish lymph, which spreads over it from the iris. The iris may be inflamed without any lymph being effused from its 12* 138 DISEASES OF THE IRIS. hinder surface, and then the pupil, though sluggish, acting imperfectly to atropinc, and never dilating widely, will present no posterior syuechiso nor any adhesion of pigment- spots to the lens, but it will always be discolored (serous iritis) ; iritis of this kind often occurs with ulceration of the cornea. When exudation into the pupil becomes or- ganized, a dense white membrane, or a delicate film (often, however, presenting one or more little clear holes), is formed over the pupil (" occlusion of the pupil"^). Pain referred to the eyeball and to the parts supplied by the first, and sometimes by the second, division of the fifth nerve is a common accompaniment of iritis, especially in the early period of the attack. It is a very variable symp- tom, and gives no clue to the amount of structural change going on in the parts, being sometimes quite an insignifi- cant feature in a case where much lymph is thrown out. The pain is seldom constant, but comes on at intervals, is often worst at night, and is described as shooting, throbbing, or aching. It is commonly referred to the temple or fore- head, as well as to the eyeball, but sometimes to the side of the nose and to the upper teeth. Photophobia and water- ing are generally proportionate to the pain. The duration of acute iritis varies from a feAV days when mild to many weeks when severe. The defect of sight is proportionate to the haziness of the cornea, aqueous, and pupillary space, but in some cases is increased by changes in the vitreous. In some cases, iritis sets in very grad- ually, causing no marked congestion or pain, but slowly giving rise to the formation of tough adhesions, and often to the growth of a thin membrane over the pupillary area; in some of these the iris becomes thickened and tough, and its large vessels undergo much dilatation, and in others keratitis punctata occurs (see Cyclitis, p. 149; Diseases of Cornea, p. 130; and Sympathetic Ophthalmitis, p. 153). DISEASES OF THE IRIS. 139 Results of iritis. Such of the results as are permanent need separate notice. Reference has been made to the ad- hesions, which are often permanent, and to the spots of uveal pigment on the lens-capsule, which are always so. Either of these conditions tells a tale of past iritis which is often a valuable aid to diagnosis. A blue iris which has undergone inflammation may remain permanently greenish. When the pupil is " excluded " or " occluded," the re- mainder of the iris being free, fluid collects in the poste- rior aqueous chamber, and by bulging the iris forwards, and diminishing the depth of the anterior chamber, except at its centre, gives the pupil a funnel-shape; if such bulg- ing be partial, or be divided by bands of tough membrane, the iris looks cystic. Secondary glaucoma is likely to fol- low, and the tension of the globe should, therefore, be care- fully noted whenever this bulging is present. " Total pos- terior synechia" always shows a severe though often a chronic iritis; it often signifies deep-seated disease, and is often followed by opacity of the lens (secondary cataract). Relapses of iritis are believed to be induced by the pres- ence of synechise, even Avhen there is no protrusion of the iris by fluid; but their influence in this direction has prob- ably been much overrated. The following are the most important points as to the causes of iritis, and the chief clinical differences between the several forms. CONSTITUTIONAL CAUSES. Syphilis. The iritis is acute; it shows a great tendency to effusion of lymph and forma- tion of vascular nodules (plastic iritis), and the nodules, when very large, may even suppurate; it is very often sym- metrical. 1 But asymmetry and absence of lymph-nodules are common. It occurs only in secondary syphilis (either acquired or inherited), and seldom relapses. It is to be 1 In two-thirds of the cases. 140 DISEASES OF THE IRIS. carefully distinguished from the iritis which often compli- cates syphilitic keratitis (p. 125). Rheumatism is the cause of most cases of relapsing un- symmetrical iritis ; there is but little tendency to effusion of lymph, and nodules are never formed, but there is occa- sionally fluid hypopyon (pp. 117 and 135); the congestion and pain are often more severe than in syphilitic iritis. A single attack is rarely symmetrical, though both eyes com- monly suffer by turns. It relapses at intervals of months or years. Even repeated attacks sometimes result in but little damage to sight. Gout is apparently a cause of some cases of both acute and insidious chronic iritis. It is per- haps doubtful whether the gout or the chronic rheumatism from which the same patients sometimes suffer is the cause of the iritis. In its tendency to relapse and to affect only one eye at a time gouty resembles rheumatic iritis. The children of gouty parents are occasionally liable to a very insidious and destructive form of chronic iritis, with dis- ease of the vitreous, keratitis punctata, and glaucoma (p. 150) (see also Chapter "Etiology"). Chronic iritis (plastic irido-choroiditis, see also p. 149). In a few cases symmetrical iritis, of a chronic, progressive and destructive character, is complicated with choroiditis, disease of vitreous and secondary cataract. These cases, for which it is at present impossible to assign any cause either general or local, are chiefly seen in young adults, and, I think, oftenest in women. Sympathetic iritis. See Sympathetic Ophthalmitis. LOCAL CAUSES. Injuries. Perforating wounds of the eyeball, particularly if irregular, contused, and compli- cated with wound of the lens, are often followed by iritis. Perforating wounds are more likely to be followed by iritis in old than in young persons. If the corneal wound sup- purate or become much infiltrated the iritis is likely to be suppurative, and the inflammation to spread to the deeper DISEASES OF THE IRIS. 141 structures . and cause destructive panophthalmitis. Iritis may follow a wound of the leus-capsule without wound of" the iris, and with only a mere puncture of the cornea. Examples of traumatic iritis from these several causes are seen after the various operations for cataract. The iritis (or more correctly irido-cyclitis) following extraction of senile cataract is often prolonged, attended by chemosis, much congestion, and the formation of tough membrane behind the iris (see "Cataract"). Iritis may also follow superficial wounds and abrasions of the cornea, or direct blows on the eye ; but it is of great importance, whenever the question of injury comes in, to ascertain whether or not there has been a perforating wound. Iritis often accompa- nies ulcers and other inflammations of the cornea especially when deep, or complicated with hypopyon, or occurring in elderly persons. Iritis may be secondary to deep-seated disease or tumor in the eye. TREATMENT. (1) In every case where iritis is present atropine is to be used often and continuously, in order to break down adhesions which have formed, and to allow any lymph subsequently formed to be thrown out beyond the area of the ordinary pupil. A strong solution (four grains of sulphate of atropine to one ounce of distilled water) is to be dropped into the conjunctival sac every hour in the early period. In many cases the synechise are, when first seen, already so tough that the atropine has no effect on them ; but even then it may still prevent new ones forming on the same circle. Moreover, the pupil when kept widely dilated is less likely to be covered over by lymph or organ- ized membrane from the iris than if contracted. Atropine also diminishes congestion and greatly relieves pain in iritis. (2) If there be severe pain with much congestion, three or four leeches should be applied to the temple, to the malar eminence, or to the side of the nose. They may be 142 DISEASES OF THE IRIS. repeated daily, in the same or smaller numbers, with ad- vantage for several days, if necessary ; or after one leech- ing repeated blistering may be substituted. Some surgeons use opiates instead of, or in addition to, leeches. Leeches occasionally increase the pain. Severe pain in iritis can nearly always be quickly relieved by artificial heat; either fomentations or dry heat, as hot as can be borne, to the eyelids. To apply dry heat, take a bunch of cotton-wool the size of two fists, hold it to the fire, or against a tin pot full of boiling water, till quite hot, and apply it to the lids ; have another piece ready and change as soon as the first gets cool ; continue this for twenty minutes or more, and repeat it several times a day. 1 Paracentesis of the ante- rior chamber should be resorted to in severe iritis if the aqueous tumor remain turbid after a few days of other treatment; the wound is to be reopened daily until there is marked improvement. (3) Kest of the eye is very important. Many a case is lengthened out and many a relapse after partial cure is brought on by the patient continuing at, or returning too soon to, work. It is not, in most cases, necessary to remain in a perfectly dark room ; to wear a shade in a room with the blinds down is generally enough, provided that no attempt be made to use the eyes. Work should not be re- sumed till at least a week after all congestion has gone off. (4) Cold draughts of air on the eye and all causes of " catching cold " are to be very carefully avoided, by keep- ing the eye warmly tied up with a large pad of cotton-wool. (5) The cause of the disease is to be treated, and into this careful inquiry should always be made. If the iritis be syphilitic, treatment for secondary syphilis is proper, mercury being given to very slight salivation for several 1 I owe my knowledge of the great value of dry heat, so ap- plied, to Mr. Liebreich. DISEASES OP THE IRIS. 14-3 months, even though all the active eye symptoms quickly pass off. The rheumatic and gouty varieties are less defi- nitely under the influence of internal remedies ; iodide of potassium, alkalies, and colchicum certainly appear to exert a good effect in some cases ; when the pain is severe, tincture of aconite is sometimes markedly useful ; mercury is seldom needed, but in protracted and severe cases it may sometimes be used with advantage. It is sometimes ad- visable to combine quinine with the mercury in syphilis, or to give it in addition to other remedies in rheumatic cases. (6) As a rule, no stimulants are to be allowed, and the bowels should be kept well open. (7) Iridectomy is needed for cases of severe iritis where judicious local and internal treatment have been carefully tried for some weeks without marked relief to the inflamma- tory symptoms, and whether or not there be increased ten- sion. It is chiefly in cases of constitutional origin, either syphilitic or rheumatic, and in the iritis accompanying ulcers of the cornea, that it is necessary. It is not applica- ble to sympathetic iritis, nor to iritis after cataract extrac- tion. In reference to iridectomy, it is to be borne in mind that unless necessary it is injurious, by producing an en- larged and irregular pupil through which, owing to spheri- cal aberration, the patient will often not see so well as through the natural pupil, even though this be partially ob- structed. The effect cf the operation in staying and abating the inflammation is very marked in some cases, but, in order to be sure that the effect is due to the operation, we must have first tried fairly the other means of cure. Indeed, in regard to all methods of local treatment, we must bear in mind that acute iritis occurs in all degrees of severity, and that the mildest cases often need only atropine and rest. Traumatic iritis, in a very early, stage is best combated by continuous cold applied by means of pieces of lint wetted 144 DISEASES OE THE IRIS. in iced water or on a block of ice, and laid upon the lids ; and by leeches. Cold is not to be used to any other form of iritis. Congenital irideremia (absence of iris) is occasionally seen, and is often associated with other congenital defects of the eye. Coloboma of the iris (congenital cleft in the iris) gives the effect of a very regularly made iridectomy. It is al- ways downwards or slightly down-in, and usually, but not always, symmetrical. There are many varieties in degree, and sometimes there is nothing more than a sort of line or seam in the iris. It often occurs without coloboma of the choroid. Persistent remains of the pupillary membrane have sometimes to be distinguished from iritic adhesions. They occur in the form of thin shreds or loops of tissue, in color resembling the iris, to the anterior surface of which, close to its pupillary border, they are attached. They are longer and slenderer than posterior synechise, and are not attached to the lens-capsule. 1 In one remarkable instance I saw well-marked remains of this membrane complicated with equally unequivocal iritic adhesions in a case of acute iritis in a man. 1 "When remains of pupillary membrane are complicated with old iritic adhesions in children, there has probably been intra- uterine iritis. DISEASES OF THE CILIARY REGION. 145 CHAPTER X. DISEASES OF THE CILIARY REGION. THIS chapter is intended to include cases in which the ciliarv body itself, or the corresponding part of the scle- rotic, or the episcleral tissue, is the sole seat, or at least the headquarters of inflammation. The abundance of vessels and nerves in the ciliary body, and the importance of its nutritive relations to the surrounding parts prepare us to find that many of the morbid processes of the ciliary region show a strong tendency to spread, according to their pre- cise position and depth, to the cornea, iris, or vitreous, and by influencing the nutrition of the lens to cause secondary cataract. Although alike on pathological and clinical grounds it is necessary to subdivide the class into groups, we may observe that in some of their more obvious and important characters all the diseases of this part show a general agreement ; thus all of them are protracted and liable to relapse, and in all there is a marked tendency to patchiness, the morbid process being most intense in certain spots of the ciliary zone, or even occurring in quite dis- crete patches. It is convenient to make three principal clinical groups, the differences between which are ac- counted for to a great extent by the depth of the tissue chiefly implicated. The most superficial may be taken first. (1) Episcleritis (more correctly SclerotHis) is the name given to one or more large patches of congestion, with some elevation of the conjunctiva from thickening of the subjacent tissues, in the ciliary jegion. The congestion generally affects the conjunctival as well as the deeper 18 146 DISEASES OF THE CILIARY KEGION. vessels, and the yellowish color of the exudation tones the bright blood-red down to a more or less rusty tinge, which is especially striking at the centre of the patch, where the thickening is greatest. The latter varies in amount, but seldom causes more than a low, Avidely spread mound of swelling. Episcleritis is a rather rare disease. It occurs chiefly on the exposed parts of the ciliary region, and especially near the outer canthus, but the patches may occur at any part of the circle; and exceptionally the inflammation is diffused over a much wider area than the ciliary zone, extending back out of view. The iris is often a little discolored and the pupil sluggish, but actual iritis is rare. There is often much aching pain. The disease is subacute, reaching its acme in not less than two or three weeks, and requiring a much longer time before absorption is complete. Fresh patches are apt to spring up while old ones are declining, and so the disease may last for months ; indeed, relapses sooner or later (in fresh spots) are the rule. It usually affects only one eye at a time, but both often suffer sooner or later. After the congestion and thickening have dis- appeared a patch of the underlying sclerotic, of rather smaller size, is generally seen to be dusky as if stained ; it is doubtful whether such patches represent thinning of the sclerotic from atrophy or only staining ; it is but seldom that they show any tendency to bulge as if thinned. In rare cases the exudation is much more abundant, and a large hemispherical swelling is formed, which may even contain pus ; such cases pass by gradations into con- junctival phlyctenulse, and are generally seen in chil- dren (compare p. 116). Episcleritis is seldom seen except in adults, and is com- moner in men than in women. It is commonest on the exposed parts of the globe, and inquiry often shows that the sufferer is, either from occupation or temperament, par- DISEASES OF THE CILIARY REGION. 147 ticularly liable to be affected by exposure to cold or by changes of temperature ; some are decidedly rheumatic. Similar patches, but of a brownish, rather translucent ap- pearance, are occasionally caused by tertiary syphilis, acquired or inherited (" gummatous sclerotitis"}. In the treatment, protection by a warm bandage, rest, the yellow ointment, the use of repeated blisters, and local stimulation of the swelling, are generally the most effica- cious. Atropine is very useful in allaying pain. Internal remedies seldom seem to exert much influence except in syphilitic cases. Lately systematic kneading of the eye through the closed lids (massage), and also scraping away the exudation with a sharp spoon, after turning back the conjunctiva, have been highly spoken of, and are certainly worth trial. (2) Sclero-keratitis and sclero-iritis ("scrofulous scle- rotitis," " anterior choroiditis"). A more deeply seated, very persistent, or relapsing subacute inflammation, char- acterized by congestion of a violet tinge (deep scleral con- gestion, p. 27, 2), being abruptly limited to the ciliary zone, and affecting some parts of the zone more than others (tendency to patchiness). Early in the case there is a slight degree of bulging of the affected part, due partly to thickening ; whilst patches of. cloudy opacity, which may or may not ulcerate, appear in the cornea close to its mar- gin. Later on, iritis generally occurs. Pain and photo- phobia are often severe. After a varying interval, always weeks, more often months, the symptoms recede. At the focus of greatest congestion, or it may be around the entire zone, the sclerotic is left of a dusky color, sometimes inter- spersed with little yellowish patches, and permanent hazi- ness of the most affected parts of the cornea remains. The disease is almost certain to relapse sooner or later ; or a succession of fresh inflammatory foci follow each other without any intervals of real recovery, the whole process 148 DISEASES OF THE CILIAKY HEGION. extending over many months. After each attack more haze of cornea and fresh iritic adhesions are left. The sclerotic, in bad cases of some years' standing, becomes much stained, and bulges very considerably (ciliary or an- terior staphyloma), and the cornea becomes both opaque and altered in curve ; the eye is then useless, though but seldom liable to further active symptoms. The characteristic appearance of an eye which has been moderately affected, is the dusky color of the sclerotic and the irregular patchy opacity of the cornea (Fig. 52), the opacities being often continuous \vith the sclerotic. The disease does not occur in children, nor does it begin late in life; most of the patients are young or middle-aged adults, FIG. 52. Relapsing selero-keratitis (from nature). and, unlike the former variety, most are women. It is not associated with any special diathesis or dyscrasia, but gen- erally goes along with a feeble circulation and liability to " catch cold ;" in some cases there is a definite family history of scrofula or of phthisis. Predisposed persons are more likely to suffer in cold weather, or after change to a colder or damper climate, or after any cause of exhaustion, such as suckling. TREATMENT is at best but palliative. Local stimulation by yellow ointment or calomel is very useful iu some cases, particularly those which verge towards the phlyctenular V DISEASES OF THE CILIARY REGION. 149 type. In the early stages, especially when the congestion is very violent and altogether subconjunctival, atropine often gives relief, and it is, of course, useful for the iritis. Re- peated blistering is also to be tried, though not all cases are benefited by it. I have not seen much benefit from setons. Warm, dry applications to the lids are, as a rule, better than cold. Mercury, in small and long-con- tinued dcses, is certainly valuable when the patient is not anaemic and feeble, but it is to be combined with cod-liver oil and iron. Protection from cold and bright light by ''goggles" is a very important measure, both during the attacks and in the intervals between them. There is no rule as to symmetry ; both eyes often suffer sooner or later, but sometimes one escapes whilst the other is attacked re- peatedly. Transition forms occur between this disease and episcleritis. (3) Cyclitis with disease of vitreous and keratitis punc- tata (chronic serous irido-choroiditis). A small but im- portant series of cases, in which there is congestion like that attending mild iritis, and dulness of sight, but usually with no pain or photophobia. Flocculi are found in the anterior part of the vitreous, or numerous small dots of deposit are seen on the posterior surface of the cornea (keratitis punctata, Fig. 47) ; the anterior chamber is often too deep, and insidious iritis usually follows. Patches of recent choroiditis are often to be seen at the fundus. Persistence and liability to relapse are features as marked here as in the other members of the cyclitic group. The final condition turns very much on the extent of the iritic adhesions, for when the synechice are numerous and tough, and the iris is much altered in structure, secondary glau- coma may arise (p. 139) or the pupil be blocked by iritic membrane. "When seen quite early, such a case will prob- ably be diagnosed as "serous iritis" or as "ciliary con- gestion," unless carefully examined, for the pupil is gen- 1?,* 150 DISEASES OF THE CILIAIIY REGION. erally free in all parts, or shows, at most, one or two ad- hesions when atropine is used; glaucomatous symptoms, however, sometimes develop early in the disease, before iritic adhesions have formed. In a few cases the punctate deposits on the back of the cornea constitute almost the only objective change (simple keratitis punctata), but these are very rare (p. 131) (compare Chronic Iritis, p. 140). The cases occur always in adolescents or young adults, and the disease is always sooner or later symmetrical. Many mild cases recover perfectly, and in others a good result is finally achieved. In respect to cause, there is strong reason to believe that many of these cases are the result of gout in a previous generation, the patient himself never having had the disease (Hutchinson). The disease seems often to be excited in predisposed persons by pro- longed overwork or anxiety, combined with underfeeding, or, what comes to the same thing, defective assimilation ; the patients often describe themselves as, or are obviously, delicate. On the other hand, in some of the worst cases, leading to secondary cataract and ultimately to shrinking of the eyes (see Chronic Iritis, p. 140), the patient appears to be, from first to last, in good health, and free from any ascertainable morbid diathesis. In the treatment, prolonged use of atropine and rest of the eyes arc the most important local measures. In certain cases iridectomy is necessary. Small doses of iodide of potassium and mercury appear to be useful in the earlier stages, given with proper precautions, and accompanied by iron, cod-liver oil, and sometimes quinine or bitters. Change of climate would probably often be beneficial. In the worst cases, where the changes are very like those resulting from sympathetic ophthalmitis, no treatment seems to have any effect. Cases of acute inflammation are occasionally seen in which most of the symptoms resemble those of acute iritis, DISEASES OF THE CILIARY REGION. 151 but with the iris so little affected that it is evidently not the headquarters of the morbid action. The tension may be much reduced, whilst repeated aud rapid variations, both in sight and objective symptoms, occur. The term "idiopathic phthisis bulbi" has been applied to some of these. Again, some cases of syphilitic inflammation, which are classed as syphilitic " iritis," might more correctly be called " cyclitis." In some cases of heredito-syphilitic kera- titis there is much cyclitic complication (p. 128), and these are always difficult to treat. Plastic or, more rarely, purulent inflammation of the ciliary body, following injury, is the usual starting-point of the changes which set up sympathetic inflammation of the fellow eye ; and the changes in the sympathizing eye gen- erally begin also in the ciliary body, quickly spreading forwards to the iris, and backwards to the choroid, vitreous, and retina. The outset of this traumatic cyclitis (jpan&ph- thalmitu) is signalized by ciliary congestion, pain, and marked tenderness to palpation ; there is often lowered tension and iritis. If the lens be transparent, a yellow or greenish reflection is, after a few days, often seen from behind it, indicating the presence of pus in the vitreous humor. SYMPATHETIC IRRITATION AND SYMPATHETIC OPIITHALMITIS. Certain morbid changes in one eye may set up functional disturbance and destructive inflammation in its fellow. The term sympathetic irritation is given to the former, and sympathetic ophthalmitis (or ophthalmia) to the latter. They may be combined, but often occur separately, and it is very important to distinguish between them. Although at present the exact nature of the process which causes sympathetic inflammation is unknown, and 152 DISEASES OF THE CILIARY REGION. though its path has not been fully traced out, it is certain (1) that the change starts from the region most richly sup- plied by branches of the ciliary nerves (composed of fibres from the fifth, sympathetic, and third), viz., the ciliary body and iris ; (2) that its first effects are generally seen in the same part of the sympathizing eye; (3) that the exciting eye has nearly always been wounded, and in its anterior part ; and that decided plastic inflammation of its uveal tract is always present ; (4) that inflammatory changes have in some cases been found in the ciliary nerves and optic nerve of the exciting eye. The morbid influence has of late years been generally believed to pass along the ciliary nerves, but the earlier hypothesis of transmission along the optic nerve has re- cently been revived, and further the bloodvessels, lym- phatics, and even the blood itself are at the present time claimed by different authors as probable channels. The histology of the subject needs to be gone over again with the most modern methods. In almost every case sympathetic inflammation is set up by a perforating wound, either accidental or operative, in the ciliary region of the other eye, i. e., within a zone, nearly a quarter of an inch wide, surrounding the cornea. The risk attending a wound in this " dangerous zone " is increased if it be lacerated, or heal slowly, or if the iris or ciliary body be engaged between the lips of the sclerotic, or if the eye contain a foreign body ; under all conditions, indeed, which make the occurrence of plastic or purulent cyclitis probable. Sympathetic inflammation may also be caused by perforating ulceration of the cornea with ante- rior synechia; and by an eye containing a tumor, though probably not unless the eye has been operated upon. A foreign body lodged in the eye, whether the wound be in the ciliary region or not, is always a possible source of sympathetic mischief; and a wound entirely corneal, if DISEASES OF THE CILIAKY REGION. 153 complicated by a large anterior synechia with dragging on the ciliary body, may also occasion it. Symptoms in the exciting eye. The exciting eye gen- erally shows ciliary congestion and photophobia, and often suffers neuralgic pain when it is causing sympathetic irri- tation. Iritis is always present in an eye which is causing sympathetic inflammation; but the iritis is often painless and without noticeable congestion, and thus may easily be overlooked. It is especially important to remember that the exciting eye, though its sight is always damaged, need not be blind, and that, under certain circumstances, it may in the end be the better eye of the two. Symptoms in the sympathizing eye. a. Sympathetic Irri- tation. The eye is, in common speech, "weak" or "irrita- ble." It is intolerant of light, and easily flushes and waters if exposed to bright light or if much used ; the ac- commodation is weakened or irritable, so that continued vision for near objects is painful or even impossible, and the ciliary muscle seems liable to give way suddenly for a short time, the patient complaining that near objects now and then suddenly become misty for a while. Temporary darkening of sight, indicating suspension of retinal func- tion, is said to occur, whilst other cases show a considerable and more lasting defect of sight without ophthalmoscopic changes, and of obscure causation. Neuralgic pains re- ferred to the eye and side of the head are also common. Such attacks may occur again and again in varying sever- ity, lasting for days or weeks, and finally ceasing without ever passing on to structural change. Sympathetic irrita- tion is always, and as a rule promptly, cured by removal of the exciting eye ; but occasionally the symptoms persist for some time afterwards. b. Sympathetic Inflammation (^Ophtlialmitis}. The disease may arise out of an attack of "irritation," but more com- monly sets in without any such warniug. It may be acute 154 DISEASES OF THE CILIARY REGION. and severe, or so insidious as to escape the notice of the patient until -well advanced. It is in all cases a prolonged and a relapsing disease ; -when once started it is self-main- taining, and its course usually extends over many months, or even a year or two. In mild cases a good recovery eventually takes place, but in a large majority the eye be- comes blind. The disease is essentially an irido-cyclitis or irido-choroiditis, the external signs being those of iritis with rapid formation of tough and extensive synechise. Its chief early peculiarities are a great liability to dotted de- posits on the back of the cornea (p. 130), a dusky tint of ciliary congestion with marked engorgement of the large vessels which perforate the sclerotic in the ciliary region (as in glaucoma), and marked thickening and muddiness of the iris, the anterior chamber becoming shallow; we must add that there is frequently tenderness on pressure in the ciliary region. If the pupil allows of ophthalmoscopic examination, we shall find the vitreous clouded by floating opacities, and there may be ueuro-retinitis. In acute and severe cases the congestion is intense, there is severe pain, photophobia, and tenderness on pressure, and the iris, be- sides being thick, is changed in color to a peculiar buff or yellowish-brown, and shows numerous enlarged bloodves- sels ("plastic" form). Attacks of intense neuralgia of the fifth nerve characterize some cases. In cases of all degrees, the tension is often increased, the eye becoming decidedly glaucomatous for a longer or shorter time. The lens often suffers, showing many small dotted opacities, and eventu- ally becoming opaque. In the worst cases the eye finally shrinks, but in many a prolonged glaucomatous state is established, with slight thinning and bulging of the scle- rotic in front, total posterior synechia, and secondary cata- ract. In the mildest cases (the so-called " serous" form), the disease never goes beyond a chronic iritis with punctate keratitis and disease of the vitreous. DISEASES OF THE CILIARY REGION. 155 Sympathetic ophthalmitis generally begins about two or three months after the injury or other cause of mischief in the exciting eye; seldom, if ever, sooner than three weeks, i. e., not until time has elapsed for well-marked inflamma- tory changes to occur at the seat of injury. On the other hand, the disease may set in at any length of time, even many years, after the injury or other disease of the ex- citing eye, particularly if the latter contain a foreign body. It occurs at all ages, but children are considered to be more liable than adults. Distinct inflammatory changes are al- ways present in the exciting eye, but, as already stated, they may be manifested by very slight subjective symp- toms. When carefully observed, these changes are found to precede by some days, if not longer, the onset of struct- ural disease in the sympathizing eye, the morbid process apparently taking some days to travel from one eye to the other. TREATMENT. By far the most important measure refers to prevention. When once sympathetic inflammation has begun we can do little to modify its course. The clear rec- ognition of this fact leads us to advise the excision of every eye which is at the same time useless and liable to cause sympathetic mischief, i. e., of all eyes which are blind from disease of the anterior segment of the globe; and to give this advice most urgently when the blind eye is al- ready tender or irritable, or is liable to become so, when it has been lost by wound, and when it is probable that it may contain a foreign body. Any lost eye in which there are signs of past iritis, whether it has been injured or not, is best removed, especially if shrunken. But much judg- ment is needed if the damaged eye, though irritable and likely to cause mischief, still retains more or less sight. Every attention must then be paid to the exact position of the wound, the evidence as to its depth, the condition of the lens, the evidence of hemorrhage, and especially to the 156 DISEASES OF THE CILIAKY REGION. yellowish haziness behind the lens, which indicates lymph or pus in the vitreous (p. 151). The date of the injury and the condition of the wound, whether healed by imme- diate union, or with scarring, puckering or flattening, are very important points. Irritation of the fellow eye may set in a few days after the injury; but since inflammation very seldom begins sooner than two or three weeks, we may, if we see the case early, watch it for a little time. Complete and prolonged rest in a darkened room is a very important element in the prevention of sympathetic irrita- tion and inflammation, and should always be insisted on when we are trying to save an injured eye (compare p. 142). In rare cases sympathetic inflammation sets in after the re- moval of the exciting eye, even after an interval of several weeks, a contingency which emphasizes the importance of excising at the earliest possible moment. When sympathetic ophthalmitis has set in we can do com- paratively little. A. The exciting eye, if quite blind or so seriously dam- aged as to be certainly for practical purposes useless, is to be excised at once, though the evidence of benefit from this course is slender. But it is not to be removed if there is reason to hope for restoration of useful sight in it ; if there be simply a moderate degree of subacute irido-cyclitis with or without traumatic cataract, and with sight propor- tionate to the state of the lens, the eye is to be carefully treated, since it may very probably in the end be the better of the two (p. 153). B. Ttie sympathizing eye. The important measures are (1) atropine, used very often as for acute iritis; (2) abso-' lute rest and exclusion of light by residence in a dark room and with a black bandage over the eyes ; (3) re- peated leeching if the symptoms are severe, or counter- irritation by blisters or by a seton in chronic cases. (4) Mercury is believed by some to be beneficial. Quinine is DISEASES OP THE CILIARY REGION. 157 sometimes given. (5) No operation is permissible till the disease has come to a standstill ; iridectomy, whilst there are active symptoms, is followed by closure of the gap with fresh lymph. When there is total posterior synechia and secondary cataract, removal of the lens and a large piece of iris by a special operation will finally be proper if the state of the eye in other respects makes it worth while. The PROGNOSIS is, as will be gathered, very grave; even in the mildest cases, when seen quite early, we must be very cautious, for the disease often slowly progresses for many months. 14 158 INJURIES. CHAPTER XL * INJURIES. INJURIES may be divided into those which affect the eyeball itself and those limited to the surrounding orbital structures. In each class a broad distinction is to be made between contusion and concussion injuries and wounds. A. INJURIES OF PARTS AROUND THE EYEBALL. (1) Contusion and concussion injuries. Ecchymosis of the skin of the eyelids from direct blows (" black eye ") is to be distinguished from extravasation into the orbital cel- lular tissue following fracture of the walls of the orbit. In ordinary "black eye" the ecchymosis is superficial, and, if it affect either the palpebral or ocular conjunctiva, does not pass far back. The ecchymosis following orbital fract- ure is deep-seated, often entirely beneath, rather than in, the skin and conjunctiva, diminishes in density towards the front and borders of the lids, and when considerable may cause proptosis. The '.wo forms may be combined when fracture is caused by direct violence to the orbit. Cold bathing, or an evaporating lotion will hasten the ab- sorption of the blood in ordinary " black eye." Fracture of the inner wall of the orbit into the nose, the sinuses opening into it, or the nasal duct, is often followed by emphysema, of the orbital cellular tissue. This can occur only when the mucous membrane is torn. The emphysema comes on quickly from "blowing the nose," and is shown by a soft, whitish, doughy swelling of the INJURIES. 159 lids, which crepitates finely under the finger; the globe is more or less protruded, and its movements limited. The emphysema disappears in a few days if the lids be kept rather firmly bandaged. These fractures are usually caused by blows over the inner angle of the orbit, but occasionally by blows over its outer rim. Partial ptosis is tui occasional result of blows upon the upper lid. It is generally accompanied by paralysis of accommodation and partial dilatation of the pupil, and it seldom lasts more than a few weeks. But the most serious, though rare, consequences which may follow blows about the orbit, either quickly or after an interval, are acute and chronic orbital abscess and cel- lulitis. Diffused acute inflammation of the cellular tissue is difficult to distinguish from acute orbital abscess, since in both there are the signs of deep inflammation, with dis- placement of the eye and limitation of its movements, chemosis of the conjunctiva, and brawny swelling and red- ness of the lids. An abscess will soon point towards some part of the eyelids, but even in cellulitis the swelling may be greater at some one part, and a feeling deceptively like fluctuation may be present. Orbital abscess may be very chronic, and simulate a solid tumor until the pus nears the surface; even then we may not be able to distinguish it from a cystic tumor, until an exploratory incision sets the question at rest (compare p. 89). Abscess of the orbit, whether acute or chronic, is very often the result of injury which has given rise to periostitis, and a large surface of bone is often laid bare. In acute cases an exploratory incision is to be made with a narrow straight knife, generally through the skin, or if practicable through the conjunctiva, as soon as fluctuation is detected. As the pus is often curdy, it is best not to use a grooved needle. Chronic cases of doubtful nature may be watched for a time. It may be necessary to go 160 INJURIES. deeply into the orbit cither with the knife, probe, or dress- ing forceps, before matter is reached. A drainage-tube should be inserted if the abscess be deep. The proptosis does not always disappear when an orbital abscess is opened, for in addition to hemorrhage caused by the operation there may be much thickening of the tissues. Sight may be injured or lost by stretching of, or pressure on, the optic nerve, and the cornea may become anaesthetic and ulcerate from damage to the ciliary nerve behind the globe. (2) Wounds. Wounds of the eyelids need no special treatment, beyond very careful apposition of sutures, some- times with a small harelip pin, so as to secure primary and accurate union. Lacerated wounds of the ocular con- junctiva need a few fine sutures if extensive, and they sel- dom lead to any deformity. Occasionally one of the recti tendons is divided or torn through, but it can seldom be kept in place by sutures. Penetrating wounds through the lids or conjunctiva, which pass deeply into the orbit, may be much more serious than they appear at first sight, since the wounding body may have caused fracture of the orbit, and damage to the brain-membranes, or a piece of the wounding instrument may have been broken off and lie imbedded in the roomy cavity of the orbit without at first exciting disturbance or causing displacement of the eye. Some most extraordi- nary cases are on record in which very large fragments of iron or other substances have lain in the orbit for a long time undetected. The optic nerve is occasionally torn across without damage to the globe. Every wound of the eyelids or conjunctiva should therefore be carefully ex- plored with the probe, and whenever possible the instru- ment which caused the wound should be examined. When a foreign body is suspected, or knoAvn, to be firmly em- bedded, and is not removable through the original wound, it is generally better to divide the outer canthus, and pro- INJURIES. 161 long the incision into the conjunctiva, than to divide the lid itself. In other cases an incision through the skin, over the margin of the orbit, at the situation of the foreign body, will be preferable. Single shot corns, imbedded and causing no symptoms, should not be interfered with unless they can be easily reached. Wounds of the orbit, by gunshot or other explosions, when extensive and caused by numerous shots or frag- ments of sand, gravel, etc., driven into the tissues, are serious, because the eyeball itself is often injured ; tetanus may also occur. B. INJURIES OF THE EYEBALL. (1) Contusion and concussion injuries. Rupture of the eyeball is commonly the result of severe direct blows. The rent is nearly always in the sclerotic, either a little behind, or close to the corneal margin, with which it is concentric; the cornea itself is but seldom rent by a blow. The rupt- ure is usually large, involves all the tunics, and is followed by hemorrhage between the retina and choroid, and into the vitreous and anterior chambers, and often by escape of the lens and of some of the vitreous ; sight is usually reduced to perception of light or of large objects. The conjunctiva, however, often escapes untorn, and in such a case if the lens pass through the rent in the sclerotic, it will be held down by the conjunctiva, and form a promi- nent, rounded, translucent swelling over the. rupture. The diagnosis of rupture is generally easy, even if the rent be more or less concealed. Shrinking of the eyeball is a com- mon result, but occasionally some vision is restored. Im- mediate excision is often best, but when there is room for hope, we should always wait until the absorption of the blood in the anterior chamber allows the deeper parts to be seen. The treatment will be the same as for wounds of the eye (p. 170). 14* 162 INJURIES. It may here be mentioned that copious hemorrhage, ac- companied by severe pain, sometimes occurs between the choroid and sclerotic as the result of sudden diminution of tension, cither by an operation, such as extraction of cataract or iridectomy, or by a glancing wound of the cor- nea. Eyes in which this occurs are for the most part al- ready unsound, and often glaucomatous. Blows often cause internal damage without rupture of the hard coats of the eye. The iris may be torn from its ciliary attachment (coredialysi^t, so that two pupils are formed (Fig. 53) or the lens Lo loosened or displaced (p. 187) FIG. 53. Separation of iris following a blow (after Lawson). by partial rupture of its suspensory ligament, so that the iris having lost its support will shake about with every movement (tremulous iris). Such lesions are likely to be attended with bleeding into the anterior chamber and into the vitreous, arid the real condition may thus be ob- scured for a time. The lens often becomes opaque after- wards. Detachment of the retina is often found after severe blows, which have caused hemorrhage into the vi- treous. Blows on the front of the eye may cause rupture of the choroid, or hemorrhage from choroidal or retinal vessels. These changes are found at the central part of the fundus, often almost exactly at the yellow spot, thus causing much damage to sight. The rents in the choroid appear after the blood has cleared up, as lines or narrow INJURIES. l(lo bands of atrophy bordered by pigment, and often slightly curved towards the disk (Fig. GGj. Hemorrhages from the choroidal vessels without rupture of the choroid, usually leave some pigment behind after absorption. Paralysis of the iris and ciliary muscle, with partial aud often irregular dilatation of the pupil, is sometimes the sole result of a blow on the eye. The defect of sight can be remedied by a convex lens. When uncomplicated these symptoms are sel- dom permanent. (See also Traumatic Iritis, pp. 140, 141.) Great defect of sight following a blow, and neither reme- died by glasses nor accounted for by blood in the anterior chamber, will generally mean copious hemorrhage into the vitreous, with or without the other changes just mentioned in the retina and choroid. The red blood may sometimes be seen by focal light, but often its pi'esence can only be inferred from the opaque state of the vitreous. Probably in most of these cases the blood comes from the large veins of the ciliary body, but sometimes from the choroid or vessels of the retina. There may be no external ecchymo- sis. The tension of the globe is to be noted ; it is not often increased unless inflammation has set in or the eye was pre- viously glaucomatous, and in some cases it is below par. The prognosis should be very guarded whenever there is reason to think, from the opaque state of the vitreous, that much bleeding has taken place, or when the iris is tremu- lous or partly detached, or if any rupture of the choroid can be made out. Blood in the anterior chamber is gen- erally absorbed within a few days, but in the vitreous ab- sorption is more tardy and less complete, permanent opaci- ties often being left. The use of atropine. the frequent application of iced water, or of an evaporating lotion, to the lids, and occasional leeching if there are inflammatory symptoms, will do all that is possible in the early periods. If the lens be loosened it is likely in time to become opaque, and it may at any time act as an irritating foreign body, 164 INJURIES. and set up a glaucomatous inflammation, or cause sympa- thetic symptoms iu the other eye (p. 187). Now and then optic neuritis occurs in the injured eye as the immediate effect of the blow. Hemorrhage behind the choroid is be- lieved to account for certain well-known cases in which, after a blow, there is defect of sight without visible change, or with localized and temporary haze of retina (" commotio retina"). Temporary myopia or astigmatism may also fol- low a blow on the eye; such changes of refraction depend on altered curvature of the lens, and are sometimes entirely removed by paralyzing the ciliary muscle with atropine. (2) Wounds. A. Surface scratches (abrasions') of the cornea cause much pain, watering, and photophobia with ciliary congestion. They are frequently due to a scratch by the finger-nail of a baby in nursing. The abraded sur- face is often very small and shows no opacity ; it is detected by watching the reflection of a window from the cornea (p. CO), whilst the patient slowly moves his eye. Now and then the irritability persists, or recurs after an interval. Minute fragments of metal or stone flying from tools, etc., often partly imbed themselves in the cornea (foreign body on the cornea), and give rise to varying degrees of irri- tability and pain. If not removed, such a fragment is soon surrounded by a hazy zone of infiltration. Foreign bodies are easily seen unless either very small or covered up by mucus or epithelium. In a doubtful case, examination by focal light (p. 60) will show the dark speck, even when it is invisible by daylight. The pupil is often smaller than its fellow, and the color of the iris altered, in cases of abrasion and of foreign body on the cornea, indicating congestion of the iris (p. 40). Actual iritis sometimes occurs, but not unless the corneal wound becomes inflamed and infiltrated. TREATMENT. (For removal of foreign bodies, see Opera- tions.) After surface injuries use a drop of castor oil to INJURIES. 165 lubricate the cornea, and apply a pad of wadding and a single length of bandage tied behind the head. Atropine is required if there is much irritation or threatened iritis. If iritis with hypopyon arise, the case will become one of hypopyon ulcer (pp. 117 and 122). Foreign bodies often adhere to the inner surface of the upper lid, and the lid must therefore be everted, and exam- ined whenever a patient with a corneal abrasion states that he has "something in his eye." Large bodies sometimes pass far back into the upper or lower conjunctiva! sulcus and lie hidden for weeks or months, causing only local inflammation and some thicken- ing of the conjunctiva. Search must be made, if needful, w y ith a wire loop or probe whenever the suspicion arises (compare p. 160). B. Burns, scalds, and injuries by caustics, etc. The con- junctiva and cornea are often damaged by splashes of molten lead, or by strong alkalies or acids, of which lime, either quick or freshly slaked, is one of the commonest. The eyeball is not often scalded, the lids closing quickly enough to prevent entrance of the steam or hot water. In none of these cases is the full eifect apparent for some days, and a cautious opinion should, therefore, always be given when the case is seen very early. The effects of such accidents aro manifested by (1) in- flammation, with or without ulceration, of the cornea; (2) scarring and shortening of the conjunctiva, and in bad cases, adhesion of its palpebral and ocular surfaces symblepharon ; (3) suppurative keratitis and hypopyon in severe cases. The most superficial burns whiten and dry the surface, and in a few hours the epithelium is shed. This is shown on the cornea by a sharply outlined, slightly depressed area, the floor of which is clear if the damage be quite superficial and recent, but more or less opalescent, or even 16(3 INJUKIES. yellowish, if the case be a few days old and the burn be deep enough to have caused destruction or inflammation of the true corneal tissue. When there is much opacity it does not completely clear, and considerable flattening of the cornea and neighboring sclerotic often occurs at the seat of deep and extensive burns. The conj uncti val whiten- ing is followed by mere desquamation and vascular reaction, or by ulceration and scarring, according to the depth of the damage. TREATMENT. In recent cases, seen before reaction has begun, a drop of castor oil once or twice a day, a few leeches to the temple, and the use of a cold evaporating lotion, or of iced water, will sometimes prevent inflamma- tion. If seen immediately after the accident, the coujunc- tival sac is to be carefully searched for fragments of whatever solid has caused the mischief, or washed with very W 7 eak acid or alkaline solution if a caustic of the opposite character have done the damage. If inflammatory reaction is already present when the case comes to notice, treatment by compress, atropine, and hot fomentations, as recommended for hypopyon ulcers (p. 122), is most suitable. There is often much pain and chemosis. Buttons of gran- ulation forming on the floor of a healing burn of conjuctiva should be snipped off*. c. Penetrating wounds and gunshot injuries. When a patient says that his eye is wounded, the first point is to examine the seat, extent, and character of the wound, ascertain the interval since the injury, and test the sight of the eye ; the next step is to make out all we can about the wounding body, and especially whether or not any fragment has been left within the eyeball. Very large foreign bodies, such as pieces of glass, some- times lie for a long time in the eye without causing much trouble, the large wound having given exit to the contents INJURIES. 1G7 of the globe and been followed by rapid shrinking Avithout inflammation. TREATMENT. Penetrating wounds are least serious when they implicate the cornea alone, or the sclerotic alone behind the ciliary region, i. e., when situated at least one- fourth of an inch behind the cornea. Penetrating wounds of the cornea, without injury to the iris or lens, and with- out any prolapse of iris, are rare ; they generally do very well, and if the case be not seen until one or two days after the injury, the wound will often have healed firmly enough to retain the aqueous, and it may be difficult to decide whether the whole thickness of the cornea has been pene- trated or not. Wounds of the sclerotic seldom unite with- out the interposition of a layer of lymph ; if seen early they should, when clean and uncomplicated by evidence of internal injury, be treated by the insertion of one or two fine sutures, followed by the use of ice (p. 143). But penetrating wounds usually are very serious to the injured eye; the iris is frequently lacerated and included in the track of the wound; the lens is punctured and becomes swollen and opaque from absorption of the aqueous tumor (traumatic cataract, p. 180), and liable in its swollen state to press on the ciliary processes and cause grave symptoms ; extensive bleeding perhaps takes place into the vitreous ; a few days later, plastic or purulent cyclitis may destroy the eye. The fellow eye is, of course, often in danger of sympathetic inflammation (p. 151). Every case has therefore to be judged from two points of view, the damage to the injured eye and the risk to the sound one; and the question of whether to sacrifice or attempt to save the former is sometimes very difficult to decide. (I.) In the two following cases the eye should be excised at once. (1) If the wound, lying wholly or partly in the "dangerous region" (p. 152), be so large and so compli- cated with injury to deeper parts that no hope of useful 108 INJURIES. sight remains. (2) If, even though the wound be small, it lie in the dangerous region, and have already set up irido- cyclitis (p. 151). (II.) There is a large class of cases in which the wound, though in the ciliary region, or involving the lens and iris through the cornea, is not of itself fatal to sight, and has not as yet led to inflammation or to skrinking of the eye. The first question then is whether the eye contains a foreign body, and if so whether or not it is steel or iron, and therefore possibly removable by a magnet ; the second question is whether the lens is wounded. A foreign body, if lying on or imbedded in the iris, the lens being intact, should be removed, usually with the portion of iris to which it is attached ; if loose in the anterior chamber, it may be difficult to remove. If it can be seen in the lens, and the condition of the eye be otherwise favorable, a scoop ex- traction may be done in the hope of removing the fragment with the lens ; or the lens may be allowed, or by a needle operation (p. 182) induced, to undergo partial absorption, so that in shrinking it may enclose the foreign body more firmly, and bring this away, when itself subsequently ex- tracted. If it is certain that the foreign body has passed into the vitreous, whether through the lens or not, and whether by gunshot or not, it is seldom possible to save the eye ; the body can of course seldom be seen, but a track of opacity through the lens with extensive hemorrhage into the vitreous, or even the latter alone, with conclusive history that the wound was made by a fragment or a shot, and not by an instrument or large body, is generally enough to settle the point in favor of excision. These rules now need modification when the foreign body is of iron or steel, since it is possible in some cases, by means of a strong electro- magnet, to remove such fragments, even when lying in the vitreous. This may be done either through the wound of entrance, more or less enlarged, or through a fresh wound INJURIES. 169 made where the body is seen or believed to lie. The method is at present new, and many forms of magnet have been used, the most successful, however, usually being those in which a small spatula instrument, powerfully magnetized by being attached to the core of an electro-magnetic coil, is introduced into the eye in search of the body. The spatula in an instrument which I have used will, when the circuit is complete, lift between six and eight ounces. Though a considerable number of eyes have now been saved with more or less useful sight, by the use of the magnet, it must be remembered that the extraction of the foreign body does not insure the safety of the eye ; that it may inflame or shrink, and remain as potent a source of sympathetic disease as before, especially so if iritis or threatened pan- ophthalmitis were present at the time of operation. 1 (III.) There remain cases of less severe character, and in which no foreign body remains in the eye: (1) the wound is in the dangerous region and complicated with traumatic cataract ; (2) in the dangerous region without traumatic cataract ; (3) there is traumatic cataract, but the wound is corneal, and, therefore, out of the dangerous zone. In the first, and still more in the second of these, there will often be much difficulty in deciding what to do, it being presumed that the wounded eye shows no iritis or other signs of severe inflammation. Some of the most difficult cases are those in group (2) of wounds by sharp instruments close to the corneal border, with considerable adhesion of the iris, or in which there is evidence that the track lies between the lens and the ciliary processes, the lens not being wounded, and useful sight remaining. If the patient be seen within two or three weeks of the injury, and the sound eye shows 1 Mr. McHardy, who was one of the first to bring the subject forward, has just given a detailed account of some of the best forms of electro-magnet in vol. i. of the Transactions of the Oph- thalmological Society (1881). 15 170 INJURIES. no irritation, we may safely watch the case for a few days. If decided sympathetic irritation (see p. 153) be present, and do not yield after a few days' treatment, excision is advisable, even though the lens of the wounded eye be un- injured. I think that if we made a rule of excising every eye with wound in the ciliary region and traumatic cata- ract (group 1), whether or not it were causing sympathetic symptoms or were itself especially irritable, we should not be far wrong, for the prospect of regaining useful vision in the eye under such circumstances is often slight. In the third group, excision is justifiable only in the rare cases where severe iritis and threatened panophthalmitis come on. The patient in all open cases must be warned, and must be seen every few days for many weeks. When sympathetic ophthalmitis (p. 153) has set in before the patient asks advice, the rule as to excision of the ex- citing eye is different (p. 157). The treatment of wounded eyes which are not excised is the same as for traumatic iritis and cataract, viz., atropine, rest, and local depletion (see pp. 141 and 180). If seen before inflammation (iritis) has begun, ice is to be used (p. 143). When the iris has prolapsed into the wound the protrusion should usually be cut off, and the cut ends, if possible, returned into the anterior chamber (see Iridec- tomy) ; if seen a few hours after the wound, the prolapse can sometimes be returned, or will retract under the use of eserine. It is sometimes important to determine whether an ex- cised eye contains a foreign body. If nothing can be found in the blood or lymph, etc., by feeling with a probe, it is best to crush the soft parts, little by little, between finger and thumb, when the smallest particle will be felt. If a shot has entered and left the eye, the counter-opening may, if recent, be found from the inside, although no ir- regularity be noticeable outside the eyeball. CATARACT. 171 CHAPTER XII. CATARACT. CATARACT means opacity of the crystalline lens, and is due to changes in the structure and composition of the lens- fibres. The capsule is often thickened, but otherwise not materially altered. These changes seldom occur through- out the whole lens at once, but begin first in a certain re- gion, e. g., the centre (nucleus) or the superficial layers (cortex), whilst in some of the forms of partial cataract the disease remains permanently confined to some well-circum- scribed part. Senile changes in the lens. With advancing age the lens, which is from birth firmest at the centre, becomes harder and flatter, and acquires a yellow color; its refractive power changes, its surface reflects more light, and its sub- stance becomes somewhat fluorescent. The result of all these changes is that at an advanced age the lens is more easily visible than in early life, the pupil becoming grayish instead of quite black. This grayness of the pupil may easily be mistaken for cataract, but ophthalmoscopic ex- amination shows that the lens is quite transparent, and the fundus seen without any blurring. The consistence of a cataract depends more on the pa- tient's age than on the position or character of the opacity. Below about thirty-five all cataracts are "soft," and the wide physical differences between cataracts depend less on variations in the cause, than on the degree of natural hard- ness the lens possesses when the opacity sets in. 172 CATARACT. FORMS OF GENERAL CATARACT. (1) Nuclear cataract. The opacity begins in, and re- mains more dense at, the nucleus of the lens, thinning off gradually in all directions towards the cortex (Fig. 56) ; the nucleus is not really opaque, but densely hazy like thick fog. The patients are generally old people, in whom the nucleus is naturally very firm and yellow; hence nuclear cataract is also usually senile and hard, to v/hich we may add that it is often amber-colored or light brownish, like " peasoup " fog. (2) Cortical cataract. The change begins in the super- ficial parts, and generally in the form of sharply defined lines or streaks, or triangular patches, which point towards the axis of the lens, and whose shape is dependent on the arrangement of the lens fibres (Fig. 57). They usually begin at the edge (equator) of the lens where they are hidden by the iris, but when large enough they encroach on the pupil as whitish streaks or triangular patches. They affect both the anterior and posterior layers of the lens, and the intervening parts may be quite clear. Sooner or later the nucleus also becomes hazy (mixed cataract), and the whole lens eventually gets opaque. Some cases of the large class known as " senile " or "hard " cataract are nuclear from beginning to end, i. e., formed by gradual extension of diffused opacity from the centre to the surface ; more commonly they are of the mixed variety. A few cataracts beginning at the nucleus, and many be- ginning at the cortex, are not senile in the sense of accom- panying old age, and are, therefore, not hard. Some such are caused by diabetes, but in many it is impossible to say, except by a general reference to bad health or premature senility, why the lens should have become diseased. Many such are known as "soft" cataracts when complete. They generally form quickly in a few months. A few are con- CATARACT. 173 genital. Whether nuclear or cortical, they are whiter and more uniform looking than the slower cataracts of old age, and the cortex often has a sheen like satin, or looks flaky, like spermaceti. In some cortical cataracts we find only a great number of very small dots or short streaks (dotted cortical cataract). Occasionally a single large wedge-shaped opacity will form at some part of the cortex and remain stationary and soli- tary for many years. Sometimes in suspected cataract, though no opaque striae are visible by focal illumination, one or more dark streaks are seen with the mirror which alter as it is differently inclined, and have much the same optical effect as cracks in glass. These "flaws" should always be looked on as the beginning of cataract. PARTIAL CATARACT. Three forms need special notice. (1) Lamellar (zonular) cataract is a peculiar and well- marked form in which the superficial laminse and the nu- cleus of the lens are clear, a layer or shell of opacity being present between them (Fig. 59). It is uncertain whether the opacity is present at birth or formed a few months later; it certainly never forms in after-life. The great majority of its subjects suffer from infantile convulsions. The size of the opaque lamella or shell, and, therefore, its depth from the surface of the lens, is subject to much variation, and it may be much smaller than is shown in the figure. The opacity is often stationary for years, perhaps for life ; and though it is generally believed that the cataract, if allowed to take its course, eventually becomes general, cases in which this can be proved are rare. (2) Pyramidal cataract. A small, sharply defined spot of chalky-white opacity is present in the middle of the pupil (at the anterior pole of the lens), looking as if it lay upon the capsule. When viewed sideways, it seems to be 15* 174 CATARACT. superficially imbedded in the lens, and also sometimes stands forwards as a little nipple or pyramid (Fig. 54). FIG. 54. Pyramidal cataract seen from the front and in section. It consists of the degenerated products of a localized in- flammation just beneath the lens-capsule, with the addition of organized lymph derived from the iris and deposited on the front of the capsule, the capsule itself being puckered FIG. 55. Magnified section of a pyramidal cataract. The fine parallel shading shows the thickness of the opacity, the double (black and white) outline is the capsule; on each side are the cortical lens fibres, many being broken up into globules beneath the opacity. Lying upon the puckered capsule over the opacity is a little fibrous tissue, the result of iritis. and folded (Fig. 55). It is always stationary and never becomes general. Pyramidal cataract is the result of central perforating ulceration of the cornea in early life, and of this ophthal- mia neonatorum is nearly always the cause. It is gener- ally associated with central opacity of the cornea. The contact between the exposed part of the lens-capsule and the inflamed cornea, which occurs when the aqueous has escaped through the hole in the ulcer, appears to set up the localized subcapsular inflammation. It is probable that the same change may occur in ophthalmia of infants with- CATARACT. 175 out perforation of the cornea, and iritis in very early life may also cause similar opacities. The term anterior polar cataract is applied both to the pyramidal form and to some less common varieties which begin in the same part of the lens. (3) Cataract, which afterwards becomes general, may begin as a thin layer at the middle of the hinder surface of the lens (posterior polar cataract) (Fig. 58). There are many varieties, but in general the pole itself shows the most change, the opacity radiating outwards from it in more or less regular spokes. The color appears grayish, yellowish, or even brown, because seen through the whole thickness of the lens. Sometimes the opacity is situated really just behind the capsule, i. e., in the hyaloid mem- brane or front of the vitreous ; but this cannot be proved during life. Cataract beginning at the posterior pole is often a sign of disease of the vitreous depending on cho- roidal disease ; it is common in the later stages of retinitis pigmeutosa and severe choroiditis, and in high degrees of myopia with disease of the vitreous. The prognosis, there- fore, should always be guarded in a case of cataract where the principal part of the opacity is in this position. When a cataract forms without known connection with other disease of the eye it is said to be "primary" The term, secondary cataract is used when it is the consequence of some local disease, such as severe iridocyclitis, glaucoma, detachment of the retina, or the growth of a tumor in the eye. The pyramidal cataract is strictly a secondary form, though not usually called so. Primary cataract is almost always symmetrical, though seldom synchronous in the two eyes; whilst secondary cataract, of course, may or may not be symmetrical. The subjective symptoms of cataract depend almost solely on the obstruction and distortion of the entering light by the opacities. Objectively cataract is shown in 176 CATARACT. advanced cases by the white or gray condition of the pupil at the plane of the iris ; in earlier stages by whitish opacity in the lens when examined by focal illumination (p. 60) and by corresponding dark portions (lines, spots, or patches) in the red pupil when examined by the ophthalmoscope mirror. Both subjective and objective symptoms differ with the position and quantity of the opacity. When the whole lens is opaque, the pupil is uniformly whitish ; the opacity lies almost on a level with the iris, no space intervening, and consequently, on examining by focal light, we find that the iris casts no shadow on the opacity ; the brightest light from the mirror will not penetrate the lens in quan- tity enough to illuminate the choroid, and hence no red reflex will be obtained. Such a cataract is said to be ma- ture or "ripe," and the affected eye will be in ordinary speech "blind." If both are equally affected, the patient will be unable to see any objects; but he will distinguish quite easily between light and shade when the eye is alter- nately covered and uncovered in ordinary daylight (good perception of light, p. /.), and will tell correctly the position of a candle flame. Diagnosis of Immature and Partial Cataracts. The patient complains of gradual failure of sight, and we find the acuteness of vision (p. 43) impaired more or less (probably more in one eye than in the other). In the earliest stages of senile cataract some degree of myopia may be developed (Chap. XX.), or owing to irregular refraction by the lens, the patient may see two or more images close together of any object with each eye (polyopia uniocularis). If he can still read moderate type, the glasses appropriate for his age and refraction, though giving some help, do not remove the defect, whilst for distant objects CATARACT. 177 vision is worse in proportion than for the near types. If, as is usual, he be presbyopic, he will be likely to choose over-strong spectacles, and to place objects too close to his eyes, so as to obtain larger retinal images, and thus com- pensate for want of clearness (p. 26). In nuclear cataract, as the axial rays of light are most obstructed, sight is often better when the pupil is rather large, and such patients tell ua that they see better in a dull light or with their back to the window, or when shading the eyes with the hand. In the cortical and more diffused forms this symptom is less marked. On examining by focal light (after dilating the pupil with atropine) an immature nuclear cataract appears as a yellowish, rather deeply seated haze, upon which a shadow is cast by the iris on the side from which the light comes (3, Fig. 56). On now using the mirror, this same opacity FIG. 56. Nuclear cataract. 1. Section of lens ; opacity densest at centre. 2. Opacity seen by transmitted light (ophthalmoscope mirror) with dilated pupil. 3. Opacity as seen by reflected light (focal illumination). appears as a dull blur in the area of the red pupil, darkest at the centre, and gradually thinning off 0:1 s:.l sides, so that, at the margin of the pupil, the full red choroidal reflex may still be present; the fundus is seen as through a fog, which is thickest in the axis of vision, so that by looking through the more lateral parts the details are bet- ter seen (2, Fig. 56). If the opacity is very dense and large, only a faint dull redness is visible quite at the border of the pupil. 178 CATARACT. Cortical opacities, if small and confined to the equator (or edge) of the lens, do not interfere with sight ; they are easily detected with a dilated pupil by throwing light very obliquely behind the iris. When large and encroaching on the pupil they are visible in ordinary daylight. They occur in the form of dots, streaks, or bars ; seen by focal light they are white or grayish, and more or less sharply defined, according as they are in the anterior or posterior layers (3, Fig. 57). With the mirror they appear black FIG. 57. Cortical cataract. References as in preceding figure. or grayish, and of rather smaller size (2, Fig. 57), and if the intervening substance is clear, the details of the fundus can be seen, sharply between the bars of opacity. Posterior polar opacities are seldom visible without care- ful focal illumination, when we find a patchy or stellate figure very deeply seated in the axis of the lens (3, Fig. 58) ; if large, it looks concave like the bottom of a shallow FIG. 58. Posterior polar cataract. References as before. cup. With the mirror it is seen as a dark star (2, Fig. 58), or network, or irregular patch, or smaller than when seen by focal light. The diagnosis of lamellar cataract is easy if its nature be understood, but by beginners it is often diagnosed as "nu- CATARACT. 179 clear." The patients are generally children or young adults; they complain of "near sight" rather than of "cataract;" for the opacity is not usually very dense, and whether the refraction of their eyes be really myopic or not, they (like other cataractous patients) compensate for dull retinal images by holding the object nearer, and so increasing the size of the images. The acuteness of vision is always defective, and cannot be fully remedied by any glasses. They often see rather better with the eyes shaded (pupils dilated), or after the use of atropine aided by con- vex glasses to substitute the accommodation. The pupil presents a deeply seated slight grayness (4, Fig. 59), and FIG 59. Lamellar cataract. Figs. 1, 2, 3, as before. Fig. 4 shows slight gray- ness of the undilated pupil, owing to the layers of opacity being deeply seated. when dilated with atropine the outline of the shell of opacity is exposed within it. It is sharply defined and circular, and by focal light is whitish, interspersed in many cases with white specks, which at its equator appear as little projections (3, Fig. 59). By this examination we easily make out that the opacity consists of two distinct layers, that there is a layer of clear lens substance (cortex) in front of the anterior layer, and that the margin (equator) of the lens is clear. By the mirror thfi opacity appears as a disk of nearly uniform grayish or dark color, sometimes 180 CATARACT. with projections, or darker dots, and surrounded by a zone of bright red reflection from the fundus corresponding to the clear margin of the lens (2, Fig. 59). The opacity often appears rather more dense just at its boundary, a sort of ring being formed there. In some cases quite large spicules or patches project from the margin of the opacity. Not only does the size of the opaque lamella, and, there- fore, its depth from the surface of the lens, differ greatly in different cases, but its thickness or degree of opacity varies also. The disease is nearly always exactly symmetrical in the two eyes. Occasionally there are two shells of opacity, one within the other, separated by a certain amount of clear lens substance. The lens may be cataractous at birth (congenital cataract). This form, of which there are several varieties, is nearly always symmetrical, and generally always involves the whole lens. Often the development of the eyeball is de- fective, and though there are no synechise, the iris often acts badly to atropine. Traumatic cataract. Severe blows on the eye may be followed by opacity of the lens, the suspensory ligament being generally torn in some part of its circle (concussion cataract), but I am not aware that cataract ever follows injury to the head without direct injury to the eye. Traumatic cataract proper is the result of wound of the lens-capsule; the aqueous passing through the aperture is imbibed by the lens-fibres, which swell up, become opaque, and finally disintegrate and are absorbed. The opacity may begin within a few hours of the wound; it pro- gresses quickly in proportion as the wound is large, and the patient young. The older the patient the more severe are the symptoms likely to be, and the worse the prognosis. A free wound of the capsule followed by rapid swelling and opacity of the whole lens, in an adult past middle life, may give rise to severe glaucomatous symptoms and CATARACT. 181 iritis. In from three to six months the wounded lens will generally be absorbed, and nothing but some chalky-look- ing detritus remain in connection with the capsule. A very fine puncture of the lens is occasionally followed by nothing more than a small patch or narrow tract of opacity, or by very slowly advancing general haze. The objects of treatment are to prevent iritis and poste- tior synechise by atropine, and by ice and leeching if there be severe inflammatory symptoms. "We endeavor to wait for the natural absorption of the cataract, being prepared to extract the lens by linear operation or suction, at any time, should glaucoma, iritis, or severe irritation arise. PROGNOSIS, a. Course. Cataracts advance with varying rapidity in different cases. As a rough rule the progress of a general cataract is rapid in proportion to the youth of the patient. Cataracts in old people commonly take from one to three years in reaching maturity sometimes much longer. If the lens be allowed to remain long after it is opaque, further degenerative changes generally occur. It may become harder and smaller, calcareous and fatty granules being formed in it ; the cortex may liquefy whilst the nucleus remains hard (Morgagnian cataract). A soft cataract may undergo partial absorption and shrink to a thin, hard, brittle disk. Soft cataract in young adults, whether from diabetes or not, is generally complete in a few months. b. Sight. The prognosis after operation is good when there is no other disease of the eye, and when the patient (although advanced in years) is in fair general health. It is not so good in diabetes, nor when the patient is in ob- viously bad health, the eyes being then less tolerant of operation. In lamellar, and especially in congenital cases, it must be guarded, for the eyes are often defective in other respects, and sometimes very intolerant of operation ; the intellect, too, is sometimes defective, rendering the patient 16 182 CATARACT. less able to make proper use of his eyes. In traumatic cataract of course everything depends on the details of the injury (see p. 166, etc.), but in general the younger the patient the better the prospect of a quiet and uncompli- cated absorption of the lens. In every case of immature cataract, the vitreous and fundus should be carefully examined by the ophthalmo- scope, and the refraction ascertained. The presence of high myopia is unfavorable, and the same is true of opaci- ties in the vitreous, indicating, as they usually do, that it is fluid. Any disease of the choroid or retina will, of course, act injuriously in proportion to its position and de- gree. In every case, whether complete or not, the size and mobility of the pupils to light and atropine and the tension of the eye are to be carefully noted. TREATMENT. In the early stages of senile and nuclear cataract sight is improved by keeping the pupil moderately dilated with a weak atropine solution (half a grain to the ounce), used about three times a week (compare p. 176). Dark glasses, by allowing some dilatation of the pupil, sometimes give relief. Stenopaic glasses are sometimes useful. With these exceptions, nothing except operative treatment is of any use. The management of lamellar cataract requires separate description. Operations for the removal of cataract are of three kinds: (1) Extraction of the lens entire through a large wound in the cornea, or at the sclero-corneal junction, the lens-capsule remaining behind. By a few operators the lens is removed entire in its capsule. (2) Gradual absorp- tion of soft cataracts by the action of the aqueous humor, admitted through needle punctures in the capsule, just as after accidental traumatic cataract (needle operations, so- lution, discission). The operation needs repetition two or three times, at intervals of a few weeks, and the whole process therefore spreads over three or four months. CATARACT. 183 (3) For soft cataracts, removal by a suction syringe or curette, introduced into the anterior chamber through a small wound near the margin of the cornea, the whole lens having been rendered semifluid by a free discission opera- tion, usually a few days previously. (See Operations.) Extraction is necessary for cataracts after about the age of forty, the lens from this age onwards being so firm that its absorption after discission occupies a much longer time than in childhood and youth ; moreover, as the swelling of the lens after puncture by the needle is less easily borne as age advances, solution operations become not only slower, but attended by more danger (p. 180). Indeed, extraction is often practised in preference to solution much earlier than forty. Suction and solution operations are applicable up to about the age of thirty -five. The suction operation is difficult, and unless well per- formed is attended by serious risk of severe iritis and cyclitis. Its advantage, as compared with needle opera- tions, lies in the saving of time, the whole lens being re- moved at one sitting. So long as senile cataract is single, or, if double, so long as the second eye is still serviceable, removal of the cata- ract will seldom be beneficial to the patient; unless his health be likely to suffer by waiting till the second eye is ready and his prospect of a good result to be thus impaired. Indeed, if one eye be still fairly good, the patient will often be dissatisfied by finding his operated eye less useful than he expected, perhaps even not so useful as the other. But if there be a period of several years between the comple- tion of cataract in the first eye and its onset in the other, the first may have become over-ripe, and therefore some- what less favorable for operation, if we wait till the second eye is affected. The removal of a single cataract in young persons is often expedient on the ground of appearance, or when it is important that the patient should not have a 184 CATARACT. "blind side." In all cases of single cataract it must be explained that after the operation the two eyes will not work together, on account of the extreme difference of re- fraction. (See Anisometropia.) Even when both cataracts are mature at the same time, it is safer to remove only one at once, because the after- treatment is more easily carried out upon one eye than both, and because after double operation any untoward result in one eye adds to the difficulty of managing its fel- low ; while a bad result after single extraction enables us to take especial precautions, and to modify the operation for the second eye. Even if the patient be so old or feeble that the second eye may never come to operation, we shall consult his interests better by endeavoring to give him one good eye than by risking a bad result in attempting to give him both at the same time. The principal causes of failure after extraction are : (1) Hemorrhage between the choroid and sclerotic, com- ing on, usually with severe pain, immediately after the operation. The blood fills the eyeball, and often oozes from the wound and soaks through the bandage. (2) Suppuration, beginning in the corneal wound, and in most cases spreading to the whole cornea, to the iris and vitreous, and ending in a total loss of the eye. It occasion- ally takes a less rapid course, and stops short of a fatal result. The alarm is given in from twelve hours to about three days after operation by the occurrence of pain, in- flammatory oedema of the lids (particularly the free border of the upper lid), and the appearance of some muco-puru- lent discharge. On raising the lid the eye is found to be greatly congested, its conjunctiva redematous, the edges of the wound yellowish, and the neighboring cornea steamy and hazy. In very rapid cases the pupil, especially near to the wound, may already be occupied by lymph. The energetic use of hot fomentations for an hour, three CATARACT. 185 or four times a day, and the constant employment between times of a tight compressive bandage, are the only local means likely to be useful, while internally full doses of quinine with ammonia, and wine or brandy, should be at once resorted to. But the great majority of these cases go on to suppurative panophthalmitis or to severe plastic irido-cyclitis with opacity of cornea and shrinking of the eyeball. (3) Iritis may set in between about the fourth and tenth days. As in commencing suppuration, so here pain, oedema of the lids, and chemosis are the earliest symptoms. There is lachrymation, but no muco-purulent discharge, and the cornea and wound remain clear and bright. The iris is discolored (unless it happen to be naturally greenish- brown), and the pupil dilates badly to atropine. When- ever in a case presenting such symptoms a good examina- tion is rendered difficult on account of the photophobia, iritis should be suspected. If the early symptoms are severe, a few leeches to the temple are very useful. Atropine and local warmth are the most important remedial measures. If atropine after a time causes irritation (p. 103), daturine or duboisine should be tried (F. 26, 27). This inflammation is plastic, ending in the formation of more or less dense membrane which occupies the area of the pupil, and often, by contracting and drawing the iris with it towards the operation scar, diminishes and displaces the pupil. (See Iridotomy.) The membrane is often dis- tinctly behind the iris and free from it ; it is then derived from the ciliary processes (irido-cyclitis). (4) The iris may prolapse into the wound at the opera- tion, or a few days afterwards by the re-opening or yielding of a weakly united wound. When iridectomy has been done, the prolapse appears as a little dark bulging at one or both ends of the wound, and often causes much irrita- bility for many weeks without actual iritis. The protrusion 16* 186 CATARACT. in the end generally flattens down, but sometimes it needs to be punctured or even removed. The occurrence of pro- lapse is a reason for keeping the eye tied up longer. After- operations are needed, when iritis has ended in more or less occlusion and contraction of the pupil. Nothing should be done until all active symptoms have subsided, and the eye has been quiet for some weeks. Sight after the removal of cataract. In accounting for the state of the sight, we have to remember that the acute- ness of sight naturally decreases in old age (p. 43). Again, slight iritis producing a little filmy opacity in the pupil is common after extraction. Some eyes without positive in- flammation remain irritable long after the operation, so that prolonged use is impossible. So that, putting aside the graver complications, we find that, even of the eyes which do best, a large proportion fail to reach anything like normal acuteness of vision. Cases are considered good when the patient can with his glasses read anything be- tween Nos. 1 and 14 Jaeger and T 6 ^ Snellen; but a much less satisfactory result than this is very useful. About five per cent, of the eyes operated upon are lost from various causes. The eye is rendered extremely hypermetropic by removal of the lens, and strong convex glasses are neces- sary for clear vision. They should seldom be allowed until three months after the operation, and at first they must not be continuously worn. Two pairs are needed ; one making the eye emmetropic, giving clear vision of distant objects (+ 10 or 11 D.), the other (about + 16 D.) for vision of objects at a short distance (8" or 10" = 20 or 25 cm.), and representing the eye when strongly accommodated. As all accommodation is lost, the patient has scarcely any range of distinct vision. Lamellar cataract. If the patient can see enough to get on fairly well at school, or in his occupation, it is best not to remove the lenses; but when the opacity is dense CATARACT. 187 enough to seriously interfere with the patient's prospects, something must always be done. The choice lies between the artificial pupil when the margin of clear lens is wide, and solution or extraction when it is narrow, or when large spicules of opacity project into it from the opaque lamella. It is very difficult to say which of the two gives on the whole the better results, and we must judge each case on its own merits. If atropine, by dilating the pupil, im- proves the sight, an artificial pupil, made by removing the iris quite up to its ciliary border, will generally be bene- ficial ; the clear border of the lens is thus exposed in the coloboma, and light passes through it more readily than through the hazy part. A very good rule is to operate on only one eye at a time, thus allowing the choice of a differ- ent operation on its fellow. Secondary cataracts with complete blindness, indicating deep disease, should never be operated upon. Dislocation of the lens in its capsule is usually caused by a blow on the eye, but may be spontaneous. It is usu- ally downwards, and only partial ; the iris is tremulous where it has lost support (p. 162), but often bulged for- ward at some other part ; the upper edge of the lens can be seen through the dilated pupil, appearing with the ophthal- moscope as a curved black line across the field. Such dislocation may cause glaucoma. The lens finally often becomes opaque. More rarely the transparent lens is com- pletely dislocated into the anterior chamber ; when of full size it causes glaucoma, but if shrunken, may remain with- out doing harm. Sometimes it can be made to pass at will through the pupil by altering the position of the head. The edge of a transparent lens in the anterior chamber appears as a bright line by focal illumination, and the iris is much pushed back two important points of distinction from "spongy" exudation in iritis (p. 136). 188 DISEASES OP THE CHOROID. CHAPTER XIII. DISEASES OF THE CHOROID. THE choroid is, next to the ciliary processes, the most vascular part of the eyeball, and from it the outer layers of the retina, and probably the vitreous humor also, mainly derive their nourishment. Inflammatory and degenerative changes often occur, some of them entirely local, as in myopia, others symptomatic of constitutional or of gen- eralized disease, such as syphilis and tuberculosis. Choroi- ditis, unlike inflammation of its continuations, the ciliary body and iris, is seldom shown by external congestion or severe pain ; and as none of its symptoms are characteristic, its diagnosis rests chiefly on ophthalmoscopic evidence. Blemishes or scars, permanent and easily seen, nearly always follow disease of the choroid, and such spots and patches are often as useful for diagnosis as cicatrices on the skin, and deserve as careful study. The retina lying over an inflamed choroid often takes part in the active changes, or atrophies afterwards ; but in other cases, apparently as severe, it is uninjured. Indeed, it is sometimes far from easy to say in which of these two structures the disease has begun, especially as changes in the pigment epithelium, which is really part of the retina, are as often the result of deep-seated retinitis or retinal hemorrhage as of super- ficial choroiditis. Patches of accumulated pigment, though usually indicating spots of former choroiditis, are some- times the result of bleeding, either from retinal or choroidal vessels, and some skill is needed in correctly interpreting such appearances. DISEASES OF THE CHOROID. 189 Appearances in health. The choroid is composed chiefly of bloodvessels and of cells containing dark-brown pig- ment. The quantity of pigment varies much in different eyes, and to some degree in different parts of the same eye ; it is very scanty in early childhood, and in persons of fair complexion ; more abundant in persons with dark hair and brown irides ; more plentiful in the region of the yellow spot than elsewhere. In old age the pigment epithelium becomes paler. When examining the choroid, we need to think of four parts: (1) the retinal pigment epithelium (which is for ophthalmoscopic purposes choroidal), recog- nized in the erect image as a fine darkish stippling ; (2) the capillary layer (chorio-capillaris), just beneath the epithe- lium, forming a very close mesh work, the separate vessels of which are not visible in life ; (3) the larger bloodvessels, often easily visible; (4) the pigmented connective-tissue cells of the choroid proper, which lie amongst the larger vessels. In the majority of eyes these four structures are so toned as to give a nearly uniform full red color by the ophthal- moscope, blood-color predominating. In very dark races the pigment is so excessive that the fundus has an uniform slaty color. In very fair persons (and young children) the deep pigment (4) is so scanty that the large vessels are separated by spaces of lighter color than themselves (Fig. 31). In dark individuals these intervascular spaces are of a deeper hue than the vessels, the latter appearing like light streams separated by dark islands (Fig. 62, a). Near to the disk and y. s. the vessels are extremely abundant and very tortuous, the interspaces being small and irregu- lar; but towards and in front of the equator, the veins take a nearly straight course, converging to their exits at the vence vorticosce, and the islands are larger and elongated. The veins are much more numerous and larger than the arteries (Fig. 61), but no distinction can be made between 190 DISEASES OF THE CHOROID. them in life. The vessels of the choroid, unlike those of the retina, present no light streak along the centre (com- pare p. 71). The pigment epithelium and the capillary layer tone down the above contrasts, and so in old age, when the epi- thelial pigment is bleached, and again when the capillary layer is atrophied after superficial choroiditis (Fig. 62, a), the distinctions described are particularly marked. Fig. 60 shows a vertical section of naturally injected human choroid ; the uppermost dark line is the pigment epithelium (1) ; next are seen the capillary vessels, cut across (2); then the more deeply seated large vessels (3), and the deep layer of stellate pigment-cells of the choroid proper (4). Fig. 61 is from an artificially injected human choroid seen from the inner surface. The shaded portion is intended to represent the general effect produced by all the vessels and the pigment epithelium. The lower part shows the large vessels with their elongated interspaces, as may be seen in a case where the pigment epithelium and chorio-capillaris are atrophied (Fig. 62, 6) ; in a dark eye these interspaces would be darker than the vessels. The middle part shows the capillaries without the pigment epithelium. Both fig- ures are magnified about four times as much as the image in the indirect ophthalmoscopic examination. ' FIG. 60. Human choroid, vertical section. Naturally injected. X 20. OPHTHALMOSCOPIC SIGNS OF DISEASE OF THE CHOROID. The changes usually met with are indicative of atrophy. This may be partial or complete; primary or following inflammation or hemorrhage; in circumscribed spots or patches, or in large and less abruptly bounded areas. Sec- DISEASES OF THE CHOROID. 191 ondary changes are often present in the corresponding parts of the retina. The chief signs of atrophy of the choroid are (1) the substitution of a paler color (varying from a FIG. 61. Vessels of human choroid artificially injected. Arteries cross-shaded. Capillaries too dark and rather too small. The uppermost shaded part represents the effect of the pigment epithelium, x 20. pale red to a full paper-white), for the full red of health, the subjacent white sclerotic being more or less visible where the atrophic changes have occurred ; (2) black pig- 192 DISEASES OF THE ClIORUil). ment in spots, patches, or rings, and in varying quantity upon or around the pale patches. These pigmentations result, 1st, from disturbance and heaping together of the normal pigment ; 2d, from increase in its quantity ; 3d, from blood-coloring matter left after extravasations. Patches of primary atrophy (e. g., in myopia) are never much pig- mented unless bleeding have taken place, The amount of pigmentation in atrophy following choroiditis is closely related to that of the healthy choroid, i. e., to the com- plexion of the person. FIG. 62. Atrophy after syphilitic choroiditis, showing various degrees of wasting Hutchinson). a. Atrophy of pigment epithelium. 6. Atrophy of epi- thelium and chorio-capillaris ; the large vessels exposed, c. Spots of complete atrophy, many with pigment accumulation. Pigment in the fundus may lie in the retina as well as in or on the choroid, and this is true whatever may have been its origin, for in choroiditis with secondary retinitis, the choroidal pigment often passes fonvards into the retina. When a spot of pigment is distinctly seen to cover over a DISEASES OF THE CHOKOID. 193 retinal vessel, that spot must be not only in, but very near the anterior (inner) surface of the retina ; and when the pigment has a linear, mossy, or lace-like pattern (Fig. 72), it is always in the retina ; these are the only conclusive evidences of its position. It is important and usually easy to distinguish between partial and complete atrophy of the choroid. In superficial atrophy affecting the pigment epithelium and capillary layer, the large vessels are peculiarly distinct (Fig. 62, a and 6). Such " capillary " or " epithelial " choroiditis often covers a large surface, the boundaries of which are some- times well defined and sinuous or map-like, but are as often ill marked ; in the latter case careful comparison between different parts of the fundus is necessary, and allowance must be made for the patient's age and complexion. Coni- FIG. 63. Atrophy after choroiditis. (Magnus.) plete atrophy is shown by the presence of patches of white or yellowish- white color of all possible variations in size, with sharply cut, circular, or undulating borders, and with or without pigment accumulations (Figs. 62, c, and 63). The retinal vessels pass unobscured over patches of atrophied 17 194 DISEASES OF THE CHOROID. choroid, proving that the appearance is caused by some change deeper than the surface of the retina. In recent choroiditis we also often see patches of palish color, but they are less sharply bounded and frequently of a grayer or whiter (less yellow) color than patches of atrophy ; moreover, the edge of such a patch is softened, the texture of the choroid being dimly visible there, be- cause only partly veiled by exudation. If the overlying retina is unaffected, its vessels are clearly seen over the diseased part; but if the retina itself is hazy or opaque, the exact seat of the exudation often cannot be at once decided. In recent cases the vitreous too is often hazy or full of FIG. 64. Minute exudations into inner layer of choroid in syphilitic choroiditis. Pigment epithelium adherent over the exudations, hut elsewhere has been washed off. Ch. Choroid; Set. Sclerotic. flocculi. Most commonly, however, patients do not come until the exudation stage of choroiditis has passed into atrophy. Section of miliary tuhercle. Inner layers of choroid comparatively unaffected. The lighter shading surrounding an artery in the deepest part of the tubercle represents the oldest part, which is caseating. Syphilitic choroiditis begins in, and is often confined to, the inner (capillary) layer of the choroid (Fig. 64), and hence it often affects the retina. In miliary tuberculosis of DISEASES OF THE CHOROID. 195 the choroid the overlying retina is clear, and the growth is, for the most part, deeply seated and around an artery (Fig. 65). After very severe choroiditis, or extensive hemor- rhage, the absorption may be incomplete; in addition to atrophy, we then see gray or white patches, or lines, which, in pattern and apparent texture, remind us of scars in the skin, or of patches and lines of old thickening on serous membranes. Very characteristic changes are seen after rupture of the choroid from sudden stretching caused by blows on the front of the eye. These ruptures, always situated in the central region, occur in the form of long tapering lines of atrophy, usually curved slightly towards the disk, and sometimes branched (Fig. 66) ; their borders are often pigmented. FIG. 66. Ruptures of Choroid. CWecker.) If seen soon after the blow, the rent is more or less hidden by blood, and the retina over it is hazy. The pathological condition known as " colloid disease " of the choroid consists in the growth of very small nodules, soft at first, afterwards becoming hard like glass, from the 196 DISEASES OF THE CHOROID. thin lamina, elastica, which lies between the pigment epi- thelium and chorio-capillaris. It is common in eyes excised for old inflammatory mischief, and in partial atrophy after choroiditis (Fig. 67). But little is known of its ophthalmo- scopic equivalent, or its clinical characters. Probably it may result from various forms of choroiditis, and may also be a natural senile change. FIG. 67. Partial atrophy after syphilitic choroiditis. Minute growths from inner surface of choroid, showing how they disturb the outer layers of the retina. X 60. Hemorrliage from the choroidal vessels is not so often recognized as from those of the retina, but may be seen sometimes, especially in old people and in highly myopic eyes. The patches are more rounded than retinal hemor- rhages, and it is often possible to recognize the striation of the overlying retina. Occasionally they are of immense size. CLINICAL FORMS OF CHOROIDAL DISEASE. (1) Numerous discrete patches of choroidal atrophy (sometimes complete, as if a round bit had been punched out, in others incomplete, though equally round and well defined) are scattered in different parts of the fundus, but are most abundant towards the periphery ; or, if scanty, are found only in the latter situation. They are more or less pigmented, unless the patient's complexion is extremely fair (Figs. 62, c, and 63). (2) The disease has the same distribution, but the patches are confluent ; or large areas of incomplete atrophy, pass- DISEASES OF THE CHOROID. 197 ing by not very well-defined boundaries into the healthy choroid around, are interspersed -with a certain number of separate patches ; or without separate patches there may be a widely spread superficial atrophy with pigmentation (Fig. 62, a and 6). These two types of choroiditis disseminata, run into one another, different names being used by authors to indicate topographical varieties. Generally both eyes are affected, though unequally ; and in some cases one escapes. The retina and disk often show signs of past or present inflam- mation. Syphilis is almost invariably the cause of symmetrical disseminated choroiditis. The choroiditis begins from one to three years after the primary disease, whether this be acquired or inherited ; occasionally at a later period. The discrete variety (Fig. 62, c), where the patches, though usually involving the whole thickness of the choroid, are not connected by areas of superficial change, is the less serious form, unless the patches are very abundant. A moderate number of such patches confined to the periphery, cause no appreciable damage to sight. The more superficial and widely spread varieties, in which the retina and disk are inflamed from the first, are far more serious. The capillary layer of the choroid sel- dom again becomes healthy, and with its atrophy, even if the deeper vessels be not much changed, the retina suffers, passing into slowly progressive atrophy. The retina often becomes pigmented (Fig. 72), its bloodvessels extremely narrowed, and the disk passes into a peculiar hazy yellowish atrophy (" waxy disk " Hutchinson, " choroiditic atrophy " Gowers). The appearances may closely imitate those in true retinitis pigmentosa, and the patient, as in that disease, often suffers from marked night-blindness. Such cases con- tinue to get worse for many years, and may become nearly blind. 17* 198 DISEASES OF THE CHOROID. Syphilitic choroiditis generally gives rise, at an early date, to opacities in the vitreous ; they are either of large size and easily seen as slowly floating ill-defined clouds, or so minute and numerous as to cause a diffuse and somewhat dense haziness ("dust-like opacities," Forster) (see p. 251). Some of the larger ones may be permanent. In the ad- vanced stages, as in true retinitis pigmentosa, posterior polar cataract is sometimes developed. There are no constant differences between choroiditis in acquired and in inherited syphilis ; in many cases it would be impossible to guess, from the ophthalmoscopic changes, with \vhich form of the disease we had to do. But there is, on the whole, a greater tendency towards pigmentation in the choroiditis of hereditary than in that of acquired syphilis, and this applies both to the choroidal patches and to the subsequent retinal pigmentation. In the treatment of syphilitic choroiditis we rely almost entirely on the constitutional remedies for syphilis mer- cury and iodide of potassium. Cases which are treated early in the exudation stage are very much benefited in sight by mercury, the visible exudations quickly melting away ; but I believe that even in these complete restitution seldom takes place, the nutrition and arrangement of the pigment epithelium and baeillary layer of the retina being quickly and permanently damaged by exudations into or upon the chorio-capillaris (as in Fig. 64). In the later periods, when the choroid is thinned by atrophy, or its inner surface roughened by little outgrowths (Fig. 67), or adhesions and cicatricial contractions have occurred be- tween it and the retina, nothing can be done. A long mercurial course should, however, always be tried if the sight be still failing, even if the changes all look old ; for in some cases, even of very long standing, fresh failure takes place from time to time, and internal treatment has a very marked influence. In acute cases it is well to pre- DISEASES OF THE CHOROID. 199 scribe also rest of the eyes in a dark room, and the em- ployment of the artificial leech or of dry cupping at in- tervals of a few days, for some weeks. But it is often difficult to insure such functional rest, for the patients seldom have pain or other discomfort. (3) The choroidal disease is limited to the central region. There are many varieties of such localized change. In myopia the elongation which occurs at the posterior pole of the eye very often causes atrophy of the choroid contiguous to the disk, and usually only on the side next the yellow spot (p. 291). The term "posterior staphyloma" is applied to this form of disease when the eye is myopic, because the atrophy is a sign of posterior bulging of the sclerotic. The term " sclerotico-choroiditis posterior " is also used. A similar, but narrow and less conspicuous crescent or zone of atrophy around the disk is seen in some other states without myopia, notably in old persons, and in glau- coma (Fig. 81). Separate round patches of complete atrophy ("punched-out" patches) at the central region may accompany the commoner changes in myopia, and must not then be ascribed to syphilitic choroiditis ; more commonly in myopia ill-defined partial atrophy is seen about the y. s., sometimes with splits or lines running hori- zontally towards this part from the disk. Central senile choroiditis. Several varieties of disease confined to the region of the y. s. and disk are seen, and chiefly in old persons. A particularly striking and rather rare form is shown in Fig. 68. In others a larger, but less defined, area is affected. Some of these appearances un- doubtedly result from large choroidal or retinal extrava- sations, but the nature of the disease in such as Fig. 68 is obscure. In another form, along with superficial atrophy, the large deep vessels are much narrowed, or even con- verted into white lines and devoid of blood column, by thickening of their coats. In another form the central 200 DISEASES OF THE CHOKOID. region is occupied by a number of very small, white, or yellowish-white dots, sometimes visible only in the erect image. This form in typical cases is very peculiar, and appears to be almost stationary ; the disks are often de- cidedly pale ; when very abundant the spots coalesce, and some pigmentation is found. The pathological anatomy FIG. 67. Central choroiditis. (Wecker and Jaeger.) and general relations of this disease are incompletely known ; it has been clinically described by Hutchinson and Tay, and is tolerably common. It is symmetrical, and the changes may sometimes be mistaken for a slight albu- minuric retinitis (see p. 94). No treatment seems to have any in-fluence. Every case of immature cataract should, when possible, be examined for central choroidal changes. (4) Anomalous forms of choroidal disease. Single, large patches of complete atrophy, with pigmentation, and not located in any particular part, are occasionally met with. There is reason to believe that some of them have DISEASES OF THE CHOKOID. 201 followed the absorption of tubercular growths in the cho- roid, while others are the result of single large hemorrhages (p. 196). Single large patches of exudation are also met with, and are perhaps tubercular (see, also, p. 149). Gen- eralized choroidal disease in patches sometimes occurs in persons who have certainly not had syphilis. I believe that in most of these the disease is due to numerous scat- tered hemorrhages into the choroid, sometimes occurring repeatedly at different dates; and leading to patches of partial atrophy with pigmentation. The local cause of the hemorrhage is obscure ; the disease often affects only one eye, and is generally seen in young males. It may perhaps be called hemorrhagic choroiditis (compare p. 254 (4)). Although the changes produced are very gross, some of these patients regain almost perfect sight, a fact, perhaps, pointing to the deep layers of the choroid as the seat of disease. Single spots of choroidal atrophy, especially towards the periphery, should, no less than abundant changes, always excite grave suspicion of former syphilis, and often furnish valuable corroborative evidence of that disease (compare Myopic Changes). The periphery cannot be fully exam- ined unless the pupil be widely dilated. A few small, scattered spots of black pigment on the choroid or in the retina, without evidence of atrophy of the choroid, often indicate former hemorrhages. Such spots are seen after recovery from albuminuric retinitis with hemorrhages, after blows on the eye, and sometimes without any relevant history. Congestion of the choroid is not commonly recognizable by the ophthalmoscope. That active congestion does occur is certain, and it would seem that myopic eyes are espe- cially liable to it, particularly when exposed to bright light and great heat. Serious hemorrhage may undoubt- edly be excited under such circumstances. In conditions 202 DISEASES OF THE CHOROID. of extreme anaemia the whole choroid becomes unmistak- ably pale. Coloboma of the choroid (congenital deficiency of the lower part) is shown ophthalmoscopically by a large sur- face of exposed sclerotic, often embracing the disk (which is much altered in form, and may be hardly recognizable), and extending downwards to the periphery, where it often narrows to a mere line or chink. The surface of the scle- rotic, as judged by the course of the retinal vessels, is often very irregular, from bulging of its floor backwards. The coloboma is occasionally limited to the part around the nerve, or may form a separate patch. Coloboma of the choroid is often seen without coloboma of the iris, and when both exist, a bridge of choroidal tissue generally separates them in the region of the ciliary body. Albinism is accompanied by congenital absence of pig- ment in the cells of the pigment epithelium and stroma of the whole uveal tract (choroid, ciliary processes, and iris). The pupil looks pink because the fundus is lighted, to a great extent, indirectly through the sclerotic. Sight is always defective, and the eyes photophobic and usually oscillating. Many almost albinotic children become mod- erately pigmented as they grow up. DISEASES OF THE RETINA. 203 CHAPTER XIV. DISEASES OF THE RETINA. OF the many morbid changes to which the retina is subject, some begin and end in this membrane, such as albuminuric retinitis and many forms of retinal hemor- rhage ; in others, the retina takes part in changes which begin in the optic nerve (neuro-retinitis), or in the choroid (choroido-retinitis) ; very serious lesions also occur from embolism or thrombosis of the central retinal vessels. The retina may be separated (" detached ") from the choroid by blood or other fluid. The retina may also be the seat of malignant growth (glioma), and probably of tubercular inflammation. In health the human retina is so nearly transparent as to be almost invisible by the ophthalmoscope during life, or to the naked eye if examined immediately after excision. We see the retinal bloodvessels, but the retina itself, as a rule, we do not see. The main bloodvessels are derived from the arteria and vena centralis, which enter the outer side of the optic nerve, about 6 mm. behind the eye, and except close to the disk, they are smaller and much less abundant than those of the choroid (Fig. 31) ; the veins and arteries are generally in pairs, the veins not being more numerous than the arteries ; all pass from or to the optic disk. At the disk anastomoses, chiefly capillary, are formed between the vessels of the retina and those of the choroid and sclerotic. As no other anastomoses are formed by the vessels of the retina, the retinal circulation beyond the disk is terminal ; and, further, as the vessels branch 204 DISEASES OF THE RETINA. dichotomously, and the branches anastomose only by means of their capillaries, the circulation of each considerable branch is terminal also. The capillaries, which are not visible by the ophthalmoscope, are narrower and much less abundant (except just at the y. s. region) than those of the choroid (compare Figs. 61 and 69), their meshes becoming wider and wider towards the anterior and less important parts of the retina. They are most abundant at the y. s. region, the only part used for accurate vision ; the very centre of this region (fovea centralu'), however, where all the layers except the cones and outer granules are exces- sively thin, contains no vessels, the capillaries forming fine close loops just around it (Fig. 69). FIG. 69. rsiN r.2O Bloodvessels of human retina at the yellow spot (artificial injection). The central gap corresponds to the fovea centralis. A. Arteries ; v. Veins ; N. Nasal side (towards disk) ; T. Temporal side. In children, especially those of dark complexion, a peculiar and striking whitish shifting reflection, or shimmer, is often seen at the yellow spot region and along the course of the principal vessels. It changes with every movement of the mirror, and reminds one of the shifting reflection from "watered ' and "shot" silk. Around the yellow spot it takes the form of a ring or zone, and is known as the DISEASES OF THE KETINA. 205 "halo round the macula" (p. 71). When the choroid is highly pigmented, even if this shifting reflection be absent, the retina is visible as a faint haze over the choroid like the "bloom" on a plum. Under the high magnifying power of the erect image the nerve-fibre layer is often visible near the disk, as a faintly marked radiating striation. The sheaths of the large central vessels at their emergence from the physiological pit (p. 69) show many variations in thickness and opacity. In rare cases the medullary sheath of the optic nerve- fibres, which should cease at the lamina cribrosa, is con- tinued up to or reproduced at the disk, especially at its margin, and causes the ophthalmoscopic appearance known as " opaque nerve-fibres." This congenital peculiarity may affect the nerve-fibres of the whole circumference of the disk or only a patch or tuft of the fibres ; it may only just overleap the edge of the disk, or may extend far into the retina, where even separate islands of opacity are some- times seen. It is to be particularly noted that the central part (physiological pit) of the disk is never affected, be- cause it contains no nerve-fibres. The affected part is pure white, and quite opaque ; at its margin the patch thins out gradually, and is striated in fine lines, which radiate from the disk like carded cotton-wool ; the retinal vessels may be buried in the opacity, or run unobscured on its surface, and are of normal size. The deep layers of the affected part of the retina being obscured by the opacity, an en- largement of the normal " blind-spot " is the result. One or both eyes may be affected. There is seldom any diffi- culty in distinguishing this condition from opacity due to neuro-retinitis. 18 206 DISEASES OF THE RETINA. OPHTHALMOSCOPIC SIGNS OF RETINAL DISEASE. Congestion. No amount of capillary congestion, whether passive or active, alters the appearance of the retina ; and as to the large vessels, it is better to speak of the arteries as unusually large or tortuous, or of the veins as turgid or tortuous, than to use the general term congestion. Capil- lary congestion of the optic disk may undoubtedly be recog- nized ; but even here great caution is needed, and much allowance must be made for differences of contrast depend- ing on the depth of tint of the choroid, for the patient's health and age, and for the brightness of the light used, or, what is the same thing, for the size of the pupil. Caution is also needed against drawing hasty inferences from the slight haziness of the outline of the disk, which may often be seen in cases of hypermetropia, and which is certainly not always morbid. The only ophthalmoscopic evidence of true retinitis is loss of transparency of the retina, and two chief types are soon recognized according as the opacity is diffused, or con- sists chiefly of abrupt spots and patches. Hemorrhages are present in many cases of retinitis ; but they are also com- mon in cases where there is no true inflammation. The state of the disk varies much, but it seldom escapes entirely in a case of extensive or prolonged retinitis. In a large majority of cases of recent retinitis the visible changes are limited to the central region, where the retina is thickest and most vascular. (1) The lessened transparency which accompanies dif- fused retinitis simply dulls the red choroidal reflex, and the term " smoky " is fairly descriptive of it. The same effect is given by slight haziness of any of the anterior media, but a mistake is excusable only when there is dif- fused mistiness of the vitreous from opacities which are too DISEASES OF THE RETINA 207 small to be easily distinguished (pp. 251 and 253), and the difficulty is then increased because this very condition of the vitreous often coexists with retinitis. A comparison of the erect and inverted images is often useful, for if the diffused haze noticed by indirect examination be caused by retinitis, then by the direct examination what before seemed a uniform haze may now appear as well-marked spotting or streaking. When the change is pronounced enough to cause a decidedly white haze of the retina there is no FIG. 70. Renal retinitis at a late stage. (Wecker and Jaeger.) longer any doubt. The retinal arteries and veins are some> times enlarged and tortuous in retinitis, and in severe cases they are generally obscured in some part of their course. These diffused forms are usually caused either by syphilis or embolism. (2) The retina generally is clear, but near the yellow spot a number of small, intensely white, rounded spots are seen (Fig. 70), either quite discrete or partly confluent. 208 DISEASES OP THE RETINA. When very abundant and confluent they form large, ab- ruptly outlined patches, often with crenated borders ; or some parts may be striated and others stippled. (3) A number of separate patches are scattered about the central region, but without special reference to the yellow spot. They are of irregular shape, white or pale buff, and sometimes striated ; they are easily distinguished from patches of choroidal atrophy (p. 190) by their color, the comparative softness of their outlines, and the absence of pigmentation. In the last two forms, hemorrhages are usually present also. FIG. 71. Recent severe retinitis in renal disease. (Gowers.) (4) There are numerous hemorrhages, with general hazi- ness intensified at places into distinct, but not abruptly defined, patches of white or yellowish-white ; the retinal vessels are extremely tortuous, and the veins dilated (Fig. 71). Forms 2 and 3 are generally associated with albuminuria, DISEASES OF THE EETINA. 209 but in rare cases similar changes are caused by cerebral disease. The changes are always nearly symmetrical. (5) Rarely a single large patch or area of white opacity is seen with softened, ill-defined edges, any retinal vessels that may cross it being obscured. In most cases such a patch of retinitis is caused by choroidal exudation beneath (p. 194). Hemorrhage into (or beneath) the retina is known by its color, which is darker than that of the average choroid ; but redder and lighter than that of a very dark choroid. Blood may be effused into any of the retinal layers, and the shape of the blood patches is mainly determined by their position. When effused into the nerve-fibre layer, or confined by the sheath of a large vessel, the extravasation takes a linear or streaked form and structure, following the direction of the nerve-fibres ; extravasations in the deeper layers are generally rounded or irregular. Very large hemorrhages, many times as large us the disk, sometimes occur near the yellow spot, and probably all the layers then become infiltrated, while sometimes the blood ruptures the anterior limiting membrane of the retina and passes into the vitreous. Retinal hemorrhages may be large or small, single or multiple ; limited to the central region or scattered in all parts ; linear, streaky, or flame-shape, punctate or blotchy ; they may lie alongside large vessels, or be in no apparent relation to visible vessels. The hemorrhage may, as already mentioned, be the primary change or may only form part of a retinitis or papillo-retinitis. A hemorrhage which is mottled and of dark, dull color is generally old. The rate of absorption varies very greatly ; hemorrhages after blows are very quickly absorbed, while those depending on rupture of diseased vessels in old people, or accompanying albu- minuric retinitis, generally last for months, and often leave permanent traces. 18* 210 DISEASES OF THE RETINA. Pigmentation of the retina lias been referred to in con- nection with choroiditis (p. 191). Whenever pigment in the fundus forms long, sharply defined lines, or is arranged in a mossy, lace-like, or reticulated pattern, we may always safely infer that it is situated in the retina, and generally that it lies along the sheaths of the retinal vessels (com- pare Fig. 72 with Fig. 69). Pigment in or on the choroid never takes such a pattern, being usually in blotches or rings. The two types, however, are often mingled in cases of choroiditis with secondary affection of the retina ; in- deed, in every case where we decide that the retina is pig- FIG. 72. Study of pigment in the retina in a specimen of secondary retinitis pigmentosa, seen from the inner (vitreous) surface. mented the choroid must be carefully examined for evi- dences of former choroiditis. Spots of pigment are not unfrequently left after the ab- sorption of retinal hemorrhages. It is seldom difficult to distinguish these spots from those which follow choroiditis; they are uniformly black or dark brown, and though some- times surrounded by a little collar of pale choroid, or by some disturbance of the pigment epithelium, they are not associated with any other signs of choroidal disease (com- pare Choroidal Hemorrhage, pp. 184 and 189). Atrophy of the retina, of which pigmentation, when present, is always a sign, has for its most constant indica- tion a marked shrinking of the retinal bloodvessels and thickening of their coats. When the atrophy follows a retinitis or choroido-retinitis (retinitis pigmentosa, syphilitic choroido-retinitis, etc.) all the layers are involved, and the DISEASES OF THE RETINA. 211 outer layers (those nearest the choroid) earlier than the inner ; but when it is secondary to disease of the optic nerve (optic neuritis, progressive atrophy, and glaucoma) only the layers of nerve-fibres and ganglion cells are atrophied, the outer layers being found perfect even after many years. A retina atrophied after retinitis often does not regain per- fect transparency, and if there have been choroiditis the retina remains especially hazy in the parts where this has been most severe. The disk in atrophy following retinitis or choroido- retinitis always passes into atrophy, often of peculiar ap- pearance, being pale, hazy, but homogeneous looking, with a yellowish or brownish tint (p. 197). Detachment (separation) of the retina. As there is no continuity of structure between the choroid and retina, the two may be easily separated by hemorrhage, effusion FIG. 73. Faction of eye with partial detachment of retina. of fluid, and morbid growths. This result is very seldom caused by primary changes in the retina, but nearly always depends upon disease of the choroid, ciliary body, or vitreous. The retina is separated at the expense of the vitreous (which is proportionately absorbed), but always remains attached at the disk and ora serrata, unless as the result of wound or great violence. The depth, area, and situation of the detachment are subject to much variety. Fig. 73 shows a diagrammatic section of an eye in which the lower part of the retina is separated. 212 DISEASES OF THE KETINA. The separated portion is usually far within the focal length of the eye, its erect image is, therefore, very easily visible by the direct method (p. 73, 1), when it appears as a dark, or gray, or whitish reflection in some part of the field, the remainder being of the proper red color; the de- tached part is gray or whitish, because the retina has be- come opaque. With care we can accurately focus the surface of the gray reflection, see that it is folded, and sec one or more retinal vessels meandering upon it in a tortu- ous course; they appear small and of dark color. If the separation be deep, the outline of its more prominent folds ^Fig, 74) can be seen standing out sharply against the red FIG. 74. Ophthalmoscopic appearance of detached retina (erect image). (After Wecker and Jaeger.) background, and in some cases the folds flap about when the eye is quickly moved. In extreme cases we can see the detached part by focal light. When the detachment is recent, especially if shallow, the red choroid is still seen through it ; the diagnosis then rests on the observation of whether the vessels in any part become darker, smaller, and more tortuous, and upon ophthalmoscopic estimation of the refraction of the retinal vessels (p. 75) at different parts of the fundus, for the. detached part will be much more hypermetropic than the rest. In very high myopia, a shallow detachment may still lie behind the principal focus, and therefore not yield an erect image without a DISEASES OF THE KETINA. 213 suitable convex lens. In such cases, and in others where minute rucks or folds of detachment are present, examina- tion by the indirect method leads to a right diagnosis ; the image of the detached portion is not in focus at the same moment as its surrounding parts, parallactic movement 1 is obtained, and the vessels are tortuous. Deep and extensive detachment is often associated with opacities in the vitreous or lens, or with iritic adhesions. All or any of these con- ditions interfere with the conclusive application of the above tests, for the full use of which a dilated pupil is often essential. The common causes of detachment are injury, myopia, and intraocular tumors. Its treatment is very unsatisfactory. Puncture of the sclerotic over the detachment, or of the separated retina itself, allowing the fluid to escape from the eye in the one case or into the vitreous in the other, have been repeatedly tried. Lately profuse sweating and salivation induced by pilocarpine (Fig. 33, A) have been recommended in recent cases. CLINICAL FORMS OF RETINAL DISEASE. The symptoms of retinal disease relate only to the failure of sight which they cause, and this may be either general or confined to a part of the field, according to the nature of the case. Neither photophobia nor pain occurs in un- complicated retinitis. Syphilitic retinitis is generally associated with and sec- ondary to choroiditis (p. 197), but in a few cases retinitis of quite the same character is primary. The vitreous in this disease, as in syphilitic choroiditis, is often hazy, and the opacities are sometimes seated very deeply, just in front of the retina. The changes are those of diffuse retinitis (p. 206, 1), with slight "smoky" haze, often confined to 1 On closing one eye and viewing two objects, one beyond the other but in the same line, one object seems to move over the other when the head is moved from side to side. 214 DISEASES OF THE RETINA. the yellow spot or disk region ; but in bad cases the haze passes into a whiter mistiness, and extends over a much larger region ; sometimes long branching streaks or bands of dense opacity are met with, and hemorrhages may occur. The disk is always hazy, and at first decidedly too red, while the retinal vessels, both arteries and veins, are some- what turgid and tortuous. In a few the disk becomes opaque and swollen (papillitis). At a late period in un- favorable cases the vessels shrink slowly, almost to threads, and the retina often becomes pigmented at the periphery. Syphilitic retinitis is one of the secondary symptoms, seldom setting in earlier than six, or later than eighteen, months after the primary disease. It occurs in congenital as well as acquired syphilis. It generally attacks both eyes, though often with an interval. Its onset is often rapid, as judged by its chief symptom, failure of sight, and it may be stated that, as a rule, the degree of amblyopia is much greater than would be expected from the ophthal- moscopic changes. Night-blindness is always a pronounced symptom. It is essentially a protracted disease, always lasting for months, and showing a remarkable tendency for many months to repeated and rapid exacerbations after temporary recoveries, but with a tendency to get worse rather than towards spontaneous cure. Amongst the early symptoms is often a "flickering," and this with the history of variations lasting for a few days, and of marked night-blindness, often lead to a correct surmise before ophthalmoscopic examination. There is, however, nothing pathognomonic in any of the symptoms. An annular defect in the visual field (" ring scotoma ") may often be found if sought; in the late stages the field is contracted. Mercury produces most marked benefit, and when used early it permanently cures a large proportion of the cases ; but in a number of cases, perhaps in those where there is most choroiditis, the disease goes slowly from bad to worse DISEASES Of T1IE RETINA. 215 for several years, in spite of very prolonged mercurial treatment. Of the efficacy of prolonged disuse of the eyes, and of local counter-irritation or depletion, strongly rec- ommended by many authors, I have had but little ex- perience. Albuminuric retinitis (papillo-retinitis). The changes are strongly marked, and so characteristic that it is possible, in most cases, to say from an ophthalmoscopic examination alone that the patient is suffering from chronic kidney disease. The earliest change (the stage of oedema and exudation) is a general haze of a dull or grayish tint in the central region of the retina, generally with some hemorrhages and soft-edged white patches (3 and 4, p. 208), and with or without haze and swelling of the disk. In this stage the sight is often unimpaired, and so the cases are seldom seen by ophthalmic surgeons till a few weeks later, when the translucent, probably albuminous, exudations into the swollen retina have passed into fatty or fibrinous degenera- tion, affecting both the nerve-fibres and connective tissue of the retina. In this, the second stage, we find a number of pure white dots, spots, or patches, in the hazy region, and especially grouped around the yellow spot. Their peculiarity is their sharp definition and pure opaque white color, which is almost glistening when they are small and round. When not very numerous, they are generally confined to the yellow spot region, from which they show a tendency to radiate in lines (Fig. 70); when very small and scanty they may be overlooked, unless we employ the erect image ; but in most cases large patches are formed by the con- fluence of small spots, and the borders of these patches are striated, crenated, or spotted. At this stage the soft-edged patches (Fig. 71) have often to a great extent disappeared or become merged into more general opacity of the retina ; 216 DISEASES OF THE RETINA. the disk is hazy and somewhat swollen, especially just at its margin, and the retina, as judged by the undulations of its vessels, and confirmed by post-mortem examinations, is much thickened. Hemorrhages are generally still present in greater or less number, and occasionally constitute the most marked feature of the case; they are usually striated. Sometimes an artery is seen sheathed by a dense white coating. 1 In another group papillitis (p. 225) is the most marked change, though some bright white retinal spots are always to be found by careful examination. The usual tendency is towards subsidence of the oedema, and absorption of the fatty deposits and extravasations, generally with improvement of sight the third stage, or stage of absorption and atrophy. In the course of several months the white spots diminish in size and number until only a few very small ones are left near the yellow spot, with, perhaps, some residual haze; the blood-patches are slowly absorbed, often leaving pigment spots, and the re- tinal arteries may be shrunken. In cases of only moderate severity almost perfect sight is restored. But when the optic disk suffers severely (severe papillitis), or if the re- tinal disease is excessive and attended by great oedema, sight either improves very little, or, as the disk passes into atrophy and the retinal vessels contract, it may sink to almost total blindness. Such a condition may be mistaken for atrophy after cerebral neuritis ; but the presence of a few minute bright dots or of some superficial disturbance of the choroid at the yellow spot, or of some scattered pigment spots left by extravasations, will generally lead to a correct inference (p. 210). In the cases attended by the greatest swelling and opacity of retina and disk, death often occurs before retrogressive changes have taken place. 1 An excellent illustration of this is given in Dr. Gower's Medi- cal Ophthalmoscopy, pi. xii., Fig. 1. DISEASES OF THE RETINA. 217 Albuminuric retinitis is symmetrical, but seldom quite equal in degree or result in the two eyes. In extreme cases it may cause detachment of the retina. The kidney disease in the malady under consideration is always chronic. The retinitis may occur in any chronic nephritis, and in the albuminuria of pregnancy. What- ever be the form of the kidney disease, the retinitis seldom occurs without other signs of active kidney mischief, such as headache, vomiting, loss of appetite, and often anasarca. The quantity of albumen varies very much. In the ab- sence of anasarca the symptoms are often put down to " biliousness," and as in such cases the failure of sight is the most troublesome symptom, the ophthalmoscope often leads to the correct diagnosis. Many of the best marked cases of albuminuric retiuitis occur in the albuminuria of pregnancy, and the prognosis for sight is good in many of these if the symptoms come on late in the pregnancy. On the other hand, some of them (probably cases of old kidney disease) do very badly, and pass into atrophy of the nerves. A second attack of retinitis sometimes occurs in connection with a relapse of renal symptoms. (For the changes which occur in the retina in other chronic general diseases, e. g., diabetes, pernicious anaemia, and leucocythaemia, see Chapter on Etiology.) The term retinitis haemorrhagica has been given to certain rare cases, where very numerous small linear or flame-shaped retinal hemorrhages are found all over the fundus, with extreme venous engorgement. It usually occurs in only one eye at a time, and comes on rapidly. The patients are often gouty. Thrombosis of the trunk of the -vena centralis retime is probably the determining cause of the condition. 1 Other cases are seen where extravasations, varying much 1 Hutchinson ; Michel, Graefe's Arch, of Ophth., xxiv. 2. 19 218 DISEASES OP THE RETINA. in size, number, and shape, are scattered in different parts of the fundus of one or both eyes. Some of them are probably allied to the above, but often the nature of the case is obscure, or the hemorrrhages are related to senile degeneration of vessels. Such cases are often called retinitis apoplectica. Lastly, in an important group, a single very large ex- travasation occurs from rupture of a large retinal vessel, probably an artery. The hemorrhage is generally in the yellow spot region ; in process of absorption it becomes mottled, the densest parts remaining longest, and, if seen in that condition for the first time, the case may be taken for one of multiple hemorrhages. These large extravasa- tions cause great defect of sight, which comes on in an hour or two, but not with absolute suddenness. Absorption, in all the groups of cases above mentioned, is very slow. Hemorrhages may occur from blows on the eye. They are usually small and quickly absorbed, differing in the latter respect very much from the cases before described. Embolism of the central artery of the retina, or of one or more of its main divisions, gives rise to a characteristic retinitis, the cause of which can in most cases be recog- nized at once if it be recent; whilst in old cases the ap- pearances, taken with the history, always lead to a right diagnosis. Thrombosis of the artery causes similar changes. The leading symptom of embolism is the occurrence of an instantaneous defect of sight, which is found on trial to be limited to one eye; sometimes the feeling is as if one eye had suddenly become "shut," the blindness being as sudden as that from quickly closing the lids ; but whether the defect amounts to absolute blindness or not, depends on the position and size of the plug. In any case, owing to the temporary establishment of collateral circulation by the capillary anastomoses at the disk (p. 203), the patient often notices an improvement of sight a few hours after the DISEASES OF THE RETINA. 219 occurrence. But this improvement is only very slight, the collateral channels being quite insufficient to meet the de- mand promptly; n.or is it often permanent, because the retina suffers very quickly from the almost complete stasis, oedema and inflammation rapidly setting in and leading to permanent damage. If the case be seen within a few days of the occurrence, the red reflex of the choroid around the yellow spot and disk is quite obscured, or partially dulled, by a diffused and uniform white mist The opacity is greatest just around the centre of the yellow spot, where the retina is very vascular (Fig. 69), and where its cellular elements (ganglion and granule layers) are more abundant than any- where else; but at the very centre of the white mist a small, round, red spot is generally seen, so well defined that it may be mistaken for a hemorrhage; it represents the fovea centralis, where the retina is so thin that the choroid .continues to shine through it when the surrounding parts are opaque; it is spoken of by authors as the "cherry-red spot at the macula lutea." This appearance is very seldom seen except after sudden arrest of arterial blood supply, by embolism or thrombosis of the arteria centralis, and per- haps by hemorrhage into the optic nerve compressing the vessels; and of these causes embolism appears to be. the commonest. The haze surrounds and generally affects the disk also, which soon becomes very pale. The small veins in the yellow spot region often stand out with great dis- tinctness, partly because enlarged by stasis, and partly from contrast with the white retina. Small hemorrhages are often present. The larger retinal vessels, both arteries and veins, are more or less diminished at and near the disk, the arteries in the most typical cases being reduced to mere threads; while both arteries and veins are sometimes ob- served to increase in size as they recede from the disk. The arteries, however, are not always extremely shrunken 220 DISEASES OF THE RETINA. in cases of retinal embolism, the variations depending upon the position and size of the plug, i. e., upon whether it causes complete occlusion or not. The sudden and com- plete failure of supply to a branch of a retinal artery is sometimes followed by its emptying and shrinking to a Avhite cord almost immediately. In other cases a large artery may for a time be little, if at all, altered in size and yet its blood column be quite stagnant, as is proved by the impossibility of producing pulsation in it by the firmest pressure on the globe, whilst the other branches respond perfectly to this test (p. 72). But in other cases, this pressure test, which showed blockage of some or all branches shortly after the onset, again produces pulsation a few days later, without any visible evidence of collateral circulation. In from one to about four weeks the cloudiness clears off, and the disk passes into moderately white atrophy ; the arteries, or some of them (according to the position of the plugging), are either reduced to bloodless white lines, or are simply narrowed considerably, but still pulsate easily on pi-ess u re. Sight is always extinguished, or only perception of large objects remains, whatever be the final state of the blood- vessels. In the rare cases, where an embolus passes beyond the disk, and is arrested in a branch at some distance from it, the changes are confined to the corresponding sector of the retina, and a limited defect of the field is the only result. It is scarcely necessary to say that no treatment can be of any use in cases of lasting occlusion of the retinal arteries. In a few cases where instantaneous blindness of both eyes has been associated with extremely diminished arteries ("ischcemia retince"^), iridectomy has been followed by return of sight; lower tension causing reestablishment of circulation. These cases generally occur after whooping- cough. (See also Quinine Blindness.) DISEASES OF THE RETINA. 221 Retinitis pigmentcsa is a very slowly progressive sym- metrical disease, leading to atrophy of the retina, with collection of black pigment in its layers and around the bloodvessels, and secondary atrophy of the disk. The earliest symptom is inability to see well at night or by artificial light (night-blindness, nyctalopia). Concentric contraction of the visual field soon occurs. These defects may reach a high degree, whilst central vision remains ex- cellent in bright daylight. The symptoms are noticed at an earlier stage by patients in whom the choroid is dark and absorbs much light. Ophthalmoscopic examination, where these symptoms have been present for some years, shows : (1) at the equator or periphery a greater or less quantity of pigment arranged in a reticulated or linear manner (Fig. 72), often with some small separate dots ; (2) in advanced cases, evidence of removal of the pigment epithelium, but never any patches of choroidal atrophy; (3) that the pigment is arranged in a belt, which is in general terms uniform, the pattern being most crowded at the centre and thinning out towards the borders of the belt; (4) that the changes are always symmetrical, and the symmetry very precise. These appearances are quite characteristic of true retinitis pig- mentosa. In addition we find (5) diminution in size of the retinal bloodvessels, the arteries in advanced cases being mere threads; (6) a peculiar hazy, yellowish, "waxy" pallor of the optic disk (p. 211); (7) sometimes the pig- mented parts of the retina are quite hazy; (8) posterior polar cataract and disease of the vitreous are often present in the later stages. The latter changes (5 to 8), however, are found in many cases of late retinitis consecutive to choroiditis, and are not peculiar to the present malady. The disease begins in childhood or adolescence, progresses slowly but surely, and as a rule ends in blindness some time after middle life. A few cases of apparently recent 19* 222 DISEASES OF THE RETINA. origin are seen in quite aged persons, and a few are con- sidered to be truly congenital. The quantity of pigment visible by the ophthalmoscope varies much in cases of apparently equal duration, and is not in direct relation to the defect of sight; cases even occur which certainly belong to the same category in which no pigment is visible during life, the retina being merely hazy, and in one such case microscopical examination revealed abundance of minutely divided pigment (Poncet). The pathogenesis of the disease is not finally settled ; it is at present doubtful whether there is from the first a slow sclerosis of the con- nective-tissue elements of the retina, with passage inwards of pigment from the pigment epithelium, or whether the disease begins in the superficial layers of the choroid and the pigment epithelium. Its cause is obscure. It is un- doubtedly strongly heritable, and many high authorities believe that it is really produced by consanguinity of marriage, either between the parents, or near ancestors of the affected persons. Many of its subjects are of full mental and bodily vigor; but others are badly grown, suffer from progressive deafness, and are defective in intel- lect. Although want of education, as a consequence of defective sight and hearing, may sometimes account for this result, we cannot thus explain the various defects and diseases of the nervous system which are not unfrequently noticed in kinsmen of the patients. That the subjects of this disease should be discouraged from marrying is suf- ficiently evident. In a few cases galvanism has been followed by improve- ment both of vision and visual 1 field, but no other treat- ment has any influence. Complications such as cataract and myopia are not un- common, and must be treated on general principles. 1 Gunn, Oph. Hosp. Reports, x. 161. DISEASES OF THE RETINA. 223 There are cases in which great difficulty is experienced in distinguishing widely diffused and superficial choroiditis, with pigmentation of retina and atrophy of the disk, from true retinitis pigmentosa. The question will generally relate to cause, as between retinitis pigmentosa and cho- roido-retinitis from syphilis (p. 197). But other cases of choroido-retinal disease occur, which, though easily dis- tinguishable from retinitis pigmentosa, are, like it, related to some general disease of the nervous system in the patient or his parents, and not to syphilis. 224 DISEASES OF THE OPTIC NERVE. CHAPTER XV. DISEASES OF THE OPTIC NERVE. THE optic nerve is often diseased in its whole length, or in some part of its course, either within the skull, in the orbit, or at its intraocular end. The effect of disease of the optic nerve in producing (1) ophthalmoscopic changes in its visible portion (the optic disk, or papilla optica), and (2) defect of sight, varies greatly according to the seat, nature, and duration of the disease. The appearance of the disk may be entirely altered by oadema and inflammation, without the nerve- fibres losing their conductivity, and, therefore, without loss or even defect of sight ; on the other hand, inflamma- tory or atrophic changes, causing destruction of the nerve- fibres, may arise in the nerve at a distance from the eye, and, whilst producing great defect of sight, cause little or no immediate change at the disk. Although we are here concerned chiefly with the ophthalmoscopic and visual sides of the question, a few words are needed as to the morbid changes in the nerve. The pathological changes to which the optic nerve is liable include those which affect other nerve-tissues. Inflammation varying in seat, cause, and rapidity, and resulting in recovery or atrophy, may originate in the nerve itself, may pass down it from the brain (descending neuritis), or may extend into it from parts around ; atrophy may occur from pressure by tumors, or by distention of neighboring cavities (e. g., the third ventricle), or from laceration or compression after fracture of the optic canal ; DISEASES OF THE OPTIC NERVE. 225 and the optic nerve is very subject to the change known as " gray degeneration " or " sclerosis." Lastly, the optic nerve being surrounded by a lymphatic space (" subvaginal space "), which is continuous through the optic foramen with the meningeal spaces in the skull, and is bounded by the tough fibrous " outer sheath" of the nerve, is liable to be affected by fluid or inflammatory products in that space. Such retention or secretion of fluid in the subvaginal space is often found post mortem, in cases of the optic neuritis about to be described as so commonly associated with intracranial disease, and has been held to explain its occurrence. Recent microscopical research, however, has shown that in many, probably in all, cases proofs of inflammation can be traced along the whole course of the optic nerves from their intracranial part to the eye. The occurrence of optic papillitis 1 in intracranial disease is probably, therefore, explained in all cases by extension of inflammation from the brain or its membranes by way of the interstitial connective tissue, or down the inner nerve-sheath, or perhaps, in some cases, along the intrinsic bloodvessels of the optic nerve. This explanation by " descending neuritis " has always been accepted for the papillitis caused by meningitis. But other hypotheses, which have been, or seem likely to be, given up, have hitherto been held by most authorities to be more applicable to the papillitis caused by cerebral tumor, because in these cases the signs of inflammation in the trunk of the nerve above the disk are often slight, and can be detected only by a careful microscopical ex- amination of well-stained sections. The part taken by the fluid which, as stated above, is often present in the 1 Papillitis has been proposed by Leber to designate the ophthal- moscopic appearances of the inflamed or swollen disk, without reference to theories of causation, or to the state of the nerve trunk. 226 DISEASES OF THE OPTIC NERVE. subvaginal space of the nerve and in greatest quantity close to the eye, is not yet known. It may possibly act in either or both of two ways ; mechanically by compressing the nerve and hindering return of blood from the retina, and thus complicating an already existing neuritis, or vitally by carrying inflammatory germs from the cranial cavity to the optic nerve. It is not yet fully known how cerebral tumors set up descending optic neuritis when the absence of fluid in the sheath precludes any appeal to its influence ; but many facts point to the probability that they do so by lighting up irritation with increase of cell growth in the surrounding brain substance, or in other cases by causing localized meningitis. Nor is it fully understood why the other cranial nerves are so seldom damaged, at least permanently. 1 As already stated in previous chapters, inflammation may extend into the disk from the retina or choroid near to it, and may occur in consequence of the sudden arrest of the blood-current in embolism and thrombosis of the central retinal vessels, in their course through the nerve. Ophthalmoscopic signs of inflammation of the optic disk. The changes caused by cedema of the disk are mingled with those of congestion and inflammation. It is no longer useful to maintain the old distinction between " swollen disk," or " choked disk," attributed to compression of the optic nerve by fluid in its sheath, or with less reason to pressure upon the ophthalmic vein at the cavernous sinus, and " optic neuritis." The latter term was formerly reserved for cases showing little cedema, but much opacity, changes which were supposed especially to indicate in- flammation passing down the trunk of the nerve from 1 For a full and masterly statement of this difficult subject, enriched with many new facts, the reader is referred to Dr. Gowers' Manual and Atlas of Medical Ophthalmoscopy (p. 63). DISEASES OF THE OPTIC NERVE. the brain. The changes are often mixed or present at different stages of the same case. The terms " neuritis " and "papillitis ' n will be here used to the exclusion of "choked disk." The most important early changes in optic papillitis are blurring of the border of the disk by a grayish opalescent haze, distention of the large retinal veins, and swelling of the disk above the surrounding retina. Swelling is shown Ophthalmoscopic appearance of severe papillitis. Several elongated patches of blood near border of disk. (After Hughlings Jackson.) Compare with Fig. 76. by the abrupt bending of the vessels, with deepening of their color and loss of the light streak they are, in fact, seen foreshortened; also by noticing that slight lateral movements of the observer's head or lens cause an apparent 1 Much light has within the last two or three years been thrown on the subject by the microscopical work of Gowers, Stephen Mackenzie, Edmunds, and Brailey, in this country. Trans, of the Ophthalmological Society, vol. i., 1881, and Trans, of the Internal. Med. Congress, 1881, vol. 3, p. 61. DISEASES OF THE OPTIC NERVE. movement of the vessels at the disk over the choroid behind, because the two objects are on different levels (j>. 213, foot- note^. The patient may die or the disease may, after n very varying time, recede at this stage. But generally, further changes occur; the haziness becomes decided opacity, which more or less obscures the central vessels and covers and extends beyond the border of the papilla F_ " - :hat the disk appears considerably increased in diameter ; its color becomes a mixture of yellow and pink with gray or white, and it looks striated or fibrous, appearances due to a whitish opacity of the nerve-fibres mingled with numerous small bloodvessels and hemor- rhages. The veins become larger and more tortuous, even kinked or knuckled; the arteries are either normal or Section of the swollen disk in papfflitis, showing that the swelling is limited to the layer of nerve-fibres (longitudinal shading) : other retinal layers not altered in thickness. (Compare with Fig. 34.) X about lo. somewhat contracted ; there may be blood patches. The swelling of the disk may attain a very high degree, the prominence being realized chiefly by attention to the above-mentioned changes in the course and appearance of the vessels. Such changes may disappear, leaving scarcely a trace; DISEASES OF THE OPTIC NERVE. 229 or a certain degree of atrophic paleness of the disk, with some narrowing of the retinal vessels and thickening of their sheaths, or other slight changes, may remain. But in many cases the disk gradually, in the course of weeks or months, passes into a state of atrophy; the opacity first becomes whiter and smoother looking ("woolly disk";; then it slowly clears off, generally first at the side next the yellow spot, and the retinal vessels simultaneously shrink to a smaller size, though they often remain tortuous f r a long time (Fig. 77). As the mist lifts, the sharp edge, and PIG. 77. Atrophy of disk after papillitis. finally the whole surface of the disk, now of a staring-white color, again comes into view. A slight haziness often re- mains, and the boundary of the disk is often notched and irregular; but these are not signs upon which too much reliance must be placed. The degree to which the central vessels are shrunken is one of the best signs of the degree of atrophy of the nerve after neuritis ("consecutive" or "post-papillitic" atrophy). Sight is seldom much affected until marked papillitis has existed some little time ; if the morbid process quickly cease no failure may take place, or sight may fail, may even sink almost to blindness, for a short time, and recovery 20 230 DISEASES OF THE OPTIC NERVE. take place if the changes cease before compression of the nerve-fibres has given rise to atrophy. Gradual failure late in the case, when retrogressive changes are already visible at the disk, is a bad sign. The sight seldom changes, either for better or worse, after the signs of active papillitis have quite passed off, and though the relations between sight and final ophthalmoscopic appearances vary, it is usually true (1) that great shrinking of the principal retinal vessels indicates great defect of sight, and generally accompanies extreme pallor with some permanent residual haziness of the disk (advanced post-papillitic atrophy) ; (2) that considerable pallor, and other slight changes, sucli as white lines bounding the vessels, or streaks caused by increase of the connective tissue of the disk, are compatible with fairly good sight, if the central vessels are not much shrunken. Advanced atrophy, undoubtedly following papillitis, does not, however,- always show signs of the past violent inflam- mation; the appearances may indeed be indistinguishable from those caused by primary atrophy. Papillitis is double in the great majority of cases; if single, it generally indicates disease in the orbit. In the double cases, however, there are often inequalities, in time, degree, and final result, between the two eyes. 1 The changes are not always limited strictly to the disk and its border (pure papillitis), for in some cases a wide zone of surrounding retina is hazy and swollen, exhibiting hemorrhages and white plaques, or lustrous white dots (papillo-retinitis, neuro-retinitis). It is not always easy to say in such a case whether the changes are due to renal disease with great swelling of the disk (p. 216), or to some intracranial malady. In renal cases there is always albu- 1 Single neuritis has been seen in a few cases of cerebral tumor by Hughlings Jackson, and others. DISEASES OF THE OPTIC NERVE. 231 minuria, the patient is seldom a young child, and the cases with most severe neuro-retinitis occur in an advanced stage of kidney disease; 1 in the cases of neuro-retinitis most closely resembling renal cases but caused by cerebral dis- ease, there will be no albumen, and the changes will sel- dom closely resemble those of albuminuria until they have existed for long and caused very great defect of sight. ETIOLOGY. Papillitis occurs chiefly in cases of irritative intracranial disease, viz., in meningitis, both acute and chronic, and in intracranial new growths of all kinds, whether inflammatory (syphilitic gummata), tubercular, or neoplastic. It is very rare in cases where there is neither iuflammation nor tissue growth, as in cerebral hemorrhage and intracranial aneurism. Further, it must be stated that no constant relationship has been proved between papillitis and the seat, extent, or duration of the intracranial disease. Papillitis has occasionally been found without coarse disease, but with widely diffused minute changes, in the brain. Thus, the occurrence of papillitis, although pointing very strongly to organic disease within the skull, and especially to intracranial tumor, is not of itself either a localizing or a differentiating symptom. Inflammation about the sphenoidal fissure, thrombosis of the cavernous sinus, and tumors and inflammations in the orbit, are occasional causes of papillitis and of descending neuritis, which is then usually one-sided, and often accompanied by extreme oedema and venous distention; in some of these there is protrusion of the eye and affection of other orbital nerves, and the exact seat of disease may be very obscure. In a few cases well-marked double papillitis occurs with- out other symptoms and without assignable cause. Other occasional causes of double papillitis, with or without 1 Gowers, p. 187. 232 DISEASES OF THE OPTIC NERVE. retinitis, are lead poisoning, the various exanthemata, sudden suppression of menstruation, simple ansemia, and, perhaps, exposure to cold. Certain cases of failure of sight, often in only one eye, with slight neuritic changes at the disk, followed by recov- ery or by atrophy, are probably to be referred to neuritis behind the eye (retro-bulbar neuritis). The changes are clinically very different from any of those above described (see page 240, 3). Syphilitic disease within the skull is a common cause of papillitis, but the eye changes alone furnish no clue to the cause, nor to its mode of action, which may be : (1) by giving rise to intracranial gumrna not in connection with the optic nerves, but acting as any other tumor acts (see above); (2) by direct implication of the chiasma or optic tracts in gummatous inflammation ; (3) in rare cases neu- ritis ending in atrophy and blindness occurs, in secondary syphilis, with severe head symptoms pointing to acute meningitis. The condition of the pupil in neuritic affections depends partly on the state of sight and partly on the rapidity of its failure. As a rule, in ainaurosis from atrophy of the disks after papillitis, the pupils are for a time rather widely dilated and motionless ; after a while they often become smaller, and, unless the blindness be complete, they regain a certain amount of mobility to light. ATROPHY OF THE OPTIC DISK. By this is meant atrophy of the nerve-fibres of the disk, and of the capillary vessels which feed it. It is shown by change of color, and in most cases by a preternatural sharpness of outline. The central retinal vessels may or may not be shrunken. The disk is too white ; milk-white, bluish, grayish, or yellowish in different cases. Its color DISEASES OF THE OPTIC NERVE. 233 may be quite uniform, dead, or opaque looking, or some one part may be whiter than another; the stippling of the lamina cribrosa (p. 69) may be more visible than in health, or, on the other hand, entirely absent, as if covered or filled up by white pairt (Figs. 78 and 79). The choroidal FIG. 78. FIG. 79. Simple atrophy of disk. Stip- Atrophy of disk from spinal dis- pling of lamina cribrosa exposed. ease. Lamina cribrosa concealed. (Wecker.) Vessels normal. (Wecker.) boundary is too sharply defined; it may be even and circular, or irregular and notched. Within it the sclerotic ring (p. 69) is often seen with unnatural clearness, being even whiter than the nerve which it encircles. Mere pallor of the disk, as is present in extreme general anaemia, must not be mistaken for atrophy ; the change is then one of color only ; there is neither unnatural distinctness, loss of transparency, nor disturbance of outline. The large retinal vessels are to be carefully noted as to size and tortuosity, both points being important in the diagnosis of cause, and for prognosis. LOCAL CAUSES. (1) The nerve-fibres undergo atrophy during the absorption and shrinkage of the new connective tissue formed during severe neuritis, whether this affect the disk alone or the whole length of the nerve (see p. 230). 20* 234 DISEASES OP THE OPTIC NERVE. (2) When the disk participates secondarily in inflam- mation of the retina or choroid it also participates in the succeeding atrophy (pp. 197, 211). (3) Atrophy of any part of the optic nerve-trunk or tract, whether from pressure, as by a tumor, or by disten- tion of the third ventricle in hydrocephalus, from injury, or localized inflammation, leads to secondary atrophy, which sooner or later becomes evident at the disk. Such cases often show the conditions of pure atrophy, without complication either by adventitious opacity or disturbance of outline, and often without change in the retinal vessels. They are not very common. (4) The optic nerves are liable to chronic sclerotic changes with thickening of the connective-tissue frame- work and atrophy of the nerve-fibres, without any occurrence of papillitis. The change in these cases appears to begin at the disk, but the exact order of events is not fully known in this large and important group. Groups 3 and 4 fur- nish the cases which are known clinically as " primary " or "progressive" atrophy of the optic disk. Clinical aspects of atrophy of the disks. As in optic neuritis, so in atrophy and pallor of the disk, there is no invariable relation between the appearance (especially the color) of the disk and the patient's sight. A considerable degree of pallor, which it may be impossible to distinguish from true atrophy, is sometimes seen with excellent central vision (p. 43), though usually accompanied by some defect of the visual field. -Again, it is often the case that the disks will look just alike, although the sight is much better in one eye than in the other. (Compare Central Amblyopia, p. 240, 4.) Patients with atrophy of the disk come to us because they cannot see well or are completely amaurotic. There are usually no other local symptoms except such as are furnished by the pupils, and in this respect cases of double DISEASES OF THE OPTIC NERVE. 235 optic atrophy present many variations. In post-papillitic atrophy the pupils are generally too large, and sluggish or motionless to light ; in most cases of primary progressive atrophy they are of ordinary size, or smaller than usual, and act very imperfectly. When only one eye is affected? the other being quite healthy, the pupil of the amaurotic eye has no direct action to light (p. 39) and it may be a little larger than its fellow. The visual field, in cases of atrophy, is generally con- tracted, or shows irregular invasions or sector-like defects. Color-blindness is a marked symptom in nearly all cases of atrophy, but is not always proportionate to the loss of vision, being in some much greater and in others much less than the state of vision would lead us to expect (see also Amblyopia). Green is the color lost soonest in nearly all cases, and red next, but in this respect variations are occa- sionally observed. A. Cases in which both disks are atrophied may be con- veniently classified as follows in regard to diagnosis and prognosis. (1) If the changes point decidedly to recently past papillitis (p. 229), there is some prospect of improvement; but, on the other hand, sight may for a time get worse. The case must, of course, be investigated most carefully as to the cause of the neuritis. If sight has been stationary for some months, further change is unlikely. (2) Whenever the retinal arteries are much shrunken, whether neuritis have occurred or not, the prognosis is bad (p. 230). (3) The most careful examination leaves it uncertain whether previous papillitis have occurred. Still, as con- secutive cannot always be distinguished from primary atrophy (p. 230), inquiry should be made for previous symptoms of intracranial disease. But in a large number of the cases, which present no ophthalmoscopic evidences 236 DISEASES OF THE OPTIC NERVE. of previous papillitis, the history will be quite negative as to cerebral symptoms ; and these will, for the most part, fall into the following two groups. (4) There are symptoms of chronic disease of the spinal cord, usually of locomotor ataxy ; or, much more rarely, symptoms of general paralysis. (5) No spinal symptoms can be made out and no cause assigned for the atrophy; these are relatively common cases. The sclerosis leading to atrophy of the disks in locomotor ataxy (4) usually comes on early in that disease, often before well-marked spinal symptoms have appeared. The optic atrophy always becomes symmetrical, though it gen- erally begins some months sooner in one eye than in. the other; it always progresses, though sometimes not for years, to complete, or all but complete blindness. The disks are usually characterized by a uniformly opaque, gray-white color, the lamina cribrosa being often concealed, although neither the central vessels nor the disk margin are obscured in the least (Fig. 79). The central vessels are often not materially lessened in size, even when the patient is quite blind. Numerous cases of progressive atrophy are seen which agree in every respect with the above, but where no signs' of spinal cord disease are present, even though the patient has been long blind (5). It is known that in some of these patients ataxic symptoms come on sooner or later, and it is highly probable that, could the cases be followed up for a sufficient number of years, this result would be found to be common. Indeed, preataxic optic atrophy is now a recognized method of onset of the disease, though our information is incomplete, and we do not yet know in what proportion of cases of optic atrophy the eye disease remains uncomplicated. Cases of this class (5) are far commoner in men than in women. DISEASES OF THE OPTIC NERVE. 237 In making the prognosis of cases of progressive, uncom- plicated amblyopia or amaurosis, with more or less atrophy of disks, special attention is to be paid to whether or not the failure is synchronous, and whether it is now equal in the two eyes. The state of the field of vision in cases seen early is also of much importance, though more difficult to make out ; peripheral contraction, as distinguished from central defect, is a bad sign, for progressive atrophy sel- dom begins with defect in the centre of the field. Cases of gradual uncomplicated failure of sight, in which the symptoms have, from the beginning, been equally sym- metrical, will generally be found to show but slight atrophic changes in proportion to the defect of sight, (Amblyopia, p. 240, 4.) B. Single amaurosis with atrophy of the disk, in a ma- jority of cases, indicates former embolism of the central artery (p. 218), or some local affection of the trunk of the optic nerve (pp. 231, 234, 240). The latter cases often give a history of having suffered from severe localized headache or neuralgia. But here it must be remembered that in cases of progressive atrophy, accompanying or pre- ceding spinal disease, a very long interval occasionally separates the onset of the disease in the two eyes, and we may see the first eye before the commencement of disease in the second. Single amaurosis following immediately after injury to the head, and leading in a few weeks to atrophy, indicates damage to the nerve from fracture of the optic canal (p. 234, 3). The blow is generally on the front of the head and on the same side as the affected eye. 238 AMBLYOPIA. CHAPTER XVI. AMBLYOPTA AND FUNCTIONAL DISORDERS OF SIGHT. THE term amblyopia means dulness of sight, but its use is generally restricted to cases of defective acuteness of sight (p. 43), short of blindness, in which the visible changes are disproportionately slight. Amaurosis indi- cates a more advanced affection complete blindness with- ont apparent cause. These terms are essentially clinical, whilst papillitis and atrophy imply easily recognized patho- logical changes in the disk. Amblyopia may depend upon disease in the retina, in any part of the optic nerve or tract, or in the optic centres ; and it may be temporary or permanent. It is always most important to distinguish single from symmetrical cases. Two common and important forms of unsymmetrical amblyopia may be considered first. (1) Amblyopia from suppression of the image in one eye, in cases of squint. A squinting person, in order to avoid the difficulties of double vision (p. 33), suppresses the consciousness of the image formed in the squinting eye. If this process be continued, the sensorium becomes perma- nently blunted for images in this eye ; we say that the eye is amblyopic when we ought to say that the corresponding centre loses perception. This defect, though often very great, affects only that part of the visual field which is common to both eyes, and is therefore least marked in the outer part of the field. It continues after the squint has disappeared, i. e., when both eyes are again directed con- stantly to the same object ; but it can be relieved or cured, AMBLYOPIA. 239 except iu very bad cases, by oft-repeated "separate practice of the defective eye, the sound eye being closed. The sup- pression is much more easily effected by some persons than others, and early in life than later ; hence those who have squinted constantly since early childhood seldom have di- plopia when they come for advice several years after- wards, while if squint be acquired later, diplopia lasts for years if not for life. When the suppression is temporary, even though often repeated, as in cases of alternating and of periodic squint, no amblyopia results. 1 (2) Amblyopia from defective retinal images. In cases of high hypermetropia or astigmatism, when clear images have never been formed, the correction of the optical de- fect by glasses at the earliest practicable age often fails, at any rate for a time, to give full acuteness of sight. Want of education in the appreciation of clear images is probably the chief cause, though defective development of the retina may also come into play. We may explain in the same way the common cases in which, with ani- sometropia, the sight of the more ametropic (p. 286) eye, even when corrected by the proper glasses, remains de- fective, although no squint have existed; and in some degree also the defect often observed after perfectly success- ful operations for cataract in children. When discovered late in life this defect is seldom altered by correcting the optical error, but in children the sight may improve when the suitable glasses are constantly worn. In cases of amblyopia not belonging to either of these categories a definite date of onset will generally be given. 1 It should be stated that. this, the commonly received, explana- tion of the amblyopia of the eyes which have squinted from early life has been assumed on the theory of congenital (rather than acquired) "correspondence" between the two retinae, and that it is doubted by so high an authority as Prof. Schweigger, of Berlin. 240 AMBLYOTIA. Two principal divisions may be formed, according as the defect is single or double. It must here be noted, how- ever, that defect or blindness of one eye often exists un- known for years, until accidentally discovered by closing the sound eye. This ignorance of the defect is most com- mon when the failure has been gradual, painless, and not accompanied by any change in the appearance of the eye. The patient is naturally alarmed at the discovery ; but much caution must be used in accepting his belief that the defective eye failed when its defect was found out. Sudden failure of one eye is, as a rule, dated correctly ; and the same is true of gradual failure of the right eye in a man used to rifle shooting, or to "sighting" for any purpose. (3) Cases of recent failure of one eye with little or no ophthalmoscopic change occur but rarely, generally in young adults; the onset is often rapid, with neuralgic pains, sometimes very severe, in the same side of the head. There may be pain in moving the eye, or tenderness when it is pressed back into the orbit. The degree of amblyopia varies much, but is often especially marked at the centre of the field. The disk of the affected eye is sometimes hazy and congested. The attack is often attributed to exposure to cold. Most of the cases recover under the use of blisters and iodide of potassium, but in a certain number the defect is permanent, and the disk becomes atrophied. A retro- bulbar neuritis, often slight and transient, most likely occurs (p. 232), and the cases are perhaps analogous to peripheral paralysis of the facial nerve. (4) Much commoner is a progressive and equal failure in both eyes, often amounting in a few weeks or months to great defect (14 or 20 Jaeger, or V. from % to y 1 ^), with no other local symptoms except perhaps a little frontal headache, but often with general want of tone, nervousness, and loss of sleep and appetite. Ophthalmoscopic changes, AMBLYOPIA. 241 never pronounced, may be quite absent. At an early period the disk is often decidedly congested, and slightly swollen and hazy, but these changes are so ill-marked that competent observers may give different accounts of the same case. Later the side of the disk next the y. s., and finally, in bad cases, the whole papilla, becomes pale, and the diagnosis of incomplete atrophy is given. The defect of sight is described as a " mist," and is usually most trouble- some in bright light and for distant objects, being less apparent early in the morning and towards evening. The pupils are normal, or at most rather sluggish to light. The defect of V. is limited to, or much greater at, the central part of the field (causing a central seotoma), and occupies an oval patch from the fixation point (corresponding to the yellow spot) outwards to the blind spot (corresponding to the optic disk), on which area the perception of green and red is also defective or absent. This symptom may often be detected by moving a red or green spot (from 5 to 15 mm. square) from the fixation point in different directions, the eye steadily fixing the upheld finger or other object; the color of the spot will be seen best (if at all) at a little distance from the fixation point (compare p. 250) ; in many cases no color defect is apparent if the patient be tested with large masses of color. The periphery of the field being good, no difficulty is experienced by the patient in going about, the large surrounding objects being visible ; hence the patient's manner differs "from that of one with progressive atrophy, Avho finds difficulty in walking about, etc., because his visual field is contracted (p. 234). The patients are almost without exception males, and at or beyond middle life. With very rare exceptions they are smokers, and have smoked for many years, and a large number are also intemperate in alcohol. The exceptions occur chiefly in a very few patients in whom a similar kind of amblyopia is hereditary, is liable to affect the female as 21 242 AMBLYOPIA. well as the male members, and sometimes comes on much earlier in life. The etiology of these cases is obscure. In some few of them there is no evidence of heredity. In the common cases it is now generally agreed that tobacco has a large share in the causation, and in the opinion of an increasing number of observers it is the sole excitant. The direct influence of alcohol, and of the various causes of general exhaustion, such as anxiety, underfeeding, and general dissipation, is still to some ex- tent an open question. My own opinion, based on the examination of a large number of cases, is that tobacco is the essential agent, and that the disuse or diminished use of tobacco is the one essential measure of treatment. It is important to remember that the disease may come on when either the quantity or the strength of the tobacco is increased, or when the health fails and a quantity which was formerly well borne becomes excessive* Hence cases of central amblyopia may, as a rule, except in the rare form above mentioned, be named tobacco amblyopia. The prognosis is good if the case come to treatment early, and if the failure have been comparatively quick. In such cases really perfect recovery may occur, and an improvement so striking that the patient considers his recovery perfect is the rule. In the more chronic cases, or cases where already the w r hole disk is pale, a moderate improvement, or even, an arrest of progress, is all we can expect. If smoking be persisted in no improvement takes place, and the amblyopia increases up to a certain point, but complete blindness very seldom, if ever, occurs. In the treatment, disuse of tobacco is the one thing essential. If the man drinks too much he should, of course, lessen the amount. It is usual to give strychnia subcutaneously or by mouth for a considerable period, but whether any med- icine acts otherwise than by improving the general tone is doubtful ; subcutaneous injections of strychnia, carefully AMBLYOPIA. 243 carried out, have not given definite results in my own cases. There is reason to believe that the disease depends on a chronic inflammation of the central bundles of the optic nerve beginning at a distance from the eye. Hemianopsia (usually called hemiopia) denotes loss of half the field of vision. When unilocular the defect is seldom quite regular, and generally depends upon detach- ment of the retina or a very large retinal hemorrhage. It is usually binocular, and then indicates disease at or behind the optic chiasma. In the great majority of cases the R. or L. lateral half of each field is lost. The line of separa- tion between the blind and the seeing halves of each field may pass vertically straight through the fixation point, but more commonly it deviates a little, so as to leave intact a small area of the field around the fixation point, so that central vision is not impaired; the transition from the seeing to the blind half may be quite abrupt, or rather gradual. Loss of the R. half of each field, meaning loss of function of the L. half of each retina, points to disease of the L. optic tract somewhere between the chiasma and the. corpora geniculata; 1 but it is believed that lateral hemiopia may also be caused by disease of the occipital lobe and angular gyrus (Ferrier). Loss of the two nasal or two temporal halves is extremely rare. Even when hemianopsia has lasted for years the optic disks seldom show any change. When lateral hemianopsia coexists with hemiplegia, the loss of sight is on the paralyzed side ; "the patient cannot see to his paralyzed side" (Hughliugs Jackson) ; sometimes only a quarter of each field is lost, e. g., I have seen the R. lower quarter lost with partial paralysis of the R. leg. 1 Because the L. optic tract consists of fibres which supply the L. half of each retina, those of them destined for the R. eye crossing over at the optic commissure. 244 AMBLYOPIA. Hysterical amblyopia and amaurosis take various forms, and real defect is sometimes mixed up with conscious feigning. In hysterical hemiansesthesia the eye on the affected side is sometimes defective or quite blind. In other cases of hysteria both eyes are defective, but one worse than the other; there is concentric contraction of the visual fields, sometimes with, sometimes without color- blindness, a varying degree of defective visual acuteness, and sight is often disproportionately bad by feeble light (hence the term " anaesthesia of the retina" is sometimes used). There may, however, be in addition irritative symptoms watering, photophobia and spasm of accommo- dation and then the term "hypersesthesia retinae" or " oculi " seems more appropriate. 1 It is important to note that in hysterical cases, even when one eye is quite blind or has bare perception of light, the reflex action of the pupil, direct as well as indirect (p. 39), is fully preserved. The prognosis is nearly always good, though recovery is sometimes slow. In some of the w T orst cases I have seen there has been considerable ametropia (p. 286). True hysterical amblyopia seems allied, from the oph- thalmic standpoint, with a much larger and more important class, best epitomized by the term asthenopia, in which pho- tophobia, irritability, and want of endurance, of the ciliary muscle (accommodative asthenopia), or sometimes of the internal recti (muscular asthenopia) with some conjunctival congestion, are the main symptoms, acuteness of sight being usually perfect, and the refraction nearly or quite normal. Of the retinal, conjunctival, and muscular factors, any one maybe more marked than the others, and it would seem that, given a certain state of the nervous system ? which may be described as impressionable or hyperassthetic, 1 These cases correspond to the kopiopia hysterica of Forster. AMBLYOPIA. 245 over-stimulation of any one is liable to set up an over-sen- sitive state of the other two. These patients often complain also of dazzling, pain at the back of the eyes, and headache, or neuralgia in the head. All the symptoms are worse after the day's work and sometimes on first waking in the morning, and they are liable to vary much with the health. Artificial light always aggravates them, because it is often flickering and insufficient, but especially because it is hot. The symptoms often last for months or years, causing great discomfort and serious loss of time. CAUSATION. The patients are seldom children or old people. Most are women, either young or not much past middle life, often very excitable, and often with feeble cir- culation. If men, they are emotional, fussy, and often hypochoudriacal. Some local cause can also generally be traced, such as close application at needle-work, reading, writing, or drawing. Sometimes working on bright colors, glittering things, or over the fire seems specially injurious. In other cases the condition follows an attack of phlycte- nular ophthalmia, or superficial ulcers, which has left the fifth nerve permanently unstable. TREATMENT. The refraction and the state of the in- ternal recti should always be carefully tested, and any error corrected by spectacles. Plain colored glasses are sometimes useful. But glasses will not cure the disease, and we must be on our guard against promising too much from their use. The patient may be assured that there is no ground for alarm, and that the symptoms will probably pass off sooner or later. He should be discouraged from thinking about his eyes, and he need seldom be quite idle. The artificial light used should be sufficient and steady (not flickering), and should be shaded to prevent the heat and light from striking directly on the eyes. Bathing the eyes freely with cold water and the occasional employment 21* 246 FUNCTIONAL DISEASES OF RETINA. of weak astringent lotions are useful, whilst cold air acts beneficially on some cases. The eyes are often much better after a rest of a day or two. Out-door exercise and only moderate use of the eyes therefore should be enjoined. General measures must be taken according to the indica- tions, especially in reference to any ovarian, uterine, or digestive troubles, or to sexual exhaustion in men. FUNCTIONAL DISEASES OF THE RETINA. Functional night-blindness (endemic nyctalopia) is caused by temporary exhaustion of the retinal sensibility from prolonged exposure to diffused, bright light. The circumstances under which it occurs usually imply not only great exposure to light, but lowered general nutrition, and possibly some particular defect in diet may be neces- sary for its production. It has often coexisted with scurvy. Sleeping with the face exposed to bright moonlight is be- lieved to aid its occurrence. It is commonest in sailors after long tropical voyages under bad conditions, and in soldiers after long marching in bright sun. In some coun- tries it prevails every year in Lent when no meat is eaten, and again in harvest time. It is now but rarely indigenous in our country, but scattered cases occur usually in chil- dren, 1 and it still occasionally prevails in large schools. In this malady two little dry films, consisting of fatty or sebaceous matter and epithelial scales, often form on the conjunctiva at the inner and outer border of the cornea. Their meaning is not understood, but they are sometimes absent in this disease and present in other conditions. In functional nyctalopia there are no ophthalmoscopic changes. The disease is soon cured by protection from bright light 1 Snell reports numerous cases from near Sheffield. Transac- tions of the Ophthalmological Society, vol. i., 1881. FUNCTIONAL DISEASES OF RETINA. 247 and improvement of health. That the affection is local in the eye is shown by the fact that darkening one eye, by means of a bandage during the daytime, has been found to restore its sight enough for the ensuing night's watch on board ship, the unprotected eye remaining as bad as ever. Snow-blindness (or ice-blindness) is essentially the same disease, with the addition of congestion, pain, photo- phobia, and sometimes of conjunctival ecchymoses. These peculiarities probably depend in some measure on the effect of the rarefied atmosphere in which the mountaineering cases occur and on the local effect of the reflected heat upon the conjunctiva. Snow-blindness is effectually pre- vented by wearing smoke-colored glasses. Hemeralopia (day-blindness) occurs in certain cases of congenital amblyopia. Micropsia. Patients sometimes complain that objects look too small. When not due to insufficiency of accom- modative power (excessive effort, p. 45), it is generally a symptom of disease of the outer layers of the retina, espe- cially in the central region, and syphilitic retinitis is the commonest cause (p. 213). Both micropsia and its opposite, megalopsia, are sometimes seen in hysterical amblyopia. Muscae volitantes are seen in the form of small dots, rings, threads, etc., moving about in the field of vision, though never actually crossing the fixation point, and never interfering with sight. They are most easily seen against the sky, or a bright background such as the micro- scope field. They depend upon minute changes in the vitreous, which are present in nearly all eyes, though in much greater quantity in some than others. They vary, or seem to vary, greatly with the health, but are of no real importance. They are most abundant and troublesome in myopic eyes. Diplopia is considered under Paralysis of the Ocular Muscles. (See also pp. 33 and 1 76, for Uniocular Diplopia.) 248 FUNCTIONAL DISEASES OF RETINA. For Affections of Sight in Megrim and Heart Disease, see Chapter XXIII. Malingering. Patients now and then pretend defect or blindness of one or both eyes, or exaggerate an existing defect, or sometimes secretly use atropine to paralyze the accommodation. In most cases the imposture is evident from other circumstances, but sometimes great difficulty is found in detecting it. Malingering is far less common here than in countries where the conscription is in force. The pretended defect is usually confined to one eye. If the patient be in reality using both eyes, a prism held before one (by preference the "blind" one) will produce double vision (p. 25). The stereoscope, and also colored glasses, may be made very useful. Another test, when only moderate defect is asserted, is to try the eye with various weak glasses, and note whether the replies are consistent ; very probably a flat glass or a weak concave may be said to " improve " or " magnify " very much. Again, atropine may be put into the sound eye, and when it has fully acted the patient be asked to read small print with both eyes ; if he reads easily the imposture is clear, for he must be reading with the so-called "blind" eye. If absolute blindness of one be asserted, the state of the pupil will be of much help (unless the patient have used atro- pine) ; for if its direct, reflex action be good (p. .39), the retina and nerve cannot be very defective (but see Hyster- ical Amblyopia). Asserted defect of both eyes is more difficult to expose, and, indeed, it may be absolutely impossible to convict the patient if he is intelligent and has had access to means of information. The state of the pupils, of the visual fields, and of color perception, are amongst the best tests. Color-blindness may be congenital or acquired. When acquired it is symptomatic of disease of the optic nerve. It may also occur in hysterical amblyopia. FUNCTIONAL DISEASES OF RETINA. 249 Congenital color-blindness is not often found unless looked for. According to recent and extended researches in various countries, a proportion varying from about three to five per cent, of the males are color-blind in greater or less degree, and it appears to be more common in the lower than in the upper classes. These facts show the importance of carefully testing all men whose employment renders good perception of color indispensable, such as railway signalmen and sailors. Color-blindness is usually partial, i. e., for only one color or one pair of complementary colors, but is occasionally total. The commonest form is that in which pure green is confused with various shades of gray and of red (red-green-blindness) ; blindness for blue and yellow is very rare. The blindness may be in- complete, perception of red, e. g., being merely enfeebled, whilst bright red and green are still recognized ; or it may be complete for all shades and tints of those colors. Con- genital color-blindness is very often hereditary, but nothing further is known of its cause, It is very rare in women (0.2 per cent.). The acutenesss of vision (i. e., perception of form) is normal. Both eyes are affected. 1 The detection of color-blindness, either congenital or acquired, is easy, if, in making the examination, we bear in mind the two points already referred to at p. 46, viz.: (1) Many persons with perfect color perception have a very imperfect knowledge of the names of the various colors, and appear color-blind if asked to name them ; (2) The really color-blind often do not know it, having learnt to compensate for their defect by attention to differences of shade and texture. Thus a signalman may be color-blind for red and green, and yet may, as a rule, correctly distin- guish the green from the red light, because one appears to him "brighter " than the other. The quickest and best way of avoiding these sources of error has been mentioned 1 But on this point farther research is needed. 250 FUNCTIONAL DISEASES OF RETINA. at p. 45. Certain standard colored Avools are given to the patient without being named, and he is asked to choose from the whole mass of skeins of wool all that appear to him of nearly the same color and shade (no two being really quite alike). If, for example, he cannot distinguish green from red, he will place the green test-skein side by side with various shades of gray and red. Wilful conceal- ment of color-blindness is impossible under this test if a sufficient number of shades be used. As it is necessary to detect slight as well as high degrees, the first or preliminary test should consist of very pale colors, and a pale pure green is to be taken as the test. For ascertaining whether the defect be of higher degree or not, stronger colors are then used ; a bright rose color, e. g., may be confused with blue, purple, green, or gray of cor- responding depth, and a scarlet with various shades and tints of brown and green. It may here be noted that the visual field is not of the same size for all colors, green and red having the smallest fields, and that the perception of all colors is, like percep- tion of form (p. 43), sharpest at the centre of the field (Fig. 26). With diminished illumination some colors are less easily perceived than others, red being the first to dis- appear, and blue persisting longest, i. e., being perceived under the lowest illumination ; but in dull light the colors are not confused as in true color-blindness. In congenital color-blindness, as we have seen, red-green-blindness is the commonest form ; and in cases of amblyopia from com- mencing atrophy of the optic nerve green and red are almost always the first colors to fail, blue remaining last. DISEASES OF THE VITREOUS. 251 CHAPTER XVII. DISEASES OF THE VITREOUS. THE vitreous humor is nourished by the vessels of the ciliary body, of the retina, and of the optic disk, and is probably influenced by the state of the choroid also. In many cases disease of the vitreous can be proved during life to be associated with (and dependent on) disease of one or other of the structures named. Thus, in connection with various surrounding morbid processes, the vitreous may be the seat of inflammation, acute or chronic, general or local, and of hemorrhage. It may also degenerate, especially in old age, its cells and solid parts undergoing fatty degeneration, become visible as opacities, whilst its general bulk becomes too fluid. The only change which we can directly prove in the vitreous during life is loss of transparency from the presence of opacities moving, or more rarely fixed, in it ; but from the freedom and quickness of their movements, some idea may also be formed of the consistence, or degree of fluidity, of the humor itself. Opacities in the vitreous may take the form of large dense masses, as from abundant or recent bleeding, or of membranes like muslin, crape, " bee's wings " of wine, bauds, knotted strings, or isolated dots ; and they may be either recent, or the remains of long antecedent exudations or hemorrhages. Again, the vitreous may become more uniformly misty, owing to the diffusion of numberless dots (" dust-like " opacities), which need careful focussing by direct examination to be separately seen. 252 DISEASES OF THE VITREOUS. Opacities in the vitreous are usually detected with great ease by direct ophthalmoscopic examination at from 10" to 18" from the patient, but are generally situated too far forward (i. e., too far within the focus of the lens-system) to be seen clearly at a very short distance (pp. 73 and 64, c). By asking the patient to move his eye sharply and fully from side to side and up and down, the opacities will be seen against the red ground, as dark figures which continue to move after the eye has come to rest ; they are thus at once distinguished from opacities in the cornea or lens, or from dimly seen spots of pigment at the fundus, which move only whilst the eye moves. The opacities in the vitreous move just as solid particles and films move in a bottle after the bottle has been shaken, and the quickness and freedom of their movement in the one case as in the other depends very much on the thinness or the viscidity of the fluid. Whenever opacities in the vitreous pass across the field quickly and make wide movements, we may be sure that the humor is too fluid ; and the contrary may be concluded when they move very lazily. In some cases only one or tw r o opacities may be present, and may only come into view now and then. Moving opacities in the vitreous obscure the fundus both to direct and indirect ophthalmo- scopic examination, in proportion to their size, density, and position ; a few isolated dots scarcely affect the brightness of the ophthalmoscopic image. The opacities may lie quite in the cortex of the vitreous, and be so attached to the retina or disk as to have no inde- pendent movement. These are generally single, are found lying either over or near to the disk, and may be the result either of inflammation or of hemorrhage ; they are often membranous, more rarely globular, and not perfectly opaque. Such an opacity should be suspected when, by indirect ophthalmoscopic examination, a localized haze or blurring of some part of the disk or its neighborhood is DISEASES OF THE VITREOUS. 253 seen. It must be searched for by the direct method with the eye at rest ; by carefully accommodating for the partic- ular part which appeared hazy, the opacity will come sharply into view, the observer being at a greater or less distance according to its depth ; if the eye be hyperme- tropic a convex correcting lens may be necessary, and if considerably myopic a concave. The kind of refraction must therefore be known in order to make this examination properly (p. 73). Densely opaque white membranes may also form over the disk or upon the retina, the nature and situation of which are diagnosed in the same way. Diffused haziness of the vitreous causes, in a correspond- ing degree, dimness of outline and darkening of all the details of the fundus, which look as if they were seen through a thin smoke. The disk, in particular, appears red, without really being so. Very much the same appear- ances may be due to diffused haze of the cornea or lens, the presence of which will, of course, have been excluded by focal illumination. There are cases, however, where though plenty of light reaches and returns from the fundus, no details can be seen, even indistinctly, by the most careful examination. Probably, in such a case, the light is scat- tered by innumerable little particles, each of which is transparent, so that though very little light is absorbed, it is all distorted and broken up, as in passing through ground glass, or white fog, or a partial mixture of fluids of different densities, such as glycerine and water. This appearance is found chiefly in syphilitic choroido-retinitis, in which dif- fuse infiltration of the vitreous with cells is known to occur. It is not always easy, nor indeed possible, to distinguish with certainty between diffuse haze of the vitreous and diffuse haze of the retina (p. 207). Crystals of cholesterin sometimes form in a fluid vit- reous, and are seen with bright illumination as minute 22 254 DISEASES OF THE VITREOUS. dancing golden spangles \vhen the eye moves about (spar- kling synchysis). They proportionately obscure the fuudus. Large opacities just behind the lens may be seen by focal light in their natural colors. In rare cases of choroido- retinitis minute growths consisting chiefly of bloodvessels form on the retina and project into the vitreous ; they are rather curiosities than of practical importance. Parasites (cysticercus) occasionally come to rest in the eye, and in development penetrate into the vitreous ; they are rarely seen in England, but are commoner on the Continent. Very rarely a foreign body may be visible in the vitreous. The following are the conditions in which disease of the vitreous is most commonly found : (1) Myopia of high degree and old standing; the opaci- ties move very freely, showing fluidity of the humor, and are sharply defined. They are often the result of former hemorrhage. , (2) After severe blows, causing rupture of the choroid or of some vessels in the ciliary body. When recent and situated near the back of the lens, the blood can often be seen by focal light; if very abundant, it so darkens the interior of the eye that nothing whatever can be seen with the mirror. (3) After perforating wounds. The opacity will be blood if the case be quite recent. Lymph or pus in the vitreous at the inner surface of the wound gives a yellow or greenish-yellow color, easily seen by focal light or even by daylight (p. 151). (4) In rare cases large hemorrhages into the vitreous occur spontaneously in healthy eyes, and in connection with hemorrhagic retinitis and hemorrhagic choroiditis. Relapses often occur, and detachment of retina may come on. The subjects are generally young adult males liable to epistaxis, constipation, and irregularity of circulation DISEASES OF THE VITREOUS. 255 (Eales) ; gout may have some influence (Hutchinsou). (See pp. 201 and 217.) In all of the above cases detachment of the retina is likely to occur sooner or later, and if present the difficulty of diagnosis between the two conditions may be consider- able (p. 213). (5) Syphilitic choroiditis and retinitis. There is often diffuse haze, in addition to large slowly floating opacities. The change here is due to inflammation, and the opacities may entirely disappear under treatment (pp. 206, 213). (6) Some cases of cyclitis and cyclo-iritis (p. 149). (7) In the early stage of sympathetic ophthalmitis. The opacities are inflammatory. (8) In various cases of old disease of choroid, usually in old persons and without proof of syphilis. No doubt many of these indicate former choroidal hemorrhages. (9) The vitreous is believed to become repeatedly and quickly hazy in the active stages of glaucoma. The point is difficult to settle clinically, because the cornea and aqueous are nearly always, and the lens often, hazy at the same time, and the opportunity of examining specimens of uncomplicated recent glaucoma scarcely ever occurs. 256 GLAUCOMA. CHAPTER XVIII. GLAUCOMA. IN this peculiar and very serious disease, the pathogno- monic objective symptom is increased tightness of the eye- capsule (sclerotic and cornea), "increased tension;" all the other phenomena peculiar to the disease depend upon this condition. The disease is much commoner after middle life, when the sclerotic becomes less distensible, than before; and it is commoner in hypermetropic eyes, where the scle- rotic is too thick, than in myopic eyes, where it is thinned by elongation of the globe. Glaucoma may be primary, coming on in an eye appar- ently healthy, or the subject of some disease, such as senile cataract, which has no influence on the glaucoma. It may also be secondary, caused by some still active disease of the eye, or by conditions left after some previous disease, such as iritis. It is always important, and seldom difficult, to distinguish between primary and secondary glaucoma. Glaucoma differs in severity and rate of progress from the most acute to the most chronic and insidious form. But in every form it is always a progressive disease, and unless checked by treatment nearly always goes on to per- manent blindness. It generally attacks both eyes, though not simultaneously, the interval varying from a few days to several years. It is customary to speak of primary glaucoma as either acute, subacute, or chronic; and this division, though arbitrary, is useful in practice. But we must remember that many intermediate forms are found, and that the same GLAUCOMA. 257 eye may, at different stages in its history, pass through each of the three conditions. It may, indeed, be here observed that acute and subacute outbursts are generally preceded by a so-called " premonitory " stage, in which the symptoms are not only chronic and mild, but remittent ; the intervals of remission becoming shorter and shorter, till at length the attacks become continuous, and the glaucomatous state is fully established. Rapid increase of presbyopia, shown by the need for a frequent change of spectacles, is a com- mon premonitory sign, though often overlooked. Chronic glaucoma sets in with a cloudiness of sight or "fog" which is liable to variations, and often quite clears off for days, or even weeks ("premonitory stage"). But in some cases, so far as the patient knows, the failure is steady, with no variations or remissions, from first to last. During the attacks of " fog " artificial lights are seen sur- rounded by colored rings ("rainbows" or "halos"), which are to be distinguished from those due to mucus on the cornea. The attacks of fog are often noticed only after long use of the eyes, as in the evening, the sight being much better in the early part of the day. The defect of sight is to be distinguished from that caused by incipient nuclear cataract, disease of the optic nerve, syphilitic reti- nitis, or attacks of megrim. Even when the sight has become permanently cloudy, complete recovery no longer occurring between the attacks, variations still take place and form a marked feature. There is no congestion and often no pain. If we see the patient during one of the brief early fits of cloudy sight, or after the fog has settled down perma- nently, the following changes will be found. A greater or less defect of sight in only one eye, or unequal in the two, and not remedied by glasses; the pupil a little larger and less active than normal ; the anterior chamber may be shallow, and there is usually slight dulness of the front of 22* 258 GLAUCOMA. the eye from steaminess of the cornea, or from haze of the aqueous, and some engorgement of the large vessels which perforate the sclerotic at a little distance from the cornea (Figs. 20 and 22); the tension will be increased (usually about -j-1, p. 30) and the field of vision may be contracted, especially 011 the nasal side. The optic disk will be found normal, pale, or sometimes congested, in early cases ; pale and cupped (p. 262) at a later stage. The cupping usually occupies the whole surface, but sometimes takes the form of a central depression, indistinguishable from a large steep-sided physiological cup (p. 77). There may be spon- taneous pulsation of all the vessels on the disk; or the arteries, if not pulsating spontaneously, will do so on very slight pressure on the eyeball (p. 72). If the case is of old standing, the tension will often be considerably increased, the pupil dilated though still active, the lens often hazy, the field of. vision greatly contracted, acuteness of vision extremely defective, the cornea sometimes clear, in other cases dull. In nearly all cases of glaucoma the temporal part of the field (nasal part of the retina) retains its func- tion longest ; and in advanced cases the patient will often himself say or show that he sees only in this direction. An eye in which the above symptoms have set in may progress to total blindness in the course of months or several years without a single "inflammatory" symptom, without either pain or redness chronic painless glaucoma (glaucoma simplex) ; and since the lens often becomes parti- ally opaque, and of a grayish or greenish hue, cases of chronic glaucoma are sometimes mistaken for senile cata- ract. But more commonly, in the course of a chronic case, periods of pain and congestion occur, with more rapid failure of sight; or the disease sets in with " inflammatory" symptoms at once. Indeed, the commonest cases are those of subacute glaucoma, where, besides the symptoms named GLAUCOMA. 259 above, we find dusky reticulated congestion of the small and large episcleral vessels in the ciliary region (Fig. 24), with pain referred to the eye, or to the side of the head, or nose, and rapid failure of sight. The increase of tension, steaminess, and some anaesthesia of the cornea, dilatation and sluggishness of pupil, and shallowing of the anterior chamber, are all more marked than is usual in chronic cases, and the media are too hazy to allow a good ophthal- moscopic examination. These symptoms, ending after a few weeks or months in complete blindness, may remain at about the same height for months afterwards with slight variations, the eye gradu- ally settling down into a permanent state of severe, but chronic, non-inflammatory glaucomatous tension. In other cases a subacute attack passes off only to return in greater severity a few weeks or days later (remittent glaucoma). Acute glaucoma differs from the other forms only in suddenness of onset, rapidity of loss of sight, and severity of congestion and pain. The congestion, both arterial and venous, is intense ; in extreme cases the lids and conjunctiva are swollen, and there is photophobia, so that the case may be mistaken for an acute ophthalmia. All the specific signs of glaucoma are intensified ; the pupil considerably dilated and motionless to light, the cornea very steamy, the anterior chamber very shallow, and tension -(-2 or 3. Sight will fall in a day or two down to the power of only count- ing fingers, or to mere perception of light, and if the case have lasted a week or two all p. 1. is usually abolished. The pain is very severe in the eye, temple, back of the head and down the nose; not unfrequently it is so bad as to cause vomiting, and the case is often mistaken, even by medical men, for a " bilious attack " with a " cold in the eye," for "neuralgia in the head," or "rheumatic oph- thalmia." Some cases, however, though very acute, are mild and remit spontaneously ; but such cases, like those 260 GLAUCOMA. mentioned in the preceding paragraph, often pass on into the severe type just described. Absolute glaucoma is glaucoma which has led to per- manent blindness. Such an eye continues to display the tension and other signs of the disease, and remains liable to relapses of acute symptoms for varying periods, but in many " absolute " cases, especially those which follow acute forms of glaucoma, changes occur sooner or later, leading to staphylomata, cataract, atrophy of iris, and finally to softening and shrinking of the globe. The term "glaucoma fulminans" denotes extremely severe acute glaucoma, abolishing sight in a few hours. As a rule, glaucoma runs the same course in the second eye as in the first, but sometimes it will be chronic in one and acute or subacute in the other. EXPLANATION OF THE SYMPTOMS. The increase of tension lowers the functional activity of the retina by com- FIG. 80. Section of very deep glaucoma cup. (Compare Fig. 34.) pressing it, and also by impeding the flow of arterial blood to and of venous blood from it. When the retinal vessels can be seen in glaucoma the arteries are somewhat nar- rowed, and often exhibit spontaneous pulsation, whilst the GLAUCOMA. 261 veins are always somewhat engorged. This want of blood must first affect the peripheral parts, because the blood has to overcome more resistance in reaching them, and this probably explains the contraction of the visual field. The nutrition of the inner retinal layers suffers if the pressure be kept up (1) from the insufficiency of arterial blood, and the changes, including hemorrhage, which follow impeded venous outflow 7 ; (2) from stretching and atrophy of the nerve-fibres on the disk. The floor of the disk (lamina FIG. 81. Ophthalmoscopic appearance of slight cupping of the disk in glaucoma. (Wecker and Jaeger.) X 7. cribrosa), being the weakest part of the eye-capsule, slowly yields and is pressed backwards, the nerve-fibres being dragged upon, displaced, and finally atrophied ; the direct pressure on the nerve-fibres, as they bend over the edge of the disk, also helps in the same process. Hence finally the disk becomes not only atrophied, but depressed or hollowed out (Fig. 80). This hollow is the well-known "glaucomatous cup" which, when deep, has an overhang- GLAUCOMA. ing edge, because the border of the disk is smaller at the level of the choroid than at the level of the lamina cribrosa (Fig. 34) ; its sides are quite steep even when the cup is shallow (Fig. 82). With the ophthalmoscope, this cupping is shown by a sudden bending of the vessels just within the border of the disk, where they look darker because foreshortened (Fig. 81) ; if the cup be deep, they may disappear beneath its edge to reappear on its floor, where they have a lighter shade (Fig. 83). The vessels, as a rule, do not all bend with equal abrupt- ness, some parts of the disk being more deeply hollowed than others, or some of the vessels spanning over the FIG. 82. Section of less advanced glaucoma cup. interval instead of hugging the wall of the cup. It is probable that increase of tension must be maintained for several months to produce cupping recognizable by the ophthalmoscope. When recent acute glaucoma has been cured by operation the disk is not cupped; often, however, it becomes very pale. Although in many cases the ex- cavation extends from the first over the whole surface of the disk, this is not always so ; the depression starts, in some of the most chronic cases, at the thinnest part (the physiological pit), and enlarges towards the periphery GLAUCOMA. 263 (p. 258). A deep cup is sometimes partly filled up by fibrous tissue, the result of chronic inflammation, its true dimen- sions not being then appreciable by the ophthalmoscope. The shallowness of the anterior chamber is probably due to advance of the lens ; it is by no means a constant symptom. The pressure on the ciliary nerves accounts for the somewhat dilated and immovable pupil and for the corneal anaesthesia. In old-standing cases the iris is often FIG. 83. Ophthalmoscopic appearance of deep cupping of the disk in glaucoma. (Altered from Liebreich.) X about 15. shrunken to a narrow rim ; in uncomplicated glaucoma iritic adhesions are never seen. The corneal changes de- pend partly on " steaminess " of the epithelium, partly upon haze of the corneal tissue from oedema (Fuchs). In recent cases the aqueous humor is somewhat turbid. The lens appears to lose some transparency even in fresh cases, if severe; in old cases, as already stated, it often becomes slowly opalescent, and finally quite opaque. It is generally stated that the vitreous humor becomes hazy during the attacks, especially in severe cases, but since it is just in these very cases that the cornea and aqueous are most dull, 264 GLAUCOMA. the statements about the vitreous are conjectural (p. 255). The internal pressure tends, in acute cases, to make the globe spherical, by reducing the curvature of the cornea to that of the sclerotic; it also in all cases weakens the accommodation, at first by pressing on the ciliary nerves, later by causing atrophy of the ciliary muscle ; these facts together explain the rapid decrease of refractive power (i. e., rapid onset or increase of presbyopia) which is some- times noticed by the patient (p. 257). The choroidal circu- lation is obstructed by the increase of pressure, and iff severe glaucoma, especially of old standing, the anterior ciliary veins (forming the episcleral plexus) (Figs. 20 and 24), as well as the arteries, become very much enlarged. FIG. 84. Section through the ciliary region in a healthy human eye. Co., cornea; Scl., sclerotic; C. M., ciliary muscle ; C. P., two ciliary processes, one larger and more prominent than the other; Jr., iris; L., marginal part of the crystalline lens; a, angle of anterior chamber; e?, membrane of Descemet, which ceases (as such) before reaching the angle a. The dotted line shows the course taken by fluid from the anterior part of the vitreous into the posterior aqueous chamber, thence through the pupil (not shown) into the anterior aqueous chamber, to the angle a. Suspen- sory ligament of lens not shown. X 10. MECHANISM OF GLAUCOMA. The increased tension is due to excess of fluid in the eyeball. Impeded escape is probably the chief cause of this excess, and recent research GLAUCOMA. 265 has proved that changes are present in nearly all glauco- matous eyes, which must lessen or prevent the normal outflow. But increased secretion, and internal vascular congestion, of the eyeball undoubtedly play an important part in some cases. Both conditions would have most effect when the sclerotic was most unyielding, i. e., in old age, and in hypermetropic eyes (p. 256). Normally there is a constant movement of fluid from the vitreous humor through the suspensory ligament of the lens into the anterior chamber in the course shown by the dotted line in Fig. 84. The fluid escapes from the anterior chamber into the lymphatics, and perhaps into the veins, of the sclerotic through the meshed tissue of the ligamentum pectinatum, which closes the angle a ; and it has been proved that very little fluid can pass through any other Ciliary region from a case of acute glaucoma of one month's duration. (1 and 2, situations of iridectomy wounds in two cases.) X 10. part of the cornea. In glaucoma this angle is nearly always closed, in recent cases by contact, in old cases by permanent cohesion between the periphery of the iris and the cornea (Figs. 85 and 86). No complete explanation of this advance of the iris has yet been given. Dr. Adolf Weber holds that the ciliary processes becoming swollen from various causes push the iris forwards and so start the 23 266 GLAUCOMA. glaucomatous state. Priestly Smith believes the primary obstruction to depend upon narrowing, or even oblitera- tion, of the circular chink (" circumlental space ") between the edge of the lens and the tips of the ciliary processes, and that this proceeds mainly from a progressive increase in the size of the lens which occurs in old age ; l obstruction FIG. 86. Ciliary region in chronic glaucoma of three years' standing. X 10. here leads to rise of pressure in the vitreous, followed by advance of the lens and ciliary processes, pressure on the iris, and closure of the angle ; swelling of the ciliary pro- cesses would be a contributory cause. Brailey holds that a chronic inflammation of the ciliary muscle and processes and of the iris, quickly passing on to atrophic shrinking, leads to narrowing of the angle and initial rise of tension ; 2 in his latest paper, however, he agrees to some extent with the view of Weber above referred to. 3 Glaucoma is some- times caused by obstruction at the pupil (circular synechia following iritis, p. 139). It may be caused by the pressure of a swollen (wounded) lens on the iris and ciliary processes (p. 180). It also often occurs in the course of sympathetic 1 Priestly Smith on Glaucoma, 1879 ; Ophth. Hosp. Reports, x. 25, 1880; Int. Med. Congress, 1881. More data are needed before this increase in the size of the lens can be assumed to occur as the rule. * Brailey, Ophth. Hosp. Reports, x. pp. 14, 89, 93 (1880). 8 Brailey, ibid., p. 282 (1881). GLAUCOMA. 267 ophthalmitis, and in some cases of irido-cyclitis (pp. 149, 154). In the latter it is due to choking of the ligamentum pectinatum by inflammatory materials, not to obliteration of the angle. EFFECT OF OVER-SUPPLY OF FLUIDS ON THE TENSION. Functional hypersemia and ordinary inflammations of the retina and choroid do not cause glaucoma, and dilata- tion of the arteries by vaso-motor paralysis is said to be accompanied by diminished tension. But tumors in, and even upon, the eye often give rise to secondary glaucoma, and probably an important factor in these cases is the active congestion and trausudation which occur near quickly growing tumors ; certainly the glaucoma stands in no definite relation either to the size or position of the tumor. A relation is observed in some cases between glaucoma and a liability to neuralgia of the fifth nerve ; and T. is said to be lowered in paralysis of this nerve. Probably the neuralgia acts indirectly by causing associ- ated congestion, and thus setting up glaucoma in an eye predisposed to it. GENERAL AND DIATHETIC CAUSES. In an eye predis- posed by the changes above mentioned at the rim of the anterior chamber, any cause of congestion may precipitate an acute attack. Vascular engorgement of the eyes in con- nection with digestive disturbances, gout, or neuralgia, or the same result brought on by the over-use of presbyopic eyes without suitable glasses, or a blow, or prolonged oph- thalmoscopic examination, may all bring it about. Atro- pine, which has the power of increasing the eye-tension, has sometimes caused an attack, probably because by lessening the width of the iris it increases its thickness, and so crowds it into the angle of the anterior chamber. Iridectomy in one eye occasionally has the effect of pre- cipitating the disease in the other, but its mode of action is unexplained. Glaucoma is commoner in women than 268 GLAUCOMA. in men, and after than before the age of forty-five. It is very rare in young adults and children, and is then gen- erally chronic and often gives rise to or is associated with other changes in the eyes. Acute cases are often dated from a period of overwork of the eyes, or of want of sleep, as from sitting up nursing, etc. There is not unfre- quently a history of gout. Hence, patients who have had glaucoma in one eye should be strongly warned as to the danger of over-using the eyes and of working without proper glasses, and against dietetic errors. TREATMENT. Iridectomy or an equivalent operation is, with very few exceptions, the only curative treatment. Eserine (the alkaloid of Calabar bean) used locally, how- ever, diminishes the tension in acute glaucoma, and some few attacks have been permanently cured by its means alone. But although really curative in only a few cases, eserine is valuable for temporary use in cases where an operation cannot be immediately performed. It has little or no effect on the tension unless marked contraction of the pupil follows its use. Eserine probably acts by stretch- ing the iris and drawing it away from the angle of the anterior chamber. Eserine causes congestion of the ciliary processes, and probably this explains why, if it do not soon relieve glaucoma by contracting the pupil, it some- times aggravates the symptoms. It is of use chiefly in recent, and especially in acute, cases. A solution of one or two grains of the sulphate to the ounce is to be used from three to six times a day, or oftener, according to cir- cumstances. The pain in acute cases may be much re- lieved by leeching, warmth to the eye, and opium, with derivative treatment, such as purgation and hot foot-baths. Iridectomy cures glaucoma by permanently reducing the tension to the normal or nearly normal pitch, but its mode of action is not fully known. It is found, however, that to ensure success: (1) the path of the incision must lie ULAUCOMA. 269 in the sclerotic from 1 to 2 mm. from the apparent corneal border (Fig. 85) ; (2) the wound should be large,-allowing removal of about a fifth of the iris ; (3) the iris should be removed quite up to its ciliary attachment ; this is best done by first cutting one end of the loop of protruding iris, then tearing it from its ciliary attachment along the whole extent of the wound, and cutting through the other end separately. (See Operations.) The evacuation of the aqueous humor by paracentesis of the anterior chamber gives only temporary relief. A mere wound in the sclerotic, differing but little in position and extent from that made for iridectomy, is suffi- cient to relieve -j- T., and to cure many cases of glaucoma permanently, and this operation (subconjunctival sclerotomy') has been largely adopted by some operators within the last few years. Even if the removal of a piece of iris should be shown to be seldom necessary, iridectomy will probably remain the better operation for most cases, be- cause it is easier to perform well. Sclerotomy is open to objection: (1) because the position and length of the wound are not perfectly under control ; if too far forward and too short the incision is insufficient, if too far back and too long there is danger of wounding the ciliary processes and getting hemorrhage into the vitreous; even shrink- ing of the operated eye and sympathetic inflammation of the other have occurred ; (2) because the iris may pro- lapse into the wound, and need removal, and the opera- tion then becomes an iridectomy ; (3) when the anterior chamber is very shallow, sclerotomy probably does not aid the exit of fluid so much as the removal of the iris does. . Several other operations, the principle of which is to make a puncture at the sclero-corneal junction, have been tried, but have not gained general confidence. Whichever operation be employed in glaucoma, the 23* 270 GLAUCOMA. formation of the operation scar in the sclerotic is certainly a most important factor. Iridectomy in acute glaucoma no doubt acts, at least in part, by removing a portion of the iris from the blocked angle (Fig. 85), and thus allowing the normal escape of fluid. It is held by some high authorities, however, that its perma- nent effect is due to the formation in the operation wound of a layer of tissue more pervious to the eye-fluids than the sclerotic ("filtration scar"). The fact that an iridec- tomy for glaucoma which heals rather slowly, is thought by many to be more favorable than one which heals im- mediately, i. e., with less new tissue, and that a slight bulg- ing of the scar is believed by some surgeons to be rather a good thing than otherwise, are probably expressions of the real value of the new tissue formed during somewhat slow healing. The curative effect of sclerotomy points in the same direction. A scar of the same character never forms if the incision be in the cornea. An operation, usually iridectomy, is to be done in all cases of acute and subacute glaucoma, whether there be great pain or not, so long as some sight still remains, and even if all p. 1. be abolished, provided this be only of a few days' duration. (See Operations.) Even if the eye be permanently quite blind, iridectomy or sclerotomy is some- times preferable to excision of the globe, for the relief of pain. (Compare p. 272, and Tumors.) In very chronic glaucoma, when well developed, the rule is less clear, for it is well known that the effect of operation in such cases is far less constant, especially if the visual field be already much contracted. As no other treatment is of use, and opei'ative treatment is certainly often bene- ficial, it should, as a rule, be adopted, the patient's judg- ment being allowed a fair weight in the decision. The same difficulty occurs in some of the so-called "premoni- tory attacks," which are really early transient attacks of GLAUCOMA. 271 slight glaucoma. When once it is clear that such attacks of temporary mistiness and rainbows are glaucomatous, and that they are getting more frequent, the operation should, as a rule, not be deferred. An exception is, however, to be made if the patient can be seen at short intervals; eserine should then have a fair trial before operation is resorted to. It is to be remembered that iridectomy done when sight is still nearly perfect may, by allowing light to pass through the margin of the lens, cause an increase of the defect (p. 14) ; and this, though not of necessity a contra-indication, must be carefully taken into account. The patient's prospect of life must also be allowed for in chronic glaucoma ; if he be old and feeble, life may end before the disease has in its natural course caused blindness. THE PROGNOSIS after operation is, in general terms, better in proportion as the disease is acute and recent. If operated on within about ten days of the onset of acute symptoms, and provided there be at least good p. 1. at the time of operation, sight is usually restored to the state in which it was at the onset, i. e., if the disease be recent, nearly perfect sight will be restored. If an acute attack occur in a chronic case, sight will be improved more or less; if the case be entirely chronic Ave can only hope, as a rule, to prevent it from getting worse. The prognosis in acute cases, however, varies a good deal with the severity as well as the acuteness. In cases combining the maximum of acuteness and severity (glaucoma fulminans) the opera- tion may be successful, even if for a day or two all p. 1. has been abolished. The full benefit of the operation is not seen for several weeks, though a marked immediate effect is produced in acute cases. A slight degree of -f- T. sometimes remains permanently after operation in cases of old standing, and does not appear deleterious, provided it be very much less 272 GLAUCOMA. than before the operation ; the eye tissues can in some de- gree adapt themselves to increased pressure. A second iridectomy in the opposite direction, or a scle- rotomy, should be done if the T., having been reduced to normal, or very slightly -f , after the first operation, rises definitely, and is accompanied by a return of other symp- toms ; but several weeks should generally elapse, for slight waves of glaucomatous tension may occur during states of temporary congestion or irritation before the eye has fully recovered from the first operation, and such symptoms may generally be relieved by other means. Cases which relapse definitely or which steadily get worse after the first opera- tion are always very grave, and the second operation must not be confidently expected to succeed. If after iridectomy in acute glaucoma the symptoms are not relieved even for a time, or become worse, some deep-seated disease is to be suspected, such as hemorrhage from the retina or choroid, or a tumor. (See Secondary Glaucoma.) OTHER TREATMENT. If we are obliged to delay the operation, the other means mentioned at p. 268 should be prescribed, including eserine drops used many times a day, and, if possible, a paracentesis of the anterior chamber. The diet should as a rule be liberal, unless the patient be plethoric. It is very important to ensure sound sleep and mental quiet. After the operation, and until the eye has settled down to a permanently quiet state, all causes likely to induce congestion of the eyes must be carefully avoided, such as use of the eyes, stooping and straining, prolonged ophthalmoscopic examination, and the use of atropine. We should be on the alert for the earliest symptoms in the second eye after operation on the first (see p. 266), and the use of eserine may be advisable as a prophylactic. In a few cases of very chronic or subacute character where high increase of T. is present, iridectomy seems to aggravate, instead of arresting, the disease, not being fol- GLAUCOMA. 273 lowed by even temporary benefit, but by persistence of -j- T., increased irritability, and still further deterioration of sight (^'glaucoma malignum"'). It is believed that the tilting forward of the lens, which sometimes follows iri- dectomy, may help to account for these symptoms. Glaucoma may occur independently in cataractous eyes ; and in eyes from which the lens has been extracted, with or without iridectomy. Secondary glaucoma may be acute or chronic, according as it is a consequence of active disease or of sequelae. Thus, chronic glaucoma may be caused by circular iritic synechia with bulging of the iris (p. 139), and various forms of chponic irido-keratitis and irido-cyclitis, especially the sympathetic form, are liable to be accompanied by it. It may follow perforating ulceratiou of the cornea with large anterior synechia. The eye often becomes tempo- rarily glaucomatous in the course of traumatic cataract, especially in patients past middle life (p. 180). In none of these cases is there much danger of mistaking second- ary for idiopathic glaucoma. But secondary glaucoma may result from various deeper changes. When the lens is dislocated, either behind or in front of the iris, it often sets up glaucoma, and sometimes of a very severe type, apparently by pressing on the ciliary processes or iris. There is generally the history of a blow ; and in posterior dislocation, even if the edge of the dis- placed lens cannot be seen, the iris is usually tremulous and its surface often bulging at one part and concave or flat at another. If we are sure that a dislocated lens is causing the symptoms, it should be extracted by a spoon operation (see Operations) ; and if lying in the anterior chamber, should usually be removed (p. 187). But in the glaucomatous state of the eye after a severe blow (p. 163) it may be impossible to feel sure of the condition of the lens, and then an iridectomy must be done and the eye be 274 GLAUCOMA. watched ; vitreous is very likely to escape at the operation if there be dislocation of the lens, for the latter condition implies rupture of the suspensory ligament. Hemorrhage into an eye whose retina is detached (e. g., in high degrees of myopia) may give rise to acute glaucoma with severe pain. A glaucomatous attack generally occurs during the growth of an intraocular tumor (p. 281). There will often be nothing in the appearance of such an eye to distinguish the case from an idiopathic glaucoma of the same severity and of long standing, for even if the lens be not opaque) and it often is so, the other media will probably be too hazy to allow an ophthalmoscopic examination. In almost every case, however, the eye will be quite blind, and will be known to have been so for weeks or months, and there will also be the negative fact that the fellow-eye shows no signs of glaucoma. A glaucomatous eye which, having been absolutely blind for several months, remains painful and inflamed, and the media of which are too opaque for ophthalmoscopic examination, should usually be excised as likely to contain a tumor, especially if there be no pre- monitory signs of glaucoma in the other eye. Tumors in the eyes of children may cause secondary glaucoma, but in these cases there is seldom any difficulty in assigning the glaucoma to its right cause. Secondary glaucoma now and then supervenes in cases of albuminuric retinitis, and of embolism of the retinal artery, and more commonly in some forms of retinal and choroidal hemorrhage (" hemor- rhagic glaucoma"). In the last-named cases the diagnosis can sometimes be completed only after an unsuccessful iri- dectomy has shown that the case is not a simple one. TUMOES AND NEW GROWTHS. 275 CHAPTER XIX. TUMORS AND NEW GROWTHS. A. FOR TUMORS AND GROWTHS OF THE EYELIDS, see Chapter V. The following may here be added. Naevus may occur on the eyelids, and implicate the con- junctiva, both of the lids and eyeball. Deep nsevi may degenerate and become partly cystic. Dermoid tumors (cystic) are not uncommon at the outer end of the eyebrow ; more rarely they occur uear the inner canthus. They lie beneath the orbicularis, and the sub- jacent bone may be superficially hollowed. They differ from sebaceous cysts in being much deeper and in being free from the skin. They often grow faster than the sur- rounding parts, and may then need extirpation, the thin cyst wall being carefully and completely removed through an incision parallel with, and situated in, the eyebrow. They contain, besides sebaceous matter, some short hairs. B. TUMORS AND GROWTHS OF THE CONJUNCTIVA AND FRONT OF THE EYEBALL. Cauliflower warts, like those on the glans penis, are sometimes seen on the ocular and palpebral conjunctiva. They have narrow pedicles, and are flattened like a cock's comb. They should be snipped off, but fresh ones are apt to spring up. Lupus of the conjunctiva is generally accompanied by lupus of the skin, and sometimes of the oral mucous mem- brane. The conjunctiva is thickened, irregularly tuber- 27G TUMORS AND NEW GROWTHS. cular, and very vascular. The disease very seldom attacks the ocular conjunctiva, and is usually confined to a part of one eyelid. It is much benefited by the usual local treatment for lupus. The eyelid, and especially the tarsus, is now and then the seat of diffused gummatous inflammation in the tertiary stage of syphilis. The infiltration gives rise to a hard, indolent swelling of the whole lid (syphilitic tarsitis). Chancres and tertiary syphilitic ulcers may occur on the lids (p. 87). Pinguecula is a small yellowish spot, looking like adipose tissue, in the conjunctiva, close to the inner or outer edge of the cornea. It consists of thickened conjunctiva and subconjunctival tissue, and contains no fat. It is com- monest in old people, and in those whose eyes are much exposed to local irritants. It is of no consequence, though advice is often asked about it. Pterygiuin is a triangular patch of thickened conjunc- tiva, generally placed in the palpebral fissure, the apex of which encroaches upon the cornea. Pterygiuin varies much in thickness, vascularity, and size. It is to be dis- tinguished from opacity of the cornea, and from the cica- tricial band (symblepharon) which often forms between lid and globe after burns or wounds of the conjunctiva. It is rare in English practice, being seldom seen except in those who have spent some years in hot countries. It is often progressive. The best treatment is to dissect it up from its apex and transplant it into a cleft in the conjunctiva below the cornea; this is more effectual than excision or ligature. Adhesion of swollen conjunctiva to a marginal ulcer of cornea is the starting-point of pterygium. Its subsequent course has given rise to much discussion ; a recent observer (Poncet) thinks it due to imprisoned microphytes. Small cysts with thin walls and clear watery contents, sometimes elongated and beaded, are not uncommon in the TUMORS AND NEW GROWTHS. 277 ocular conjunctiva near the inner and outer canthus. They are probably formed by distention of valved lymphatic trunks. Dermoid tumors (solid) of the eyeball are much scarcer than the cystic dermoids of the eyebrow (p. 274). They are whitish, smooth, hemispherical and firm, and are gen- erally placed in the palpebral fissure. They may be wholly on the conjunctiva and movable, or partly on the cornea and fixed. They are solid, and hairs may grow from their surface. They are often combined with other congenital anomalies of the eye or lids. When seated on the cornea they cannot be entirely removed. The- swelling in some cases of episcleritis may be mis- taken for a tumor. (See p. 146.) Fibro-fatty growth, forming a yellowish, lobulated, tongue-like protrusion from between the lid and the globe, is rather a curiosity than of much importance. It gen- erally lies in front of the lachrymal gland. It is congenital but is apt in after-life to grow disproportionately. Cystic tumors may be met with beneath the palpebral conjunctiva. Some are caused by occlusion, and distention of the duct of the lachrymal gland (p. 90), but others can- not be so explained. (See Nsevus.) Fibrous, and even bony tumors are occasionally seen in the substance of the upper lid, perhaps starting from the tarsus; and soft, pedunculated (polypoid) growths have been met with in the sulcus between lid and globe. Malignant tumors arise much less commonly on the front of the eye than in the choroid or retina. They may be either epithelial or sarcomatous. An injury is often stated to be the cause of the growth. Epithelioma may begin on the ocular conjunctiva, in which case it remains movable, or at the sclero-corneal junction, when it quickly encroaches on the cornea, in- filtrates its superficial layers and becomes fixed. It may 24 278 TUMOES AND NEW GROWTHS. be pigmented. When such a growth is not seen until late, it may perhaps be as large as a walnut, may cover or sur- round the cornea, and present a papillary or lobulated surface, and the glands in front of the ear may be enlarged. Sarcoma in this region may or may not be pigmented. It generally arises at the sclero-corneal junction, and when small the conjunctiva is traceable over the growth. But in advanced cases it may be impossible from the clinical features to diagnose the nature of a tumor in this part. Movable tumors (epithelioma) not involving the cornea may be cut off, but are very likely to recur ; and recurrence is still more likely in the case of growths fixed to the cornea or sclerotic. Removal of the eyeball at an early date, especially in the case of sarcomata, is the best course in the majority of cases. The lachrymal sac is occasionally the seat of new growth, which may be mistaken for chronic mucocele (p. 91). C. TUMORS OF THE ORBIT. A tumor of any notable size in the orbit always causes protrusion of the eye (jproptosis), with or without lateral displacement and limitation of its movement. As a rule, there are no inflammatory symptoms (see exceptions below). It is obvious that the diagnosis of the size, attachments, and nature of growths in the orbit, must often be left open, since the deep parts of this cavity cannot be explored. A tumor in the orbit may have originated in some of the loose orbital tissues, in the lachrymal gland, in the peri- osteum, upon or within the eyeball, or from the optic nerve ; or it may have encroached upon the orbit from one of the neighboring cavities. Tumors in the orbit when fluctuating may be either cystic or ill-defined, and may or may not pulsate. They may be solid, and either movable or fixed by broad attachments to the wall of the cavity. ORBITAL TUMORS. 279 Sight is often damaged or destroyed in the corresponding eye by compression or by infiltration of the optic nerve. (See Intraocular Tumors.) (1) Distention of the frontal sinus by retained mucus causes a well-marked, fixed, usually very chronic swelling, not adherent to the skin, at the upper inner angle of the orbit above the tendo oculi. At first hard, when advanced it fluctuates. Its course is usually slow, but acute suppura- tion may supervene, and the swelling be mistaken for a lachrymal abscess (p. 92). There is generally a history of injury. The aim of treatment is to reestablish a perma- nent opening between the floor of the sinus and the nose. The most prominent part of the swelling is freely opened ; a finger is passed up the nostril, and the floor of the dis- tended sinus perforated on the finger by a trocar introduced from above. A thick seton or small drainage-tube is then passed through the hole so made and brought out at the nostril ; it must be worn for several weeks or months. (2) Ivory exostoses sometimes grow from the walls of the same sinus or from neighboring parts, beginning com- paratively early in life, increasing very slowly, and causing absorption of some portions of their containing walls. In removing these tumors there is serious danger of fracturing the cranial walls of their containing cavity, and wounding the dura mater. (3) Tumors encroaching on one or both orbits from the base of the skull, the antrum, the nasal cavity, or the temporal fossa, generally admit of correct diagnosis, but their treatment does not belong to the ophthalmic surgeon. The suspicion of tumor on the inner or lower wall of the orbit should always lead the ophthalmic surgeon to an ex- amination of the palate, pharynx,,and teeth, of the- permea- bility of each nostril, of the functions of the cranial nerves, of the state of the glands behind the jaw on both sides, and .to an inquiry as to epistaxis or discharge from the nose. 280 TUMORS AND NEW GROWTHS. (4) Pulsating tumors of the orbit and cases of prop- tosis with, pulsation are probably in most cases due to arterio-venous intercommunication in the cavernous sinus, in consequence of which the ophthalmic vein and its branches become greatly distended with partly arterial blood. In a large number the symptoms have followed rather gradually after a severe injury to the head, whilst in others they come on suddenly with pain and noises in the head, without apparent cause. These idiopathic cases are usually in senile persons. In several examples of both forms a communication has been found post mortem between the internal carotid and the cavernous sinus, the result of wound from fracture of the base of the skull in the traumatic cases and of rupture of an aneurism in the idiopathic ones. The typical symptoms are proptosis, with chemosis, pulsation of the eyeball, paralysis of orbital nerves, a soft pulsating tumor under the inner part of the orbital arch, and a bruit. A bruit with proptosis and conjunctival swelling may be present, without demonstra- ble tumor or pulsation. Ligature of the common carotid has been practised with good results in a large number of cases of pulsating exophthalmos, but the treatment of these cases does not belong to the ophthalmic surgeon. The symptoms above described are not caused by unrup- tured aneurism of the internal carotid. Aneurism of the intra-orbital arteries and arterio-venous communications in the orbit, if they occur, are excessively rare. Erectile tumors, well-defined and separable, but not causing de- cided pulsation, are sometimes met with in the orbit, and can be dissected out. (5) A tumor which fluctuates but does not pulsate, is free from inflammatory symptoms, and not connected with the frontal sinus, may be a chronic orbital abscess (see also p. 89), a hydatid, or a cyst containing bloody or other fluid and of uncertain origin. An exploratory ORBITAL TUMORS. 281 puncture should be made after sufficiently watching the case, and the further treatment must be conditional. Per- fectly clear, thin fluid probably indicates a hydatid, and in this case the swelling is likely to return after puncture and the cyst will need removal through a free opening. The echinococcus hydatid often contains daughter-cysts, some of which escape puncture. Suppuration may take place around any species of hydatid. (6) Examination leads to the diagnosis of a solid tumor limited to the orbit. We must try to determine whether the growth began in the eyeball or optic nerve, or in some of the surrounding tissues. We therefore examine the globe for symptoms of intraocular tumor. (See below.) Solid growths independent of the eyeball may arise as follows : (a) From the periosteum ; these are firmly at- tached by a broad base, are generally malignant, and seldom admit of successful removal. (6) The lachrymal gland (compare p. 89) is the seat of various morbid growths, including carcinoma ; a great part of the growth is in the position of the gland, and can be explored by the finger. Although such a growth is often attached firmly to the orbital wall, its position, lobulated outline, and well-defined boundary will often lead to a correct diagnosis. Tumors of the lachrymal gland should always be removed if they are increasing ; for we can never feel sure that they are innocent, (c) Solid tumors originating in some of the softer orbital tissues, especially the form known as cylindroma, or plexiform sarcoma, occur more rarely, (d) Tumors of the optic nerve, usually myxoma- tous, occur, though rarely; th^.y generally cause neuro- retinitis and blindness, but no absolute pathognomonic symptoms ; they may sometimes be extirpated without removing the globe. When an orbital tumor is found during operation to be adherent to the wall or to infiltrate the tissues around it, 24* 282 TUMORS AND NEW GROWTHS. chloride of zinc paste should be applied on strips of lint, either at once, or the next day when oozing has ceased. If the periosteum be affected, it is to be stripped off, and the paste applied to the bare bone. Hemorrhage from the depth of the orbit can always be controlled by perchloride of iron and a firm graduated compress. In every case of suspected primary orbital tumor (unless it be quite clearly limited to the lachrymal gland) the question of syphilis must be carefully gone into. Neither periosteal nor cellular nodes are common in the orbit, but both occur and disappear under proper treatment. D. INTRAOCULAR TUMORS. By far the commonest forms are glioma of the retina and sarcoma of the choroid. Giioma of the retina is always a disease of infancy or early childhood, the patients being generally under two years old when first brought for treatment ; it may, how- ever, be present at birth, and may begin as late as the eleventh or twelfth year. Glioma is very soft, composed of small, round cells which grow from the granule layers of the retina, and it either grows outwards, causing detach- ment of the retina, or inwards into the vitreous; often several, more or less separate, lobules are present. It runs a comparatively quick course, filling the eyeball in a few months, spreading by contact to the choroid, and thence to the sclerotic and orbit. It is especially prone to travel back along the optic nerve to the brain ; and it may cause secondary deposits in the brain and in the scalp, and more rarely in distant parts. If the eye be removed before either the optic nerve or the orbital tissues are infiltrated, the cure is radical, but in the more numerous cases, where the patient is not seen till what may be called, clinically, the second stage (see below), a fatal return occurs in the INTRAOCULAR TUMORS. 283 orbit or within the skull. Glioma sometimes occurs in both eyes one after the other, and in several children of the same parents. The earliest symptom is a shining whitish appearance deep in the eye, and the eye is soon noticed to be blind ; as there is neither pain nor redness, advice is seldom sought at this stage. If examined, T. is found to be n. or rather .* When the peculiar appearance has become very striking or the eye becomes painful, the child is brought. In this (the second) stage there is generally some conges- tion of the scleral vessels, and a white, pink, or yellowish reflection from behind the lens (which remains clear), steaminess of the cornea, mydriasis, T. -J-, anterior chamber of uniform depth ; there may be enlargement or promi- nence of the eyeball. On focal examination some vessels can generally be seen on the whitish background, and white specks of calcareous degeneration are sometimes present. Cases are not uncommon in young children in which the above appearances are simulated by inflammatory changes in the vitreous, with detachment of the retina; and the differential diagnosis is occasionally difficult. In these pseudo-glioma cases iritic adhesions are present, T. is , the eye usually somewhat shrunken, the anterior chamber deep at its periphery, whilst absent or shallow at the centre. There is often the history of a definite inflammatory attack with acute cerebral symptoms, preceding the peculiar ap- pearance in the pupil. When in any doubt, the eye should be excised. Sarcoma of the choroid and ciliary body is a growth of late or middle life, being rarely seen below the age of thirty-five. The majority of these tumors are pigmented (melanotic), some being quite black, others mottled or 1 The occurrence of slightly reduced T. in the earliest stage of glioma was first pointed out to me by Dr. Brailey. 284 TUMORS AND NEW GROWTHS. streaked. A few are quite free from pigment. Some are spindle-celled or mixed, others composed of round cells ; some are truly alveolar, but in many specimens there is very little connective-tissue stroma, and no very defined arrangement of the cells. These tumors are moderately firm but friable; some are very vascular, and hemorrhages often occur in them. The tumor generally grows from a broad base, and forms a well-defined rounded prominence, pushing the retina before it ; blood or serous fluid is gen- erally effused round its base, so that the retinal detachment is much more extensive than the tumor. These tumors often grow slowly so long as they are wholly contained within the eye, and two, three, or more years may pass be- fore the growth passes out of the eye and invades the orbit. Though this does not usually occur till the globe is filled to distention by the growth, it may happen much earlier, the cells passing out along the sheaths of the perforating blood- vessels, and producing large extraocular growths, while the intraocular primary tumor is still quite small. The lymphatic glands do not enlarge, but there is great danger of secondary growths in distant parts, especially in the liver, a risk not entirely absent, even when the eye tumor is quite small. Hence early removal of the globe is of the utmost importance, and a good, though not too confident, prognosis may be given when the optic nerve and tissues of the orbit show no signs of disease. SYMPTOMS AND COURSE. If the case be seen early, when defect of sight is the only symptom, the tumor can often be seen and recognized by its well-defined rounded outline, some folds of detached retina often being visible near it. The pupil, cornea, and eye-tension will probably be quite natural. But sooner or later the tumor in its growth sets up symptoms of acute or subacute glaucoma and sometimes iritis; subsequently secondary cataract forms. It is in the glaucomatous (second) stage that relief INTRAOCULAR TUMORS. 285 is usually sought. Unless some part of the tumor happen to be visible outside the sclerotic, or project into the an- terior chamber, a positive diagnosis often cannot now be given owing to the opacity of the media, although by ex- clusion we may often arrive at great probability. If the eye be left alone, or iridectomy be performed, glaucomatous attacks and pain will recur, and the eye will enlarge and gradually be disorganized by the increasing growth, which will then quickly fill the orbit and fungate. But sometimes a deceptive period of quiet follows the glaucomatous attack, and perhaps even some shrinking and reduction of tension may occur, after which the growth makes a fresh start and becomes apparent. It is chiefly in very old patients that this slow course is noticed. Sarcoma is especially likely to form in eyes previously injured, or already shrunken from disease. Thus it is apparent that in a majority of cases the pres- ence of choroidal tumor can only be conjectured. We suspect a tumor and urge excision in the following cases : (1) When an eye that has been for some time failing or blind from deep-seated disease becomes painful, congested, and glaucomatous (there being no glaucoma of the other eye), and particularly if there be secondary cataract. (2) Similar eyes with normal or diminished tension are best excised, as possibly containing tumor. (3) In exten- sive detachment of retina confined to one eye, without history of injury or evidence of myopia, the patient should be warned, or the eye excised, according to cir- cumstances. In all suspicious cases the cut end of the optic nerve of the excised eye should be carefully looked at, and if it be pigmented or thickened another piece should be at once removed, and the orbit searched by the finger for evidence of growth ; the surface of the eye should also be carefully examined for external growths. When infection of the 286 TUMORS AND NEW GROWTHS. nerve or orbit is suspected chloride of zinc should be ap- plied as already directed. Tubercular growths of large size may occur in the choroid. The diagnosis is uncertain till after excision, and the treatment differs in no way from that of malignant growths. The patients are generally young. Tumors of the iris are rare. Melanotic as well as un- pigmented sarcomata are occasionally met with. Sebaceous or epithelial tumors are also seen ; they are nearly always the result of transplantation of epithelium, or even of a hair, into the iris through a perforating wound of the cornea. In rare cases cystic tumors with thin walls are formed in connection with the iris, particularly in eyes which have been operated on for cataract. The term granuloma is applied to several forms of non- malignant tumor of the iris, some of which are large tubercles, some syphilitic gummata of large size, and some true granulation tissue following wounds. These forms are all accompanied by iritis. REFRACTION AND ACCOMMODATION. 287 CHAPTER XX. ERRORS OF REFRACTION AND ACCOMMODATION. As stated at p. 25, 19, when the length of the eye is normal and the accommodation relaxed, only parallel rays are focussed on the retina, and conversely pencils of rays emerging from the retina are parallel on leaving the eye (Fig. 87, and pp. 17 and 18, 11 and 12), and this, the JIG. 87. Pencils of parallel rays entering or emerging from emmetropic eye. condition of the normal eye in distant vision, is called em- metropia (E). All permanent departures from the condi- tion in which, with relaxed accommodation, the retina lies at the principal focus are known collectively as ametropia. FIG. 88. Emmetropia. Distant objects (parallel rays) focussed on retina; near objects (divergent rays) focussed behind retina. In E. rays from any near object, e. g. y divergent rays from Ob, Fig. 88, are focussed behind the retina at CF, every 288 REFRACTION AND ACCOMMODATION. conjugate focus being beyond the principal focus (p. 18, 13). Reaching the retina before focussing, such rays will form a blurred image, and the object Ob will therefore be seen dimly. But by using accommodation the convexity of the crystalline lens can be increased and its focal length shortened, so as to make the conjugate focus of Ob coincide exactly with the retina (CF, Fig. 89). Under this condition the object Ob will be clearly seen, whilst the focus of a FIG. 89. Eye during accommodation. Near objects (divergent rays) focussed on retina; distant objects (parallel rays) focussed in front of retina. Dotted line in front of lens shows its increase of convexity. distant object, which in Fig. 88 was formed on the retina, will now lie in front of it (F, Fig. 89), and the distant ob- ject will appear indistinct. The nearest point of distinct vision (p.) and the farthest (r.) have been defined at p. 44. MYOPIA. (M.) In Fig. 88, if the retina were at CF instead of at F, a clear image would be formed of an object at Ob, without any effort of accommodation, whilst objects farther off would be focussed in front of the retina. This state, in which the posterior part of the eyeball is too long, so that, with the accommodation at rest, the retina lies at the con- jugate focus of an object at a comparatively small distance, is called Short-sight or Myopia (M.) (Axial Myopia). In Fig. 90 the inner line at K is the retina, and F the principal focus of the lens-system, i. e., the position of the retina in the normal eye. Rays emerging from R will, on MYOPIA. 289 leaving the eye, be convergent, and, meeting at the conju- gate focus it', will form a clear image in the air. Con- versely, an object at R' will form a clear image on the retina (R) (compare Figs. 9 and 11). The image of every object at a greater distance than R' will be formed more or less in front of R, and every such object must, therefore, be FIG. 90. Myopia. Retina beyond principal focus, hence only near objects (divergent rays) focussed on retina. seen indistinctly. But objects nearer than R' will be seen clearly by exerting accommodation, just as in the normal eye (Figs. 88 and 89, and p. 44). In myopia the indistinctness of objects beyond the far point (r) is lessened by partly closing the eyelids. This habit is often noticed in short-sighted people who do not wear glasses, and from it the word myopia is derived. The distance of r (V, Fig. 90) from the eye will depend on the distance of its conjugate focus R, i. e., upon the amount of elongation of the eye. The greater the distance of R beyond F, the less will be the distance of its conjugate focus R' (= r); in other words, the higher will be the myopia, and the more indistinct will distant objects be. If the elongation of the eye be very slight, R nearly coin- ciding with F, R' (= r) will be at a much greater distance (compare p. 19, 16), and distant objects will be less indis- tinct. As the retinal images formed in a myopic eye are larger than normal (p. 25, 19), myopic persons can dis- tinguish smaller objects at the same distance than those with normal eyes. 25 290 REFRACTION AND ACCOMMODATION. SYMPTOMS OF M. In low degrees the patient's com- plaint is that he cannot see distant objects clearly ; in moderate and high degrees it is rather that he can see distinctly only when things are held very close, for objects a few feet off are so indistinct that many such persons neglect them. Adults often tell us that their distant sight was good till about eight or ten years of age, that it then began to shorten, and that the defect after increasing for several years at length became stationary. In many cases, no other complaint is made ; but in a certain number complications are present. There is often intolerance of light, an additional cause for the half-closed lids and frowning expression so often noticed. Aching of the eyes is a very common and troublesome symptom, and is especially frequent if the myopia is increasing ; it is often brought on and always made worse by over-use of the eyes, but sometimes is very troublesome when quite at rest, and even in bed at night. One or both internal recti often act deficiently in myopia, so that convergence of the optic axes for near vision becomes difficult, painful, or impossible, and various degrees of divergent strabismus result ; this occurs oftenest, but by no means only, in the higher degrees of M. where r is so near that binocular vision involves a strong effort of convergence. When this "muscular asthenopia" or "insufficiency of the internal recti" is slight or inter- mittent it causes indistinctness, " dancing," and sometimes actual diplopia, besides the other discomforts above men- tioned ; but diplopia is seldom present when a constant divergent squint has been established. The lower degrees of M. are sometimes accompanied by involuntary contrac- tion of the ciliary muscle ("spasm of accommodation ") by which M. is temporarily increased ; and the habitual approximation of objects which thus becomes necessary is one cause of still further elongation of the eye and in- MYOPIA. 291 crease of the structural M. Floating specks (muscce voli- tantes, p. 247) are especially common and troublesome in myopia. Objective signs and complications. In high degrees of M. the sclerotic is enlarged in all directions (Fig. 91) ; the eye FIG. 91. Section of a highly myopic eyeball. The retina has been removed. often looks too prominent or too large, and its movements are somewhat impeded. But apparent prominence of the eye may depend on many other causes (p. 34, 6). The existence of myopia is made certain by the ophthal- moscope in four different ways. (1) By direct examination, the image of the fundus formed in the air (Fig. 90) is clearly visible to the observer, if he be not nearer to it than his own near point, p. The image is inverted and magnified, the enlargement being greater the further it is formed from the patient's eye (p. 21, 17), i. e., the lower the M. For very low degrees this test is not easy to use, because of the great distance (3' or 4', e. or less, from its border. The zone of conjunctiva so in- cluded, together with the whole of its subconjunctival tissue down to the sclerotic, is now carefully removed by snipping with the scissors. The surface, being left to heal, granu- lates and contracts, and finally a narrow band of white scar-tissue is left, which obliterates the vessels running to LACHRYMAL APPARATUS. 341 the cornea and prevents the formation of new ones. The subconjunctival fascia is often found much thickened in these cases. Care must be taken not to make the incision too far from the cornea, lest the insertions of the recti be damaged. The zone of tissue should be removed in one piece. The symptoms are generally made worse for a time, and the final result is not reached for several months. In some cases the operation has, in my experience, been very successful, whilst in others, without apparent reason, it has quite failed in its purpose, the cure of the pannus. B. OPERATIONS ox THE LACHRYMAL APPARATUS. 1. Lachrymal abscess. (See p. 92). 2. Slitting up the lower canaliculus. This is best done by means of a knife with a blunt ,_ or probe point, and a blade narrow enough to "~| enter the punctum. The best forms of these knives are Weber's knife with a probe end (Fig. 112); Bowman's, with nearly parallel FIG. 112. Weber's canaliculus knife. borders and a rounded end (Fig. 113), and Liebreich's (Fig. 114). Position as for 1. (1) the lower lid is drawn tightly outwards and downwards by the thumb. (2) The canalicu- lus knife is passed vertically into the punctum, and then turned horizontally and passed on through the neck of the 29* 342 OPERATIONS. canaliculus till it reaches the bony (inner) wall of the lach- rymal sac. It is then raised up from heel towards point, and thus made to divide the canaliculus, care being taken that the neck is freely divided. Liebreich's knife cuts ita FIG. 113. Bowman's canaliculus knife. FIG. 114. Liebreich's knife for canaliculus and nasal duct. own way without being raised. The lower canaliculus may also be divided with a Beer's knife (Fig. 135), which is run along a fine grooved director (Fig. Ill), previously intro- duced. In cases of mucocele it is good practice to divide the wall of the sac freely, and to divide the upper canali- culus. 3. Catheterism of the nasal duct. After dividing the canaliculus, pass a No. 6 Bowman's lachrymal probe hori- zontally along its floor until it strikes the inner bony wall of the sac. Then raise it to the vertical position, and push it steadily down the duct (downwards and a little outwards and backwards) till the floor of the nose is reached. Bowman's earlier probes were in six sizes, of which the largest was 2 V-h ^ n< i n diameter. Mr. Bowman afterwards adopted much larger probes with bulbous ends; and several such patterns are now in use. The probe used should be the largest that will pass easily. 4. A stricture of the duct may be incised with any of the canaliculus knives, although Weber's and Bowman's are too slender to be used with safety. Liebreich's is in- tended to be so used, and a special knife for the purpose had STKABISMUS. 343 previously been introduced by Stilling. The knife is used as a probe, being pushed quite down the duct, then partly withdrawn and turned in other directions, and pushed down again. There is generally bleeding from the nose. In all these procedures it is essential to be certain that the probe or knife rests against the bony (nasal) wall of the lachrymal sac before it is raised into the vertical direc- tion. If the probe be stopped at the entrance of the canaliculus into the sac (as may easily happen if the canal be not thoroughly slit in its whole length), the lid will be pulled upon and puckered whenever the instrument is pushed towards the nose ; but if the probe has reached the sac, backward and forward movements will not usually cause puckering of the lid. If in the former case the instrument be turned up, and an attempt made to pass it down the duct, a false passage will be made. The direction of the two nasal ducts is either parallel or such that if prolonged upwards they would converge slightly ; they very seldom diverge. The probe when in the duct should, even if, as usual, its lower end be curved forwards, rest against and indent the eyebrow ; if it stands forwards from the brow it is usually in a false passage. 6. Abscess of the lachrymal gland or of the orbit (pp. 89 and 159). C. OPERATIONS FOR STRABISMUS. Tenotomy. The object is to divide the tendon close to its insertion into the sclerotic. In this country the operation is usually done subconjunctivally, but in the operations of Graefe and Snellen the tendon is more or less exposed to view. The internal and external recti are the only ten- dons commonly divided, and the internal by far the more frequently. Anaesthesia is seldom necessary except for children. Position recumbent. The operator usually 344 OPERATIONS. stands on the patient's right side for whichever eye is to be operated on, but some prefer to stand behind and use curved scissors. Instruments: Stop speculum (Fig. 115 shows a convenient and common pattern), straight scissors, FIG. 115. Stop-spring speculum. with blunted points (Fig. 116), toothed fixation forceps (Fig. 117), strabismus hook (Fig. 118). There are several patterns of hooks, differing in the length and sharpness of the curve, and in the form of the tip. In some the tip is slightly bulbous ; in others the hook is flattened sideways, but not enlarged at the end. I prefer such a flattened hook. OPERATIONS. Critchetfs operation. (1) After intro- ducing the speculum take the fixation forceps in the left hand, and pinch up a fold of conjunctiva over the lower border of the tendon (say of the right internal rectus) at its insertion. With the scissors make a small opening in this fold close to the forceps end, the cut being made in the direction of the caruncle. The capsule of Tenon is now identified as a layer of fascia, which can be moved over the sclerotic ; this fascia is to be pinched up and an open- ing made in it corresponding to the conjunctival wound. By taking deep hold with the forceps both conjunctiva and capsule may often be divided at one stroke, but with less certainty than in separate stages. As a rule both con- STRABISMUS. 345 junctiva and Tenon's capsule are thicker in children than in adults. (2) Take the hook in the right hand (retaining the lip of the wound with the forceps in the left), and pass it, con- cavity downwards and point backwards, through the open- 340 OPERATIONS. ing in the capsule as far as its elbow, keeping its end always flat against the sclerotic. Next turn the end of the hook upwards, still guided by the sclerotic, between the tendon and the globe until its end is seen projecting beneath the conjunctiva above the upper border of the tendon. On now attempting to draw the hook towards the cornea it will be stopped by the tendon. If Tenon's capsule have not been well opened, the hook cannot be passed beneath the FIG. 118. Strabismus hook (the bent part is represented too thin) tendon, nor swept round the sclerotic. (3) Lay down the forceps, transfer the hook to the left hand, holding its handle parallel with the side of the nose, and tightening the tendon by traction forwards and outwards; pass the scissors, with the blades slightly opened, into the wound, and push them straight up between the hook and the eye. The tendon being included between the blades, is divided at two or three snips, with a crisp sound and feeling. When the whole breadth of the tendon is divided the hook slips forwards beneath the conjunctiva up to the edge of the cornea. It is well by reintroducing the hook to make sure that no small strands of the tendon have escaped, for the operation does not succeed unless the division be quite complete. The effect of the tenotomy may, if necessary, be increased by tying the eye out; a stout suture is passed through the conjunctiva, embracing about a quarter of an inch, close to the outer border of the cornea, and the eye being drawn outwards, the two ends of the thread are firmly attached by strapping to the skin of the temple, and left for two days. No after-treatment is needed, but the patient is more STRABISMUS. 347 comfortable if the eye be tied up for a few hours. If there be much conjunctival bleeding (as is common when no an- aesthetic is used), a second small hole may be cut in the conjunctiva over the upper border of the tendon, to let the blood escape. The difficulties for beginners are (1) to be sure of open- ing Tenon's capsule; (2) to avoid pushing the tendon in front of the scissors, especially when only the upper part remains undivided. Division of one internal rectus by this operation di- minishes the squint by about two lines (4 mm.). After the operation just described the tendon, in retract- ing, draws with it, to a varying extent, the neighboring parts of Tenon's capsule and the conjunctiva, and these in- direct but wide attachments, on their part, prevent the tendon from retracting fully, and hence the maximum effect of its division is not obtained ; moreover, the caruncle is drawn back by the retreating tendon, and a hollowness at the inner canthus results; this is, however, very slight if the operation wound be made small, and as near as pos- sible to the cornea. To avoid this deformity, and at the same time increase the effect, the following modification was introduced by Mr. Liebreich. Liebreich's operation. After making the conjunctival wound as above, the scissors are passed between the con- junctiva and Tenon's capsule, and by repeated horizontal snips are made to separate these membranes freely from one another over the tendon, as far as the caruncle. The capsule is then opened and the tendon divided as in the former operation. The conjunctival wound is closed by a suture. This operation has considerably more effect than Critchett's operation, often with less deformity. But in some cases the deformity is extreme. The immediate effect of the tenotomy of a rectus muscle is somewhat lessened after a few days by the reunion of the 348 OPERATIONS. tendon with the sclerotic, but after a few weeks or months it is again increased by the stretching of this new tissue (final stage). Readjustment or Advancement consists in bringing for- wards to a new attachment the tendon of a rectus (gener- ally the internal, occasionally the external), which has be- come attached too far back after a previous tenotomy or has become weakened, e. g., in myopia. There are several different operations, but in nearly all of them the tendon is held in its new position by sutures. The operation is tedious and painful, and the patient must always be under an anaesthetic. The instruments are the same as for tenotomy. I generally perform the operation as follows (essentially by Critchett's method) : A vertical incision is made about 4 mm. from the cornea, exposing the whole width of the tendon, but the conjunctiva is not extensively dissected up from it. The tendon is then divided on a hook in the usual way. Three double-needled sutures are then passed from within outwards through the flap formed by the tendon, fascia, and conjunctiva, at a considerable distance from its free edge, and the flap then shortened by cutting off its free border. The deep ends of the sutures are next passed, by means of their remaining needles, from within outwards through fascia and conjunctiva, close to the border of the cornea, taking as broad a hold as possible. At this stage the external rectus is to be divided and a stout traction suture introduced at the outer side of the eye (see preceding page), by which it can be drawn in. The three tendon sutures are now tied and the eye rolled in, and kept as far inwards as possible by fastening the traction suture to the bridge of the nose with strapping. The traction suture cuts out in two or three days ; the tendon sutures should be left in a week. The pain and swelling, which for a few days are sometimes considerable, are best relieved by ap- EXCISION OF THE EYE. 349 plication of ice or a spirit lotion to the lids. The final result is not reached for several weeks (p. 323). D. EXCISION OF THE EYE. Instruments as for squint, but the scissors curved on the flat. The operator may stand either behind or in front. (1) Divide the ocular conjunctiva all round close to the cornea, but leave, at one side, enough to hold by with the forceps. (2) Open Tenon's capsule and divide each rectus tendon and the neighboring fascia on the hook ; the two obliques are seldom divided on the hook. (3) Make the eye start forwards by pressing the speculum back behind the equator of the globe. (4) Pass the scissors backwards along the sclerotic till their open blades can be felt to em- brace the optic nerve (recognized by its toughness and thickness), and divide it by a single cut while steadying the globe with a finger of the other hand. Finish by dividing the oblique muscles and remaining soft parts close to the globe. Apply pressure for a minute or two, and then tie up tightly for six or eight hours with an elastic pad of small sponges overlaid by cotton wool. There is scarcely ever serious bleeding. The artificial eye may be fitted in from two to three weeks. 1 After some weeks or months a button of granulation tissue occasionally grows from the scar at the bottom of the conjunctiva! sac, and should be snipped off*. The operation is more difficult when the eye is ruptured or shrunken, or the surrounding parts much inflamed and adherent. The order of division of the muscles is quite 1 The glass eye must be renewed as often as it gets rough, gen- erally at least once a year. Some persons have much difficulty in tolerating it, and they must be content to wear it for only a part of the day. It is always to be removed at bed-time. 30 350 OPERATIONS. immaterial. The important points are to leave as much conjunctiva as possible, so as to form a deep bed for the glass eye, and by keeping the scissors close to the globe during the whole operation, to avoid unnecessary laceration of the tissues. "When, as in some cases of intraocular tumor, it is desired to remove another piece of the optic nerve, the nerve be felt for with the finger, seized and drawn forward with the forceps, and cut off further back with the scissors. Abscission is the removal of a staphylomatous cornea with the front part of the sclerotic, leaving the hinder part of the globe with the muscles attached, to serve as a mova- ble stump for carrying the artificial eye. Four or five semicircular needles carrying sutures are made to puncture and counter-puncture the sclerotic just in front of the at- tachments of the recti; the part of the globe in front of the needles is cut off, the needles drawn through, and the sutures tied. The operation is admissible only when the ciliary region is free from disease, and has, therefore, a very limited application; even in the most favorable cases the stump is not entirely free from the risk of setting up sym- pathetic inflammation. It is said that if the sutures are passed only through the conjunctiva or the muscles, the risk is less than when they are passed through the sclerotic. The recently revived operation of optico-tiliary neurotomy, in which the optic nerve and all the ciliary nerves are divided without removal of the globe, with the view of preventing sympathetic disease appears to me to be bad surgery. The sensibility of the cornea, abolished by the operation, often returns, proving that the ciliary nerves have reunited. The cut ends of the optic nerve have also been found reunited. The operation, therefore, cannot be relied upon to destroy these, nor, it may be added, any of the other possible paths (p. 152) along which sympathetic irritation and inflammation may travel. CORNEA. 351 E. OPERATIONS ON TELE CORNEA. Removal of foreign bodies. Position as for 1. Instru- ments : a steel spud (Fig. 119), or a broad needle with double cutting edge (Fig. 120). The eyelids are held open by the index and ring fingers, and the eyeball steadied by the middle finger placed against the temporal side of the globe. The chip is gently picked or tilted off by placing the edge of the spud beneath it, or, if firmly em- bedded, a certain amount of scraping may be necessary. The first few touches, by which the epithelium is removed, cause the most pain. If the foreign body be barely em- FIG. 119. FIG. 120. Corneal spud. Broad needle. bedded in the epithelium, a touch with a little roll of blotting paper will often detach it. When a fragment of iron has been present for more than a couple of days, its corneal bed is usually stained by rust, and a little plate or ring of brown corneal slough can often be picked off after the removal of the chip ; but, as a rule, this minute slough may be left to separate spontaneously. AFTER-TREATMENT. The protection of the corneal sur- face from friction and irritation by keeping the eye tied up is generally sufficient ; a drop or two of castor oil placed in the conjunctival sac lubricates the cornea and lessens the irritation. Atropine is to be used if there be marked congestion and photophobia. When a splinter is deeply and firmly embedded, especi- ally if it has penetrated the cornea and projects into the anterior chamber, the operation is much more difficult, and is no longer a " minor " one. Unless great care be taken the splinter in such a case may be pushed on into 352 OPERATIONS, the chamber, and the iris or lens be wounded. This may sometimes be prevented by passing a broad needle through the cornea at another part and laying it against the inner surface of the wound, so as to form a guard or foil to the foreign body, the latter being removed by spud or forceps from, the front. A foreign body in the anterior chamber should, in re- cent cases, always be removed, and the piece of iris on which it lies must generally be excised. In cases of old standing we may judge by the symptoms whether to oper- ate or not. Paracentesis of the anterior chamber. Position as for 1 or recumbent ; anaesthesia seldom necessary. Instruments : a paracentesis needle (Fig. 121) with a very small, short, FIG. 121. Paracentesis needle and probe mounted on same handle. triangular blade bent at an obtuse angle (like a minute bent keratome), or a broad needle (Fig. 120). The former is more safe, as the blade is too short to reach the iris or lens, even if the patient should jerk his head. If the con- tents of the chamber do not follow the needle on its with- drawal, a small probe (Fig. 121) is passed into the wound. In cases where the operation needs repetition every day the original wound can be reopened with the probe, but if more than two days elapse a fresh puncture is necessary. Spec- ulum and fixation forceps should be used unless the patient has good self-control. Corneal section for hypopyon ulcer. Position recum- bent. Anaesthesia not usually needed. Instruments : a Graefe's or Beer's cataract knife (Figs. 129 and 135), speculum and fixation forceps. The incision is carried through the whole thickness of the cornea from one side CORNEA. 353 of the ulcer to the other, being both begun and finished in sound tissue. Or it may be placed entirely in sound cornea or at the sclero-corneal junction (p. 123), leaving the ulcer untouched. The knife is entered at an angle with the plane of the iris, its edge straight forwards ; when its point is seen or judged to have perforated the cornea, the handle is de- pressed until the back of the knife lies parallel with the iris, and the blade then pushed straight across the ulcer to the point chosen for counter-puncture ; or more often in practice it is just pushed on till it cuts its way out. The aqueous ought not to escape until the point of the knife is engaged in its counter-puncture, but an earlier escape can- not always be avoided. Notwithstanding the apparent risk to the iris and lens, accidents seldom happen if the back of the knife be carefully kept parallel to them, or the point even directed a little forwards. If it is desired to keep the wound open, its edges are to be separated by a probe every second or third day. The wound closes quickly at first, unless kept open, but after having been opened a few times, it sometimes remains patent for longer. Operations for conical cornea. The object is to produce a scar at the apex of the cone, which by contracting shall reduce the curvature, and so diminish the high degree of irregular myopic astigmatism to which the condition gives rise. There are three methods. (1) Graefe's operation consists in first carefully shaving off the apex of the cone without entering the anterior chamber, and then applying solid mitigated nitrate of silver to the raw surface, the resulting ulceration being followed by some scarring. The applica- tion needs great care, and the after-treatment is trouble- some, as there is the risk that more inflammation than is wished for may set in. (2) In another operation the apex of the cone is cut off with a cataract-knife, the anterior 30* 354 OPERATIONS. chamber being entered, and the wound either left to close or united by sutures. There are several different modes of removing the little piece of cornea. (3) Mr. Bowman re- moves the outer layers of the cone by means of a very delicate cutting trephine, and leaves the surface to heal and contract. I believe that No. 2 gives on the whole the best results. AFTER-TREATMENT. Atropine and compressive bandage until the wound has closed ; antiphlogistic treatment, and heat locally, if inflammatory symptoms arise. All operations for conical cornea are difficult to perform and somewhat uncertain in result, but in many cases vision improves from barely seeing very large letters before opera- tion to reading small print afterwards. Th,e final result is never gained for several months. An artificial pupil is often necessary if the corneal opacity remains finally large enough to obstruct the light. F. OPERATIONS ON THE IRIS. A portion of the iris is very often removed by operation (iridectomy), and with various objects. The principal of these are (1) the direct improvement of sight by altering the position and size of the pupil (artificial pupil) ; (2) to influence the course of an active disease glaucoma, iritis, ulcer of cornea with hypopyon ; (3) to remove the risks at- tending "exclusion" and "occlusion" of the pupil, by re- storing communication between the anterior and posterior chambers ; (4) as a stage in the extraction of cataract. Artificial pupil. The object is to remove the portion of iris in the position best adapted to sight ; thus in cases of leucoma the iridectomy is made opposite the clearest part of the cornea. When the state of the cornea allows it, the new pupil should be made down-inwards or straight down- wards ; the next best place is outward or out-upward, and straight upwards is, of course, least useful, because the new IRIS. 355 pupil will be covered by the lid. The coloboma should generally be small, and often only the inner (pupillary) part of the chosen portion is to be removed, the outer (ciliary) part being left (Fig. 122) so as to prevent the FIG. 122. Iridectomy downwards for artificial pupil. Line of incision is intended for extraction of cataract. (Wecker.) light from passing through the margin of the lens. After such an operation the pupil will be oval or pear-shaped, and widest towards the centre. The incision should lie in the cornea! tissue, if only the pupillary part of the iris is to be removed ; but if only a narrow zone of cornea remain clear, the incision must lie a little outside the sclero-corneal junction, lest its scar should interfere with the transparency of the remaining clear cornea. The loop of iris should be cut off with a single snip. In Iridectomy for glaucoma the coloboma is to be large, the iris to be removed quite up to its ciliary attachment, FIG. 123. Iridectomy for glaucoma (from Wecker). and the incision to lie as far back in the sclerotic as possi- ble (1 to 2 mm. from the border of the cornea is not too far). The sides of the coloboma should be parallel, or wider towards the incision than towards the pupil ("key- hole pupil") (Fig. 123). The loop of iris, when drawn 356 OPERATIONS. out, is usually cut first in one angle of the wound, then torn from its ciliary attachment by carefully drawing it over to the other angle of the wound, and its other end then cut, the points of the scissors being pushed just within the lips of the wound to ensure removal of the largest possible portion. The difficulty of making an artificial pupil (for optical purposes) of the best shape, i. e., broad towards the natural pupil and narrow towards the circumference, is, owing to the small size of the parts, much greater than would be at first supposed, and several methods are in use. In Mr. Critchett's iridodesis the loop of iris is drawn out through a small opening, and strangulated by a fine ligature tied round it just over the incision ; the little loop soon drops off", and the result is a pear-shaped pupil, with its broad end towards the centre. The inclusion of iris in the track of the wound has sometimes set up severe irritation, and even destructive irido-cyclitis, and on this account the operation is now but seldom performed. Another plan is to draw out a small loop of iris with a blunt hook (TyrelPs hook), and to cut off only the pupillary portion ; this method is uncertain, but, on the whole, it gives good results. Mr. Carter cuts out a V-shaped bit of iris by introducing a pair of blunt-ended iridotomy scissors through the corneal incision, opening the blades, and cutting out just as much iris as is intruded between them by the gush of the escaping aqueous. This operation requires much nicety, and entails some risk of wounding the lens, but when well performed it gives an excellent artificial pupil. Iridotomy (iritomy). In this operation an artificial pupil is formed by the natural gaping of a simple incision in the iris, or by making a V-shaped incision and allowing the tongue-shaped piece to retract. It is only applicable when the lens is absent. Through a small incision in the cornea, between the centre and margin, the scissors (shears) IRIS. 357 FIG. 124. shown at Fig. 124 are passed; the more pointed blade is passed behind the iris as far as is deemed necessary, and the iris and false membrane divided by a single closure of the blades. It is sometimes necessary to make a second cut at an angle with the first, so as to include a V-shaped tongue of iris which will shrink and allow a larger pupil. Iridotomy is most useful when the iris has become tightly drawn towards the operation scar by iritis occurring after cataract extraction (Fig. 136). The line of the cut in the iris should lie as nearly as may be across the direction of its fibres, and should always be^as long as possible. In cases of this sort, or when without much dragging of the iris towards the scar, the pupil is filled by iritic or cyclitic membrane after cataract extraction, iridotomy yields a better pupil than iridectomy, and with less disturbance of, and no dragging upon, the ciliary body. The operation of iridectomy. Po- sition recumbent ; the operator usually stands behind. Anaesthesia is always strongly advisable, though in urgent cases iridectomy can be successfully performed by an adept without it. Instruments: stop speculum (Fig. 115), fixation forceps, bent keratome (Fig. 125), iris forceps bent at various angles, according to the position of the iridectomy (Fig. 127), iris scissors with elbow bend (Fig. 126), of which some pat- Iridotomy scissors. 358 OPERATIONS. terns have one or both blades probe-pointed, a curette (Fig. 131) for replacing the cut ends of the iris and pre- venting their incarceration in the angles of the wound. The iridotomy scissors (Fig. 124) are very convenient, especially for downward and inward operations, and for the left hand. A Graefe's cataract knife (Fig. 129) may be used if the anterior chamber be very shallow. The conjunctiva is held by the fixation forceps near the cornea at a point opposite to the place selected for punct- ure. (1) The keratome is to be entered slowly, steadily pushed on across the anterior chamber till the wound is of the desired size, then slowly withdrawn, and in its course carefully rotated to one side, so as to lengthen the internal wound. Two points need attention in making the incision : as soon as the point of the knife is visible in the anterior FIG. 125. Bent triangular keratome. chamber it must be tilted slightly forwards to avoid wound- ing the iris and lens ; and care must be taken not to tilt it sideways, for by so doing the wound instead of lying par- allel with the border of the cornea will lie more or less across it. The incision is made almost as much by lifting the eye against the knife with the fixation forceps, as by pushing the knife against the eye. The fixation forceps are now laid down, or if fixation be still necessary, they are given to an assistant, who is to gently draw the eye into the position required for the next step ; in so doing he is to draw away from the eye, not to push the ends of the forceps against the sclerotic. (2) The iris forceps are in- troduced, closed, into the wound and passed very nearly to the pupillary border of the iris, before being opened IRIS. 359 and made to grasp it. Ey seizing the pupillary part of the iris its inner circle is certain to be brought outside the wound, when the forceps are now withdrawn ; if the iris be seized in the middle of its breadth, a button-hole may be cut out and the pupillary part left standing. Often the iris is carried into the wound by the gush of aqueous as the keratome is withdrawn, and it is then seized without passing the forceps so far into the chamber. (3) The loop of iris having been cut off, either at a single snip, or by 360 OPERATIONS. cutting first one end and then the other, as in glaucoma (p. 355), the tip of the curette is gently introduced into each angle of the wound to free the iris, should it be en- tangled; this little precaution is of importance in order to prevent inclusion of the iris in the track of the wound. The speculum is now removed and both eyes bandaged over a pad of cotton-wool, either with a four-tailed bandage of knitted cotton, or two or three turns of a soft calico or flannel roller. The anterior chamber is refilled in twenty-four hours, except in cases of glaucoma, when the wound frequently leaks more or less for several days. It is better in all cases to keep the eye bandaged for a week, the wound being but feebly united, and likely to give way from any slight blow or other accident. When the incision lies in, or partly in, the sclerotic, some bleeding generally occurs; when the eye is much congested this hemorrhage is con- siderable, and the blood may run into the anterior chamber either during or after the excision of the iris; it can be drawn out by depressing the lip of the wound with the curette, but if the chamber again fills, no prolonged efforts need be made, since the blood is usually absorbed without trouble in a few days. In diseased, especially glaucoma- tous, eyes secondary hemorrhage sometimes occurs from the iris several days after the operation, and the absorption of this blood is often slow. Sclerotomy is an operation for dividing the sclerotic near to the margin of the cornea. It is employed in glaucoma instead of iridectomy, or after iridectomy has failed. The pupil is to be contracted as much as possible by eserine before the operation. It is performed subconjunctivally, a Graefe's cataract knife (Fig. 129) being entered through the sclerotic near the margin of the cornea, 1 passed in front 1 Wecker makes it 1 mm. from the clear cornea. In my own operations the distance is generally about 2 mm. IRIS. 361 of the iris, and brought out at a corresponding point on the other side, or as to include nearly one-third of the circum- ference ; the puncture and counter-puncture are then en- larged by slow sawing movements ; the central third of the FIG. 128. Diagrammatic section of ciliary region, showing path of wound in iridectomy for glaucoma (/) and in sclerotomy (S). (Compare Fig. 8j, 1 and 2.) sclerotic flap, and the whole of the conjunctiva (except at the punctures) are left undivided. The knife is then slowly withdrawn. The scleral wounds often gape a little in the next few days. The whole operation is to be done very slowly that the aqueous humor may escape gradually ; any rush of fluid is likely to carry the iris into the wound and cause a permanent prolapse, and this is considered by nearly all operators as very undesirable, if not a source of danger. If decided prolapse occur, the iris should be ex- cised, and the operation then becomes a very peripheral iridectomy. A moderate degree of bulging and separation of the lips of the two scleral wounds takes place for a week or two, when the scar flattens down, and finally a mere bluish line is left. Sclerotomy is difficult to perform well; if the incision be too long and too far back, there is danger of hemorrhage into the vitreous and even of puckering and inflammation of the scar and sympathetic ophthalmitis of the other eye ; in other cases it may be too short or too 31 362 OPERATIONS. far forward, and then it is no better than an incision for iridectoiny. In Fig. 128, /shows the line of incision in iridectomy for glaucoma, and S the line in sclerotouiy. Comparison with Fig. 84, however, will show that the incisions for iridectomy in glaucoma differ in position a good deal. G. OPERATIONS FOR CATARACT. 1. Extraction of cataract has been systematically prac- tised for nearly a century and a half. The operation has passed through many important changes, and many differ- ent procedures are still in use. There is also much di- versity of practice in regard to anaesthesia, but a large number of the most experienced operators frequently dis- FIG. 129. Graefe's cataract knife. pense with it. All the operations are difficult to perform well, and much practice is needed to ensure the best pros- pects of success. Further, the sources of possible failure FIG. 130. Cataract spoon. are numerous, and since in avoiding one we are very apt to fall into another, it is scarcely likely that any one opera- tion will in all its details ever be universally adopted. At present the majority of surgeons adhere more or less closely to the operation known as the " modified linear " method of von Graefe. All operations for extraction of hard cataract agree in the following points : (1) An incision is made in the cornea, CATARACT. 363 at the junction of the cornea and sclerotic, or even slightly in the sclerotic, large enough to give passage to the crystalline lens without its being broken or altered in shape. The knife now almost uni- versally employed is the narrow, thin, straight knife of von Graefe (Fig. 129). (2) The cap- sule is freely opened with a small, sharp-pointed instrument (cystotome or pricker, Fig. 131). (3) The lens is removed through the rent in the capsule (the latter structure remaining be- hind), either by pressure and manipulation outside the eye, or by the introduction of a traction instrument (scoop or spoon, Fig. 130) passed behind the lens. Most operators have abandoned the habitual use of the scoop, reserv- ing it for certain emergencies and special cases. (4) Iridectomy is very often performed as the second stage, not with the primary object of S facilitating the exit of the lens, but to lessen < the after-risks of iritis ; since it has been found that, where no iridectomy is done, the portion of iris traversed by the lens is often so bruised or stretched as to become the starting-point of severe traumatic iritis. The following are the most important types of operation at present practised. (a) Linear extraction (best described here, though not applicable to hard cataract). A small incision (4 to 6 mm.) is made by a kera- tome (Fig. 125) well within the outer margin of the cornea. It is often better, though not es- sential, to make a small iridectomy. After open- ing the capsule the lens is squeezed out piece- meal or coaxed out by depressing the outer lip of the wound with the curette (Fig. 131). Only soft cataracts or those with a very small, hard nucleus can be so dealt with. 364 OPERATIONS. The wish to extend the principle of a straight wound to full-sized hard cataracts led von Graefe, in 1865, to intro- duce (5) the "modified linear" or "peripheral linear" ex- traction, in which the incision lies slightly beyond the sclero-corneal junction (Fig. 133, 2), and consequently in- volves the conjunctiva, of which a flap is made. The incision is intended to form an arc of the largest possible circle, i. e., of the sclerotic, not of the cornea, and its plane, therefore, must form as nearly as may be a radius of the scleral curve and lie at a considerable angle with that of the iris (Fig. 134, 2). A large iridectomy is performed as the second stage. The incision is made with the long narrow knife of von Graefe (Fig. 129), which is at first directed towards the centre of the pupil and then brought up to the seat of counter-puncture. The edge is turned somewhat forward during the greater part of the proceed- ing, and the cut completed by sawing movements. The iridectomy is occasionally made several weeks before the extraction ("preliminary iridectomy"), the parts being allowed to become perfectly quiet in the interval. The disadvantages of the peripheral linear extraction are, the frequency of bleeding from the conjunctiva into the an- terior chamber, the parts being thus obscured ; a consider- able risk of loss of vitreous, owing to the peripheral position of the wound, and sometimes a difficulty in making the lens present well ; a small but appreciable risk that the operated eye will set up sympathetic inflam- mation, the wound lying in the "dangerous region" (p. 152) ; lastly, there is a tendency to make the wound rather too short in order to avoid some of these risks, and thus difficulties are introduced in the clean removal of the lens. Its great advantage lies in the very small risk of suppurative inflammation. (c) Short flap (de Wecker). The incision, made with the same knife, lies exactly at the sclero-corneal junction, CATARACT. 365 and is of such an extent that it has a height of about 3 mm. (i of the diameter of the cornea) (Fig. 132). The iridec- tomy is small (as in Fig. 122). For very large cataracts this incision is not quite large enough. FIG. 132. Short flap. A variety of this operation consists in placing the in- cision rather further down, and at the same time giving it a somewhat sharper curve, so that it forms an arc of a smaller circle than before, but is still not concentric with the cornea (Fig. 133, 3, upper section). The puncture is FIG. 133. I 2 3 Paths of incisions for extraction of cataract. 1, Old flap; 2, peripheral linear ; 3 (upper figure), a variety of the peripheral linear ; (lower figure) corneal section. The wound appears as a narrow slit (2) or a broad track (1), when seen from the front, according to the inclination of its plane. Compare Fig. 134. The dotted circle shows the outline of the lens. directed somewhat downwards (as at the right-hand end of the figure), and its plane, which at the puncture and counter-puncture is almost parallel with the iris, alters to nearly a right angle at the summit of the flap. The track of the wound, if shaded, would appear as in the figure. (d) The incision has nearly the same curve and plane as in b, but the greater part of the incision lies considerably within the margin of the cornea (corneal section), and iridectomy is usually dispensed with. In Liebreich's and 31* OPEKATIONS. Bader's operation the section is made downwards and its * plane forms an angle of about 45 with that of the iris (Fig. 133, 3, lower section). In Lebrun's corneal operation an almost identical section is made upwards; the upper section of 3, Fig. 133, if placed further down in the cornea, would nearly represent it. The corneal operations, without FIG. 134. The same sections seen in profile, showing the plane of the incision in 1, 2, and the lower section of 3. iridectomy, are comparatively easy to perform, and usually do not require anaesthesia, but they are often complicated by extensive adhesion of the iris to the scar. It is un- likely that they will gain general adoption. It is an advantage to contract the pupil with eserine before, and to continue its use for a day or two after, the operations c and d, so as to lessen the risk of the iris be- coming permanently engaged in the wound. (e) Flap extraction (Daviel, Beer). The incision is slightly within the visible margin of the cornea, concentric with it, and equal to at least half its circumference (1, Fig. 133), thus forming a large arc of a small circle ; and the plane of the incision is parallel with that of the iris (1, Fig. 134). No iridectomy is made. The incision is made with the triangular knife of Beer (Fig. 135), in which the blade near its heel is somewhat wider than the height of the flap, and the section completed by simply pushing the knife across the anterior chamber flat with CATARACT. 367 the iris, its back corresponding to the base of the intended flap. The inner length of the wound is less than the outer by the thickness of the obliquely cut cornea at each end (1, Fig. 133). The after-treatment in flap extraction is troublesome. When everything does well the result is almost perfect, the pupil retaining its natural size, shape, and mobility. FIG. 135. Beer's cataract knife. The operation is usually done without anaesthesia, and neither speculum nor fixation forceps are needed. The great height of the flap in proportion to its width renders it very liable to gape or even to fall forwards, and this, with the fact that the whole wound lies in corneal tissue, considerably increases the risk of rapid suppurative in- flammation of the cornea. The iris often prolapses and becomes adherent to the wound, and even apart from this, severe iritis is a common occurrence. For these reasons the old flap extraction has been almost abandoned in favor of the peripheral linear, corneal section, and short flap operations, which, though giving perhaps a smaller per- centage of results that can be called " perfect," yield a much larger average of useful eyes. Historically, the flap operation was the earliest ; then came the linear operation ; thirdly, the modified or periph- eral linear operation, with iridectomy; and lastly, the modern corneal operations and short flap, the aim of which is to gain the substantial advantages both of the old flap and the modified linear methods, without the great risks of the former or the imperfections of the latter. Of other operations the most important is Pagenstecher's, 368 OPERATIONS. in which the lens is removed by means of a scoop or vectis in its unbroken capsule. It is especially applicable to cataracts which are over-ripe or are complicated with old iritis, and to Morgagnian cataract. The chief complications which may arise during extrac- tion of cataract are: (1) too short an incision; this is best remedied by enlarging with iris scissors. (2) Escape of vitreous before expulsion of the lens ; this is a signal for the prompt removal of the lens with a scoop (Fig. 130), and the vitreous is to be cut off level with the wound by scissors. (3) Portions of the lens remaining behind after the chief bulk has been expelled ; they should be coaxed out by gentle manipulation through the lower lid after removal of the speculum. After-treatment of extraction by modified linear, short flap, and corneal operations. The patient is best in bed for a week. The dressing after the operation consists of a piece of soft linen overlaid by a pad of cotton-wool, and kept in place by a four-tailed bandage of knitted cotton, or a narrow flannel roller. Both eyes are to be bandaged. The room should be kept nearly dark for at least a week, all dressings and examinations being made by the light of a candle. The dressings are removed and the lids gently cleansed with warm water twice a day, their edges being just separated by gently drawing down the lower lid, so as to allow any retained tears to escape ; this cleansing is very grateful to the patient. Some surgeons open the lids and look at the eye the day after the operation ; others, and amongst them myself, prefer to leave them closed for several days unless there are signs that the case is doing badly (p. 184). 1 It is a good practice to use one drop of atropine 1 Old people occasionally get delirious during th confinement in bed after iridectomy or extraction of cataract, and for such patients the rules as to bandaging and darkness may well be re- laxed. CATARACT. 369 daily after the third day, to prevent adhesions should iritis set in. During the first few hours there will be some sore- ness and smarting, and at the first dressing a little blood- stained fluid, but after this there should be no material discomfort, and nothing more than a little mucous dis- charge, such as old people often have. "When first exam- ined (from two to seven days after the operation) the eye is always rather congested from having been tied up; but there should be no chemosis, the wound should be united so as to retain the aqueous, and its edges clear. The pupil is ex- pected to be black, unless it is known that portions of lens- matter have been left behind. If all be well, the bandage may be left off during the daytime at the end of a week or ten days, a shade being worn; but the bandage should be reapplied at night for the first two or three weeks to pre- vent accidents from movements during sleep. At the end of a fortnight, if the weather be fine, the patient may begin to go out, the eyes being carefully protected from light and wind by dark goggles, and he may be out of the surgeen's hands in from three to four weeks. AFTER-OPERATIONS. When iritis occurs (p. 185) the pupil becomes more or less occluded by false membrane, FIG. 136. Diagram of occlusion and displacement of pupil from iritis after upward extraction of cataract. and the contraction of this may draw the iris towards the scar, so that the pupil is at once blocked and displaced (Fig. 136). In slight cases sight is greatly improved by simply tearing across the membrane and capsule with a fine 370 OPERATIONS. needle, the case being treated for a few days as after needle operations for soft cataract. But in severer cases an arti- ficial pupil must be made, either by iridectomy or iridotomy (p. 357). 2. Solution or discission operations. In these the lens is gradually absorbed by the action of aqueous humor admitted through a wound in the capsule (p. 180). (1) The pupil is fully dilated by atropine; (2) an anaesthetic is given unless the patient is old enough to control himself well, for the slightest movement is attended by risk; (3) the lids are held open by the fingers, or a stop speculum and fixation forceps used ; (4) a fine cataract needle (Fig. 137) is directed to a point a little within the border of the FIG. 137. Cataract needle. cornea (usually the outer border), and when close to its surface is plunged quickly and rather obliquely into the anterior chamber. Its point is then carried to the centre of the pupil (Fig. 138), dipped back through the lens- FIG. 138. Discission of cataract. capsule, and a few gentle movements made so as to break up the centre of the anterior layers of the lens ; (6) the needle is then steadily withdrawn. Special care is to be taken not to wound nor even touch the iris, either on entering or withdrawing the needle, and not to stir up the lens deeply nor too freely. CATARACT. 371 AFTER-TREATMENT. The pupil to be kept widely di- lated with atropine (F. 24), a drop being applied after the operation, and at least six times a day afterwards, or much oftener if there be threatening of iritis. Ice or iced water is in every case to be applied constantly for forty-eight hours after the operation, 1 as for traumatic iritis (p. 143), and the patient to remain in bed in a darkened room for a few days. A little ciliary congestion for two or three days need cause no uneasiness, but the occurrence of pain and increase of congestion with alteration in the color of the iris (commencing iritis), are indications for the appli- cation of leeches near the eye, and the more frequent use of atropine. If the cataract were complete, no marked change will be seen for some weeks ; if partial (e. g., lamellar), the neigh- borhood of the needle wound will become opaque in one or two days. In from six to eight weeks the lens will have become notably smaller (flattened or hollowed on the front surface). If the eye be perfectly quiet, but not unless, the operation may now be repeated in exactly the same way, and with the same after-treatment and precautions, but the needle may be used more freely. The bulk of the lens will generally disappear after the second operation, but the needle often needs to be used a third or a fourth time for the disintegration of small residual pieces, or in order to tear the capsule if it has not retracted enough to leave a clear central pupil. A small whitish dot remains in the cornea at the seat of each needle puncture. 3. Extraction by suction. This operation is applicable to soft cataracts. The eye is thoroughly atropized, and an oblique opening made in the cornea with a keratome or broad needle (Fig. 120) between its centre and margin, 1 I have to thank Mr. Gunn, the late able house-surgeon at Moorfields, for this valuable suggestion. 372 OPERATIONS. and the lens-capsule freely lacerated. The needle being withdrawn, the nose of the syringe is passed through the wound and gently dipped into the lacerated lens substance. Very gentle suction is now used, and the semifluid lens- matter drawn gradually into the syringe. The instrument is not to be passed behind the iris in search of fragments. Nearly the whole of the lens is removed. The after-treat- ment is the same as for needle operations. Two forms of syringe are in use : Teale's, in which the suction is made by the mouth applied to a piece of flexible India-rubber tubing ; Bowman's, in which the suction is obtained by a sliding piston worked by the thumb moving along the syringe. It is often better, and in lamellar cataract neces- sary, to break up the lens freely with a fine needle a few days before using the syringe, and thus allow it to be thoroughly macerated and softened in the aqueous humor ; the patient must be kept in a darkened room, and atropine and ice used freely in the interval between the needle operation and the suction ; and the surgeon must be pre- pared to interfere before the day appointed for the suction should inflammatory symptoms be set up by the rapid swelling of the lens. Suction is a very delicate operation, but in my experi- ence highly satisfactory. If the lens do not easily enter the syringe, it is best to convert the operation into a linear extraction (p. 363, a). PART III. DISEASES OF THE EYE IN RELATION TO GENERAL DISEASES. CHAPTE1I XXIII. IN stating very shortly the most important facts bearing on the connection between diseases of the eye and of other parts of the body, it is convenient to make the following subdivisions : (A) the eye-changes occur as part of a gen- eral disease; (B) the ocular disease is symptomatic of some local malady at a distance ; (C) the eye shares in a local process, affecting the neighboring parts. (For the clinical details of the various eye diseases re- ferred to in this chapter, see Part II. A. General diseases, in which the eye is liable to suffer. Syphilis is, directly or indirectly, the cause of a large proportion of the more serious diseases of the eye. 1. Acquired syphilis. Primary stage. Hard chancres are occasionally seen on the eyelid. I have once seen one far back on the conjunctiva. Secondary stage (sore throat, shedding of hair, eruption, and condylomata). Iritis is common between two and eight or nine months, and does not occur later than about eighteen months, after the contagion ; in considerably more than half the cases both eyes suffer ; there is a marked tendency to exudation of lymph (plastic iritis), shown by 82 ( 373 ) 374 ETIOLOGY. keratitis punctata, haze of cornea, and less commonly by lymph-nodulea on the iris. In some cases there are symp- toms of severe cyclitis with but little iritis ; but the cyclitis of acquired syphilis does not give rise to ciliary staphyloma (compare p. 137). Syphilitic iritis, though sometimes pro- tracted, rarely relapses after complete subsidence. Cho- roiditis and retinitis generally set in rather later, from six months to about two years after the chancre. The two conditions are most often seen together, but either may occur singly ; and in each the vitreous generally becomes inflamed. These conditions are essentially chronic, the retinitis being often, and the choroiditis sometimes, liable to repeated exacerbations or recurrences ; whilst in some cases the secondary atrophic changes progress slowly for years, almost to blindness, often with pigmentation of the retina. Syphilitic choroiditis and retinitis usually affect both eyes, but often in an unequal degree. 1 In a few cases detachment of the retina and secondary cataract occur in secondary syphilis. Keratitis, indistinguishable from that of inherited syphilis, is amongst the rarest events in tha acquired disease; when it occurs it usually does so in the secondary stage. Later periods. Ulceration of the skin and conjunctiva of the lids, gummatous infiltration of the lids, and nodes in the orbit (whether cellular or periosteal) occur but rarely. Oculo-motor paralysis is one of the commonest ocular results of syphilis. It may depend upon gumma (syphilitic neuroma) of the affected nerve in the orbit or in the skull, or upon gummatous inflammation of the dura mater at the base of the skull, matting the nerves together, 1 Choroiditis sometimes occurs at a later stage, in only one eye, and without retinitis, when it deserves to be classed as a tertiary symptom. But these cases are, I believe, much less common than the symmetrical choroiditis (or choroido-retinitis) of secondary syphilis. ETIOLOGY. 375 or on disease of nerve centres, causing ophthalmoplegia externa. The gummatous nerve lesions seldom occur very late in tertiary syphilis. Diseases of the optic nerve in relation to acquired syphilis. The retinitis of the secondary stage affects the disk, and when atrophy of the retina and choroid occur the disk becomes wasted in proportion ; in rare cases the reti- nitis of secondary syphilis is replaced by well-marked pa- pillitis of local origin. Such cases must not be confused with others, equally rare, in which double papillitis, passing into atrophy, occurs with all the symptoms of severe men- ingitis in secondary syphilis. Tertiary syphilitic disease, anywhere within the cranium, commonly causes papillitis, in the same way as do other coarse intracranial lesions ; but gummatous inflammation of the trunk of the optic nerve, or of the chiasma, may also be the cause of descend- ing neuritis. Primary progressive atrophy of the disks occurs in association with locomotor ataxia and ophthalmo- plegia externa of syphilitic origin ; probably in a few instances the optic atrophy occurs alone, or for a time pre- cedes the other changes, in syphilitic, as it is known to do in non-syphilitic, ataxia. 2. Inherited syphilis. In the secondary stage. Iritis corresponding to that iu the acquired disease is seen in a small number of cases, and occurs between the ages of about two and fifteen months. It often gives rise to much exudation, leading to occlusion of the pupil, and is fre- quently accompanied by deeper changes. It is very often symmetrical, and is much commoner in girls than boys. Choroiditis and retinitis, of precisely the same forms as in acquired syphilis, occur at the corresponding period of the disease, i. e., between six months and about three years of age ; and they show as much (some observers think more) tendency to the degenerative and atrophic results already described. In the later stages keratitis, which is the com- 876 ETIOLOGY. monest eye disease caused by inherited syphilis, occurs. It 'is commonest between six and fifteen years old, but is sometimes seen as early as two or three years, and is occa- sionally deferred till after thirty. The disease is frequently complicated with iritis and cyclitis, and, though tending to recovery, shows a considerable liability to relapse. It almost always attacks both eyes, though sometimes at an interval of many months. When the patient is unusually young, the disease as a rule runs a mild and short course. The oculo-motor palsies occur but rarely in inherited syphi- lis, but a few well-authenticated cases are on record. Smallpox causes inflammation and ulceration of the cornea, leading, in the worst cases, to total destruction, but in a large number to nothing worse than a chronic vas- cular ulcer. The corneal disease comes on some days after the eruption (tenth to fourteenth day from its commence- ment), and after the onset of the secondary fever. Iritis, uncomplicated and showing nothing characteristic of its cause, sometimes occurs some weeks after an attack of smallpox. Only in very rare cases do variolous pustules form on the eye, and even then they are always on the con- junctiva, not on the cornea. Scarlet fever, typhus, and some other exanthemata may be followed by rapid and complete loss of sight, lasting a day or two, showing no ophthalmoscopic changes, and end- ing in recovery. Such attacks are believed to be ursemic, or at any rate dependent on some toxic condition of the blood. A peculiarity of these cases is the preservation of the action of the pupils to light. Very severe purulent or diphtheritic ophthalmia sometimes occurs during scarlet fever. Diphtheria. By far the commonest result is paralysis (often incomplete) of the ciliary muscles (cycloplegia) ; the pupils are not affected except in severe cases, when they ETIOLOGY. 377 may be rather large and sluggish. 1 The symptoms gener- ally come on from four to six weeks after the commence- ment of the illness, last about a month, and disappear completely. Diphtheritic cycloplegia is usually, but not invariably, accompanied by paralysis of the soft palate. In most of the cases seen by ophthalmic surgeons, the attack of diphtheria has been mild, sometimes extremely so, the case often being described as "ulcerated throat;" but in- quiry often yields a history of other and severer cases in the family, and of general depression and weakness in the patient, out of proportion to his throat symptoms. We find that most of the patients who apply with diphtheritic cyclo- plegia arc hypermetropic, doubtless because those with normal (and, a fortiori, with myopic) refraction are much less troubled by paresis of accommodation, and often do not find it necessary to seek advice. Concomitant conver- gent squint is sometimes developed in hypermetropic children during the diphtheritic paresis, owing to the in- creased efforts at accommodation (p. 302). Paralysis of the external muscles is occasionally seen ; I have never myself seen any except the external rectus affected, and recovery has been rapid. Diphtheritic and membranous ophthalmia are occasion- ally caused by direct inoculation of the conjunctiva by diphtheritic material from the throat of another person; or by extension up the nasal duct from the nose to the conjunctiva. But in the majority of cases of " diphtheritic " and " membranous " ophthalmia the disease is a local one, in which the inflammation takes on this special form ; and they occur in no ascertainable relation to any infectious disease. No doubt there is often something peculiar in the patient's health, or in the state of his eye-tissues, which gives a proclivity to this kind of inflammation. Diph- theritic ophthalmia of all degrees is more common in 1 Further observations are wanted. 32* 378 ETIOLOGY. young children than in adults. The worst cases generally occur after measles, or during or after scarlet fever, broncho-pneumonia, or severe infantile diarrhoea. Old granular disease of the conjunctiva also confers a liability to a diphtheritic type of inflammation, and the same ten- dency is sometimes seen in ophthalmia neonatorum and in gonorrhoeal ophthalmia. As there seems but seldom any reason to look upon diphtheritic ophthalmia as the local manifestation of a specific blood disease, the term " diph- theria of the conjunctiva" should, I think, seldom be used. Measles is a prolific source of ophthalmia tarsi in all its forms, and of corneal ulcers, particularly of the phlycten- ular forms. It also gives rise to a troublesome muco- purulent ophthalmia, and under bad hygienic conditions this may be aggravated, by cultivation and transmission, into destructive disease of purulent, membranous, or diph- theritic type. Chicken-pox is sometimes followed by a transient attack of mild conjunctivitis. Whooping-cough often, like measles, leaves a proneness to corneal ulcers. In a few rare cases the condition known as ischcemia retina (sudden temporary arterial bloodless- ness) has occurred. Malarial fevers, especially the severe forms met with in hot countries, are sometimes the cause of retinal hemor- rhage (often large and periarterial), and even of consid- erable neuro-retinitis ; where there is much pigment in the blood, the swollen disk may have a peculiar gray color. When real albuminuria is caused by malarial disease, albuminuric retinitis may occur. Relapsing fever is sometimes followed during conva- lescence by inflammatory symptoms with opacities in the vitreous (cyclitis) with or without iritis; recovery takes place. These cases are commoner in some epidemics than in others. ETIOLOGY. 379 Epidemic cerebro-spinal meningitis also, in a few cases, gives rise to acute choroiditis, with pain, chemosis, and great tendency to rapid exudation of lymph into the vitreous and anterior chambers, and often leading to dis- organization of the eye, and blindness. 1 It is believed that the inflammation may either extend to the eye along the optic nerve, or may occur independently in the brain and the eye. Deafness from disease of the internal ear is even commoner than the eye disease. Purpura has been observed in a few cases to be accom- panied by retinal or subretinal hemorrhages; they are sometimes perivascular and linear, and in other cases form large blotches. They have also been found in Scurvy. In Pyaemia one or both eyes may be lost by septic emboli lodging in the vessels of the choroid or retina, and setting up suppurative panophthalmitis. The symptoms are swell- ing of the lids, loss of sight, congestion, especially of the perforating ciliary vessels (Fig. 22), chemosis, discoloration and duluess of aqueous and iris. There may or may not be some protrusion and loss of mobility, and conjunctival discharge. Pain, sometimes very severe, may be almost absent; probably its presence indicates rise of tension. A yellow reflex is often seen from the vitreous. The eye- ball generally suppurates if the patient lives long enough. Sometimes both eyes are affected, together or with an in- terval. In cases of Septicaemia abundant retinal hemor- rhages of large size may occur in both eyes ; they come on a few days before death and are thus of grave significance. As they are not present in typhoid and other fevers of cor- responding severity, their presence is sometimes an aid in differential diagnosis. 1 1 Possibly some of the cases in which similar eye conditions are seen without apparent cause may be the accompaniments of slight and unrecognized meningitis. (See Pseudo-glioma, p. 283.) 3 Gowers, Medical Ophthalmoscopy, 2d edit., p. 255. 380 ETIOLOGY. Lead poisoning is an occasional cause of optic neuro- retinitis leading to atrophy, of atrophy ensuing upon chronic amblyopia, and of rapid and usually transient amblyopia. The former two are the most common; the atrophy, whether primary or consecutive to papillitis, is generally accompanied by very marked shrinking of retinal arteries, and great defect of sight or complete blindness ; it is generally symmetrical, but one eye may precede the other. Other symptoms of lead poisoning, usually chronic but occasionally acute, are nearly always present. Care must be taken not to confuse albuminuric retinitis from kidney disease induced by lead, with the changes here alluded to, which are due in some more direct manner to the influence of the metal. The deposition of lead upon corneal ulcers has been re- ferred to at p. 133. Alcohol. Some observers still hold that alcohol, especi- ally in the form of distilled spirits, may cause a particular form of symmetrical amblyopia (the so-called amblyopia potatorum). The difficulty of arriving at the truth de- pends chiefly upon the fact that most drinkers are also smokers, and that tobacco, whether smoked or chewed, is allowed by all authorities to be one of the causes (or as most now hold, the sole cause) of a similar disease. The question of whether alcohol directly causes disease of the optic nerves will not be settled until observers are much more careful than they have hitherto been to record as typical cases of alcoholic amblyopia, only those in which the patient does not use even the smallest quantity of tobacco in any shape. Magnan thinks alcoholic amblyopia less common than some have supposed. 1 Tobacco. Whatever may be the truth (and it is con- fessedly difficult to arrive at) as to the direct influence of 1 Magnan On Alcoholism, Greenfield's translation, p. 42. ETIOLOGY. 381 alcohol, and of the various substances often combined with it, there is no doubt whatever that tobacco, whether smoked or chewed, does act directly on the optic nerves, and in such a manner as to give rise to definite, and usually very char- acteristic, symptoms. The amblyopia seldom comes on until tobacco has been used for many years. The quantity needed to cause symptoms is, cceteris paribus, a matter of idiosyncrasy, and very small doses will produce the disease in men who in other respects also are unable to tolerate large quantities of the drug. Predisposing causes exert a very important influence: amongst these are to be espe- cially noted increasing age ; nervous exhaustion from overwork, anxiety, or loss of sleep ; chronic dyspepsia, whether from drinking or other causes ; and probably sexual excesses, and exposure to tropical heat (or light). A large proportion of the patients drink to excess, and thus make themselves more susceptible to tobacco, both by injuring the nervous system and the stomach. But some remarkable cases are seen in men who have for long been total abstainers, in others who have lately become ab- stainers without lessening their tobacco, and in yet others who are strictly moderate in alcohol and in whom increas- ing age is the only recognizable predisposing cause. The strong tobaccos produce the disease far more readily than the weaker sorts, and chewing is more dangerous than smoking. Probably alcohol in very moderate doses coun- teracts, rather than increases, the injurious effect of tobacco on the nervous system and optic nerves (Hutchinson). Quinine, taken in very large doses, at short intervals, has in a few cases caused serious visual symptoms. Sight in both eyes may be totally lost for a time, but recovery, more or less perfect, takes place eventually, sometimes in a few days, sometimes not for months. There is great con- traction of the field even after perfect recovery of central vision ; the disks are pale and the retinal arteries extremely 382 ETIOLOGY. diminished. The symptoms are therefore those of almost arrested supply of arterial blood to the retina. Kidney disease. The common and well-known retino- neuritis, associated with renal albuminuria, and of which several clinical types are found, has been already described. It need only be noted that the disease is commonest with chronic granular kidneys and in the kidney disease of pregnancy, but that it is also seen in the chronic forms fol- lowing acute nephritis and in lardaceous disease ; and that it is rare in children. Detachment of the retina is an oc- casional result in extreme cases. The prognosis as regards vision is best in the cases depending on albuminuria of pregnancy. The retinitis is intimately associated with the albuminuria, though the nature of the connection is obscure ; it is not caused by the cardiac hypertrophy which is so often present. The failure of sight caused by albuminuric retinitis has often led to the correct diagnosis of cases which had been treated for dyspepsia, headache, or " biliousness." Diabetes sometimes causes cataract. In young or mid- dle-aged patients the cataract usually forms quickly, and is of course soft. As it is always symmetrical, the rapid formation of double complete cataract, at a comparatively early age, should always lead to the suspicion of diabetes. In old persons the progress of diabetic cataract is much slower, and often shows no peculiarities. The relation of the lenticular opacity to the diabetes has not been satis- factorily explained : the presence of sugar in the lens, the action of sugar or its derivatives dissolved in the aqueous and vitreous, the abstraction of water from the lens owing to the increased density of the blood, and, lastly, degenera- tion of the lens from the general cachexia attending the disease, have all been offered in explanation. In a few cases retinitis occurs attended by great osdema and copious (probably capillary) hemorrhages into the retina and vitreous. In other cases amblyopia from disease of the ETIOLOGY. 383 optic nerves comes on and may closely resemble the central amblyopia caused by tobacco. Leucocythsemia is often accompanied by retinal hemor- rhages, less commonly by whitish spots bordered by blood, and consisting of white corpuscles ; these spots may be thick enough to project forwards. Occasionally there is general haziness of the retina. In severe cases the whole fundus is remarkably pale, whether there be other changes or not. 1 The changes are usually symmetrical. Progressive pernicious anaemia is marked by a strong tendency to retinal hemorrhages ; these are usually grouped chiefly near the disk, and are striated (Gowers). White patches are also common, and occasionally well-marked neuritis occurs. I have seen hemorrhages of different dates, and in one case, shown to me by Dr. Sharkey, there had evidently been a large extravasation from the choroid at an earlier period. The disk and fundus participate in the general pallor. Heart disease is variously related to changes in the eyes and alterations of sight. Aortic incompetence often pro- duces visible pulsation of the retinal arteries. This pulsa- tion differs from that seen in glaucoma by extending in many cases far beyond the disk, and in not being so marked as to cause complete emptying of the larger vessels during the diastole. In glaucoma the pulsation is confined to the disk. The difference is explained by the different mode of production in the two cases ; in the one incomplete closure of the aortic orifice lowers the pressure in the whole blood-column during the diastole, and allows a reflux of blood from the eye ; in the other heightened intraocular tension, telling chiefly on the comparatively yielding 1 For a full account of the changes, see Gowers' Medical Oph- thalmoscopy. Dr. Sharkey has lately shown me a case with diffuse retinitis, very numerous punctiform hemorrhages, chiefly peripheral, and dilatation with extreme tortuosity of the veins. 384 ETIOLOGY. tissues of the optic disk, increases the resistance to the arterial blood. Valvular disease of the heart is generally present in the cases of sudden lasting blindness of one eye, clinically diagnosed as embolism of the arteria centralis retina, but in some of which thrombosis of the artery or of its companion vein, or blocking of the internal carotid 1 and ophthalmic arteries, has been found post-mortem. Brief temporary failure, or loss of sight, is not uncommon in the subjects of valvular heart disease, and in some persons who are liable to recurring headaches (see Megrim). After re- peated attacks of this kind, one eye sometimes fails to recover, and atrophy of the disk comes on ; possibly re- peated temporary failures of retinal circulation at length give rise to thrombosis. In another group of cases which needs investigation, sight fails during successive pregnan- cies or lactations, recovering between times ; some of these may be cases of renal retinitis ; accommodative asthenopia must also be excluded (p. 301). It is probable that high arterial tension predisposes to intraocular hemorrhage in cases where the small vessels are unsound, and that the frequent association of retinal hemorrhage with cardiac disease is thus explained. Acute generalized tuberculosis is sometimes accom- panied by the growth of miliary tubercles in the choroid ; they are most common when there is no meningitis. Chronic large growths of confluent tubercles are occasionally seen in the eye, and may simulate malignant tumors. There is reason to suspect that choroidal tubercles sometimes form in cases of tubercular meningitis which recover, and that certain cases of localized choroiditis not accompanied by serious general symptoms may be of tubercular character. Rheumatism. In acute rheumatism Dr. Barlow informs me that he has more than once seen well-marked conges- 1 Gowers' Medical Ophthalmoscopy, p. 29. ETIOLOGY. 385 tion of the eyes and photophobia ; but neither iritis nor other inflammatory changes occur. The subjects of chronic rheumatism are, however, subject to relapsing iritis. Some of these patients give a history of acute articular rheuma- tism as the starting-point of their chronic troubles, others of a prolonged subacute attack, lasting for many months, whilst in others again the articular symptoms have never been severe. In yet another series a liability to facial or muscular rheumatism, or to recurrent neuralgia from ex- posure to cold or damp, is the only "rheumatic" symp- tom of which a history is given ; in some of these the neuralgia is probably gouty. It is to be remembered that the eye is now and then the first part to be attacked by an inflammation, which later events show to be clearly re- lated to rheumatism or to gout. Gonorrhoaal rheumatism is not unfrequently the starting- point of relapsing iritis and chronic relapsing rheumatism. Rheumatic iritis occurring for the first time in the primary attack of gonorrhceal rheumatism is, in my experience, more often symmetrical than other forms of arthritic iritis, or than the later attacks of iritis in the same patient ; a fact which sometimes makes the distinction between rheu- matic and syphilitic iritis difficult. It is believed that rheumatism is the cause of some cases of non-suppurating orbital cellulitis, and of relapsing epi- scleritis. Rheumatism is also believed to cause some of the ocular paralyses. Gout. Gouty persons are not very unfrequently the sub- jects of recurrent iritis indistinguishable from that which occurs in rheumatism. Rheumatism and gout seem some- times so mixed that it is not always possible to assign to each its right share in the causation of iritis ; but that the subjects of true " chalk gout " are liable to relapsing iritis is undoubted. There is, on the whole, more tendency to insidious forms of iritis in gout than in rheumatism. It is 33 386 ETIOLOGY. also generally believed that the subjects of gout, or persons whose near relatives suffer from it, are particularly subject to glaucoma; acute glaucoma was indeed the "arthritic ophthalmia" of earlier authors. Hemorrhagic retinitis is also commoner in gouty persons than in others ; it may be single or double, and is to be distinguished from albu- min uric retinitis. It has also been observed that the children or descendants of gouty persons, without being themselves subject to gout, are sometimes attacked in early adult life by an insidious form of irido-cyclitis often leading to secondary glaucoma and serious damage to sight j 1 both eyes are attacked sooner or later. The cases in this group probably seem rarer than they are, from the impossibility in many instances of getting a full family history. Several different clinical types may be recognized in the large group of maladies referred to in this section under the name of "iritis." Besides cases of pure iritis, we may distinguish some as cyclitis, in some cases with increase, in others with decrease of tension ; in another group the sclerotic and conjunctiva are chiefly affected (true "rheu- matic ophthalmia" without iritis); a fourth group, in which the pain is disproportionately severe, may be spoken of as neuralgic. In a large majority, however, the iris is the headquarters of the morbid action. All arthritic eye diseases are marked by a strong tendency to relapse ; they usually attack only one eye at a time, though both suffer sooner or later ; and they are all much influenced by con- ditions of weather, being commonest in spring and autumn. The strumous condition is a fruitful source of superficial eye diseases, which are for the most part tedious and re- lapsing, are often accompanied by severe irritative symp- toms, but, as a rule, do not lead to serious damage. The best types are (1) the different varieties of ophthalmia 1 Hutchinson, Lancet, Jan. 1873. ETIOLOGY. 387 tarsi ; (2) all forms of phlyctenular ophthalmia (" pus- tular" or "herpetic" diseases of the cornea and con- junctiva) ; (3) many superficial relapsing ulcers of cornea in children and adolescents, though not distinctly phlyc- tenular in origin, are certainly strumous ; (4) many of the less common, but very serious varieties of cyclo-keratitis in adults occur in connection with lowered health, suscepti- bility to cold, and sluggish but irritable circulation, if not with decidedly scrofulous manifestations ; (5) lupus is, of course, a strumous disease, whether attacking the parts around the eye or other parts. Entozoa sometimes come to rest and develop in the eye or orbit. The commonest intraocular parasite is the cysti- cercus celluloses; it is excessively rare in this country, but commoner on the Continent. The cysticercus may be found either beneath the retina, in the vitreous, or upon the iris, and may sometimes be recognized in each of these positions by its movements. The parasite has been successfully ex- tracted from the vitreous ; when situated on the iris its removal involves an iridectomy. Sometimes it develops under the conjunctiva, where I have seen it set up sup- purative inflammation. The echinoeoccus hydatid with multiple cysts may develop to a large size in the orbit, and cause much displacement of the eyeball. B. Eye disease, or eye symptoms, indicative of local dis- ease at a distance. Megrim is well known to be sometimes accompanied or even solely manifested by temporary disorder of sight. This generally takes the form of a flickering cloud (" flit- tering scotoma " of German authors) with serrated borders, which, beginning near the centre of the field, spreads eccentrically so as to produce a large defect in the field, a sort of hemianopsia; the borders of the cloud may be brilliantly colored. It affects both eyes, and is visible when the lids are closed. The attack lasts only a short 388 ETIOLOGY. time, and perfect sight returns. In many patients this amblyopia is the precursor of a severe sick headache, but in others it constitutes the whole attack ; it never follows the headache. Less definite and characteristic symptoms (dimness, cloudiness, or nauscsc) are complained of by some patients. Neuralgia of the fifth nerve, especially of its first divi- sion, in a few cases precedes or accompanies failure of sight in the corresponding eye with neuritis or atrophy of the disk (p. 240, 3). A liability to neuralgia of the face and head is not unfrequently observed in persons who subse- quently suffer from glaucoma. Intense neuralgic pain in the face or head sometimes causes dimness of sight of the same eye, whilst the pain lasts. The old belief that injury to branches of the fifth nerve can cause amaurosis is not borne out by modern experience, injury to the optic nerve by fracture of the skull furnishing the true explanation of such cases (p. 237). Sympathetic ophthalmitis is the only known instance in which inflammation of the eyeball is caused by local dis- ease of an independent part. Diseases of the central nervous system may be shown in the eye either at the optic disk (papillitis and atrophy), or in the muscles (strabismus and diplopia). The diseases which most often cause papillitis are intra- cranial tumors, syphilitic growths, and meningitis. Abscess of the brain and softening from embolism and thrombosis less commonly cause it, and cerebral hemorrhage scarcely ever. Papillitis has been found in a few cases of acute and subacute myelitis; 1 it does not occur in spinal meningitis. In a very large proportion (Dr. Gowers thinks at least four-fifths) of all the cases of cerebral tumor (including syphilitic growths) neuritis occurs at some period. The 1 Gowers, loc. cit, p. 161 ; Dreschfeld, Lancet, Jan. 7, 1882. ETIOLOGY. 389 severity and duration of the neuritis vary much, and prob- ably depend in many cases on the rate of progress, as well as on the character, of the morbid growth. It not uncom- monly sets in at no long interval before death, whilst in other cases it is very chronic. There is nothing in the characters or course of the neuritis to help us in the locali- zation of intracranial tumor; and except that a very high degree of neuritis, with signs of great obstruction to the retinal circulation, generally indicates cerebral tumor, the pathological character of the intracranial disease, whether tumor, meningitis, or syphilitic disease, is not much eluci- dated by the mere occurrence of papillitis. Tumors also sometimes cause simple optic atrophy by pressing upon or invading some part of the optic fibres. Intracranial syphilitic disease is a common cause of papillitis, the disease being either a gummatous growth in the brain, or a growth or thickening beginning in the dura mater, or basilar meningitis. The prognosis is much better than in cerebral tumors if vigorous treatment be adopted early, and in all cases of papillitis, where intracranial dis- ease is diagnosed and syphilis even remotely possible, mercury and iodide of potassium should be promptly given. Meningitis often causes papillitis, but in this respect much depends on its position and duration. Meningitis limited to the convexity, whatever its cause, is seldom ac- companied by ophthalmoscopic changes; on the other hand, basilar meningitis very often causes neuritis. The neuritis in basilar meningitis is probably proportionate to the duration and intensity of the intracranial mischief, being comparatively slight in acute and rapidly fatal cases, whether tubercular or not. In tubercular cases the disease se^ms especially related to the occurrence of inflammatory changes about the chiasma (Gowers) ; and the neuritis in cases of cerebral tumor also seems sometimes to be caused 33* 390 ETIOLOGY. by secondary meningitis set up by the growth. When patients recover from meningitis the neuritis may pass into atrophy and cause amaurosis; such cases are commonest in children, and form a group, well known to ophthalmic surgeons; it is probable that some of them may be in- stances of recovery from tubercular meningitis. In rare cases papillitis occurs with severe head symptoms, ending in death, but without microscopic changes in the brain or membranes. Microscopical changes in the brain substance, justifying the term cerebritis, have been found in one such case by Dr. Button, and in another by Dr. Stephen Mac- kenzie. It must not be forgotten that optic neuritis may be caused by various altered conditions of the blood ; and that it is occasionally seen without any evidence either of central nervous disease or of a morbid state of the blood. Cerebral tumors also sometimes cause atrophy from press- ure, without papillitis. Hydrocephalus rarely causes papillitis, but often at a late stage causes atrophy of the optic nerves from the pressure of the distended third ventricle on the chiasma. Dr. Barlow informs me that he has several times seen a very gross form of choroiditis ending in immense patches of atrophy; I have recorded one such case and seen others. The diseases most commonly causing atrophy not pre- ceded by papillitis are the chronic progressive diseases of the spinal cord, especially locomotor ataxia. The atrophy in these cases is slowly progressive, double, though seldom beginning at the same time in both eyes, and it always ends in blindness, although sometimes not until after many years. Similar atrophy sometimes occurs in the early stages of general paralysis of the insane, but chiefly in cases complicated by marked ataxic symptoms. It is also, but much more rarely, seen in lateral and in insular sclerosis. In the latter, amblyopia without ophthalmo- ETIOLOGY. 891 scopic changes is occasionally seen, and sight may improve or almost recover after having been defective for some time. Motor disorders of the eyes. Some of the commoner causes of ocular palsy have been already given. It may be mentioned here that basilar meningitis often causes paralysis of one or more of the ocular nerves with squint- ing (and double vision if the patient be conscious), and further, that the palsy in such cases often varies, or appears to vary, from day to day. Locomotor ataxia and general paralysis of the insane are sometimes preceded by paralysis (usually temporary) of one or more of the eye muscles, causing diplopia ; and there may for years be nothing else to attract attention. The same diseases may also be ushered in by internal ocular paralysis. The most frequent variety is loss of the reflex action of the pupils whilst their associated action remains ; when shaded and lighted they remain absolutely motion- less, but they dilate when accommodation is relaxed and contract when it is in action (p. 39). This phenomenon is known as the "Argyll Robertson symptom." 1 It is often, though by no means always, associated with a permanently contracted state of the pupils, and hence the term "spinal myosis" is often, but incorrectly, used. This reflex pa- ralysis of the iris is one of the most valuable of the early signs of locomotor ataxia. We do not, however, yet know how often it may occur in healthy persons or without eventual spinal disease; it certainly has comparatively little significance in old persons. The complementary symptom, loss of associated, with retained reflex, action of the pupils has not been fully studied. Any of the other internal paralyses may also in certain cases occur as a pre- cursor of ataxia. Paralysis of one third nerve coming on 1 Argyll Robertson, Edinburgh Med. Journ., 1869, 703. ETIOLOGY. with hemiplegia of the opposite side may, but does not necessarily, indicate disease of the cms cerebri on the side of the palsied third nerve. 1 Ophthalmoplegia externa has been already mentioned ; it may here be added that cases occur in which this condition appears to be " functional," in which at any rate the symptoms come on quickly and pass off completely, coming on again perhaps at a later period ; of these cases, I have seen several in young adults. Ophthalmoplegia externa is the extreme type of a large and important class of ocular palsies, to which much atten- tion has been given recently, characterized by the paralysis of certain movements (usually associated movements of the two eyes), not of the muscles supplied by a certain nerve. There may, e. g., be loss of power of both eyes to look up- wards (both superior recti) or loss of power to look to the right (R. external and L. internal rectus) ; and yet in the latter case the L. internal rectus if differently associated, as with the R. internal during convergence, may act per- fectly well. Such associated paralyses are explained by lesions affecting the centres for certain combined move- ments, which are more 'central anatomically and higher physiologically, than the centres of origin of the nerve- trunks. The symptoms may be temporary or permanent, acute or chronic, and caused by various fine or coarse anatomical changes; and they are frequently associated with other and graver nervous symptoms. From the ophthalmic point of view, it is of great importance to make the differential diagnosis between cases of peripheral palsy due to disease of the trunks of the third or other ocular nerves, and cases of associated palsy which should usually be relegated to the physician. Insular (disseminated) sclerosis is often accompanied by 1 For exceptions, see Robin, Troubles Oculaires dans lea Mai. de l'Ence"phale, 1880, p. 95. ETIOLOGY. 393 nystagmus, characterized by irregularity, both of the am- plitude and rapidity of the movements. There appears to be an intimate relation between the occurrence of Convulsions and the formation of lamellar cataract, this form of cataract being scarcely ever seen except in those who have had fits in infancy. A very striking deformity of the teeth is also nearly always present, depending upon an abruptly limited deficiency or absence of the enamel on the part furthest from the gum. The teeth affected are the first molars, incisors, and canines, of the permanent set. The dental changes are quite different from those which are pathognomonic of inherited syphilis, although mixed forms are sometimes seen. The relation between the convulsions, the cataract, and the defective dental enamel has not been satisfactorily explained. Mr. Hutchinson has collected many facts in favor of the belief that the dental defect is due to stomatitis interfering with the calcification of the enamel before the eruption of the teeth, and that mercury is the commonest cause of this stomatitis. On this hypothesis the coincidence of the dental defect and the cataract is due to mercury having been usually prescribed for the infantile convulsions from which these cataractous children suffer. There also seems, how- ever, much probability in the supposition that the defect of the crystalline lens and of the enamel, both of them epi- thelial structures, may be caused by some common in- fluence ; although the facts that the peculiar teeth are often seen without the cataract, and the cataract occa- sionally seen with perfect teeth, appear to weaken this view. C. Cases in which the eye shares in a local process affect- ing the neighboring parts. In herpes zoster of the first division of the fifth nerve the eye participates. When only the supra-orbital or supra-trochlear branches are attacked, the eyeball usually 394 ETIOLOGY. escapes, or is only superficially congested. But if the eruption occur on the parts supplied by the nasal branch (i. e., if the spots extend down to the tip of the nose), there is usually inflammation of the proper tissues of the eyeball (ulceration or infiltration of cornea, and iritis) ; for the sensitive nerves of the cornea, iris, and choroid are derived, through the long root of the ophthalmic ganglion, from the nasal branch. Occasionally the eye suffers, however, when the nasal branch escapes. The pain and swelling of the herpetic region are often so great that the attack gets the name of "erysipelas." In rare cases paralysis of the third and atrophy of the optic nerve occur with the herpes. In paralysis of the first division of the fifth the cornea and conjunctiva are anaesthetic ; the cornea may be touched or rubbed without the patient feeling it at all. In many cases ulceration of the cornea, usually uncontrollable and destructive in character, takes place. It is doubtful whether this is due directly to paralysis of trophic fibres running in the trunk of the fifth, or indirectly to the an- aesthesia. The ansesthesia operates first by allowing injuries and irritations to occur unperceived, and, secondly, by re- moving the reflex effect of the sensitive nerves on the calibre of the bloodvessels, and thus permitting inflamma- tion to go on uncontrolled. In paralysis of the facial nerve the eyelids cannot be shut, and the cornea remains more or less exposed. When a strong effort is made to close the lids the eyeball rolls up- wards beneath the upper lid. Epiphora is a common result of facial palsy. Severe ulceration of the cornea may result from the exposure. Paralysis of the cervical sympathetic causes some nar- rowing of the palpebral fissure from slight drooping of the upper lid, apparent recession of the eye into the orbit, and more or less myosis from paralysis of the dilator of the pupil (p. 329). No changes are observed in the calibre of ETIOLOGY. 395 the bloodvessels of the eye. The pupil is said to be less contracted after division of the sympathetic trunk than when the trunk of the fifth (and Avith it the oculo-sympa- thetic fibres) is cut, and knowledge of this may be now and then useful in diagnosis. In exophthalmic goitre the eyeballs are too prominent, and the protrusion, though not always quite equal, is almost invariably bilateral. It is often apparently in- creased in slight cases by an involuntary and excessive retraction of the upper lids, especially when the patient looks down. In severe cases the proptosis may be so great as to prevent full closure of the lids, and in these ulceration of the cornea, is to be feared. In such cases it is beneficial to shorten the palpebral fissure by uniting the borders of the lids at the outer canthus, or even to unite the lids in their whole length (p. 338). No changes are present in the fundus, excepting sometimes dilatation of arteries and spontaneous arterial pulsation. Erysipelas of the face sometimes invades the deep tissues of the orbit and causes blindness by affecting the optic nerve and retina. On recovering from the erysipelas in such a case the eye is found to be blind and the ophthalmo- scope shows either simple atrophy of the disk, or signs of past retinitis also. Other forms of orbital cellulitis may lead to the same result. Note on the teeth in hereditary syphilis. None of the first set of teeth are characteristically altered, though the incisors frequently decay early. In the permanent set only two teeth, the central upper incisors, are to be relied upon; but the other incisors, both upper and lower, and the first molars, are often deformed from the same cause. The characteristic change in the upper central incisors appears to depend upon defective formation of the dentine, and in a less degree of the enamel, of the central lobe of the tooth. Soon after the 396 ETIOLOGY. eruption of the tooth this lobe wears away, leaving at the centre of the cutting edge a vertical notch. If the cause have acted so intensely as entirely to prevent the develop- ment of the central lobe, we find, instead of the notch, a narrowing and thinning of the cutting edge in comparison with the crown, and this, according to its degree, produces a resemblance to a screw-driver, or to a peg. The teeth are also usually too small in every dimension, so that the incisors are often separated from one another by consider- able spaces. In extreme cases all the incisors are peggy and much dwarfed. APPENDIX FORMULAE, ETC. NITRATE OF SILVER : 1. Mitigated Solid Nitrate of Silver : Nitrate of Silver 2, Nitrate of Potash 1. Fused together and run into moulds to form short, pointed sticks. Used for granular lids and purulent ophthalmia. The strength above given is known as No. 1, and is that which I generally use; three weaker forms are made, known as Nos. 2, 3, and 4, containing respectively 3, 3, and 4 parts of nitrate of potash to 1 of nitrate of silver. Pure nitrate of silver is never to be used to the conjunctiva. 2. Solutions of Nitrate of Silver : (1) Nitrate of Silver gr. x or xx, Distilled Water j. Used by the surgeon for purulent ophthalmia, recent granular lids, and some cases of ulcer of the cornea. 3. (2) Nitrate of Silver gr. j or ij, Distilled Water |j. Used by the patient in various forms of acute ophthalmia; only a few drops to be used at a time, and not more than three times a day. All solutions of nitrate of silver should be kept either in a deep-blue bottle, or in a dark place. SULPHATE OF COPPER : 4. A crystal of Pure Sulphate of Copper, smoothly pointed may be used for touching granular lids of old standing. 5. Lapis Divinus : Sulphate of Copper 1, Alum 1, Nitrate of Potash 1. Fused together, and camphor equal to -^ of the whole added. The preparation is run into moulds to form sticks. It should be kept in a stoppered bottle. Largely used for the treatment of chronic granular lids. 34 398 APPENDIX. LEAD LOTION : 6. Liquor Plumbi Subacetatis (B. P.) gj, Distilled Water Oj. (1 in 160.) Used in chronic conjunctivitis, when the cornea is sound, and in inflammation of the eyelids and lachrymal sac. SPIRIT LOTION : 7. Eectified (or Methylated) Spirit giv, Water ^xvj. Used as an evaporating lotion to allay or prevent inflammation of the wound after operations on the eyelids. 8. Lead and Spirit Lotion : Spirit Lotion Oj, Liquor Plumbi Subacetatis (B. P.) gij. Used in the same cases when there is no fear that the cornea is abaded or ulcerated. A better antiphlogistic than spirit alone. MERCURY : 9. Calomel Powder : Used for dusting on the cornea in some cases of ulceration. It is flicked into the eye from a dry camel-hair brush. 10. Yellow Oxide of Mercury ("Yellow ointment,'' 1 " Pagen- stecher's ointment ") : Yellow Oxide of Mercury gr iij, Vaseline zj. (1 in 20.) 11. A weaker preparation, containing gr. j of the Yellow Oxide to gj (1 in 60), is sometimes useful. Used in many cases of corneal ulceration and recent corneal nebulae, a morsel as large as a hemp-seed being inserted within the lower lid by means of a small brush once or twice a day. It is also suitable for ophthalmia tarsi. 12. Yellow Ointment with Atropine : Yellow Oxide of Mercury gr. iij, Sulphate of Atropia gr. , Vaseline j. Used in -the same way as 10 and 11. 13. Red Oxide of Mercury :. Red Oxide of Mercury gr. iij, Vaseline ^j. Used for ophthalmia tarsi, etc. Was formerly used for corneal ulcers and nebulae; but the yellow oxide, which being made by precipitation is not crystalline, is now generally preferred because less irritating. APPENDIX. 399 14. Nitrate of Mercury (Citrine Ointment}: Unguentum Hydrargyri Xitratis (B. P.) gj, Vaseline or Prepared Lard 3vij. Used in the same cases as 13. SULPHATE OF ZINC: 15. Sulphate of Zinc gr. j or ij, Water or liose Water Jj. CHLORIDE OF ZINC: 16. Chloride of Zinc gr. ij, Water 5J, If there is a deposit, add of Dilute Hydrochloric Acid, just enough to make a clear solution. ALTTM: 17. Alum gr. iv to gr. x, Water |j. The above lotions are in common use in the milder forms of acute and chronic ophthalmia. The chloride of zinc occasionally irritates; it is especially used in purulent and severe catarrhal ophthalmia instead of the weak nitrate of silver lotions. The stronger alum lotion is often used in the same cases. The alum and sulphate of zinc lotions may be used unsparingly to the conjunctiva; the chloride, even in severe cases, not more than six times a day. CARBONATE OF SODIUM: 18. Carbonate of Sodium gr. x, Water I). Used for softening the crusts in severe ophthalmia tarsi. A small quantity of the lotion, diluted with its own bulk of hot water, to be used for soaking the edges of the eyelids for ten or fifteen minutes night and morning. TAR AND SODA: 19. Carbonate of Sodium giss, Liquor Carbonis Deterg^ens gj to $ss, Water to Oj. Used in the same cases as the last. BORAX: 20. Biborate of Sodium gr. x, Water ^j. Used in the same cases as the last. QUININE LOTION : 21. Sulphate of Quinine gr. iij, Acid Sulph. dil. (B. P.), just enough to dissolve, Water gj. Used in diphtheritic ophthalmia. 400 APPENDIX. BORACIC ACID LOTION: 22. Boracic Acid 4, Water 100 by weight. Used as an antiseptic before and after operations on the eyeball, and in the treatment of suppurating ulcers of the cornea. CARBOLIC ACID LOTION: 23. Absolute Phenol 5, Water by weight 100. Used in purulent ophthalmia. It is very important to use absolutely pure carbolic acid for application to the conjunctiva. Severe irritation often follows if any other varieties are employed. MYDRIATICS AND MYOTICS : 24. (1) Strong Atropine Drops : Liquor Atropiae Sulphatis (B. P.) (Sulphate of Atropia gr. iv, Distilled water ^j). Used in all cases where the rapid and full action of the drug is required. Atropine (a single drop, of 2 grains to 5], or about .5 percent.) begins to act on the pupil in about 15 minutes, and on the accommodation a few minutes later; it produces full dila- tation of the pupil (9 mm.) in 30 to 40 minutes, and full paraly- sis of accommodation in about 2 hours. Both remain at their height for 24 hours, and the effect does not pass off entirely till from 3 to 7 days, the accommodation recovering rather sooner than the pupil. If stronger solutions be used several times, the action continues longer. Atropine is absorbed into the aqueous humor and acts locally vipon the iris. The effects of atropine are only very temporarily overcome by eserine. 25. (2) Weak Atropine Drops : Sulphate of Atropia gr. J, Distilled water gj. Used when, for optical purposes, it is desired to keep the pupil dilated for a long time, as in immature nuclear cataract. A single drop about three times a week will generally suffice. Solutions of sulphate of atropine keep for an indefinite time; the flocculent sediment which often forms does not impair their efficiency. The addition of 1 part of carbolic acid to 1000 of the solution is said to prevent "atropine irritation." The liquor atropine (B. P.), which contains rectified spirit, is irritating to the eye and should not be used. 26. Daturine : Sulphate of Daturia gr. iv Distilled water j. Used as a mydriatic in cases where atropine causes conjunctiva! irritation. APPENDIX. 401 27. Duboisine : Sulphate of Duboisia gr. j. Distilled water gj. A new mydriatic, acting more quickly and powerfully, and passing off in a shorter time, than atropine. Is tolerated in cases where atropine causes conjunctivitis. To be used with caution, as well-marked toxic symptoms are sometimes caused. Duboisine begins to act on the pupil and accommodation in less than 10 minutes, produces full mydriasis in less than 20 minutes, and complete cycloplegia in about 1 hour. The maximum effect does not last quite as long as, and the effect passes off completely rather sooner than, that of atropine. Duboisine seldom breaks down iritic adhesions which have already resisted atropine. Ita chief use seems to be for cases in which atropine causes irritation. 28. Homatropine : Hydrobromate of Homatropine gr. iv, Distilled water 3jj. A new mydriatic, acting rather more quickly and passing off much sooner than atropine; very convenient, therefore, for di- lating the pupil for ophthalmoscopic examination. Homatropine begins to act on the pupil and accommodation in from 5 to 10 minutes; the greatest dilatation of pupil (usually, however, rather less than that obtained by atropine) is reached in about 35 minutes, and complete, or nearly complete cycloplegia in an hour or rather less (with a solution of gr. iv to ^j). The greatest effect is only maintained, however, for an hour or two, and both pupil and accommodation usually recover completely in 24 hours or less. 29. Eserine (the Alkaloid of Calabar Bean) : Sulphate of Eseria gr. iv, Distilled water ^j. Used in mydriasis and paralysis of the accommodation whether caused by atropine or by nerve lesions, in some forms of corneal ulcer, and in acute glaucoma. 30. A weaker solution (gr. j to ^j) is often better borne. Eserine begins to act on the pupil and accommodation in about 5 minutes; its maximum effect is reached in 15 to 30 minutes. Its effect on the accommodation lasts only an hour or two, but the pupil does not completely recover for many hours, sometimes 2 or 3- days. After several weeks' use the effects last longer, but never as long as those of atropine. A very weak solution acts only on the pupil, not on the accommodation. Eserine causes pain in the eye and head, and twitching of the orbicularis ; the pain, some- times severe, seldom lasts long. All the mydriatics and myotics may be obtained in the form of 34* 402 APPENDIX. small gelatine disks of known strength (made by Savory and Moore), which are sometimes more convenient than the solutions. Of the mydriatics, homatropine and duboisine are much the most expensive (about Is. 6d. a grain). Eserine sulphate is also expen- sive (about Is. a grain). Atropine sulphate costs rather more than Id. a grain. 31. Belladonna Fomentation : Extract of Belladonna ^j to.^ij, Water Oj. Warmed in a cup or small basin and used as a hot fomentation in suppurating and serpiginous ulcers of cornea. 32. Pilocarpine for Subcutaneous Injection: Hydrochlorate of Pilocarpine gr. v, Distilled water gj. Dose, 3 minims, gradually increased, to be injected daily or less often. Used in cases of retinal detachment, choroiditis, and retinitis. 32A. Pilocarpine Drops, gr. iv. to ^j. Pilocarpine is a myotic like eserine, but its action is much weaker. 33. STRYCHNIA /or Subcutaneous Injection: Liquor Strychnise (B. P.) gr. iv, to ^j. Dose, 2 minims ($ grain), gradually increased, for subcutaneous injection. To be injected once a day. IODOFORM. This substance seems likely to be of real service in some forms of ophthalmia, especially in purulent, gonorrhceal, and granular cases. It is reported to arrest discharge more quickly than nitrate of silver, and its application is certainly far less painful. It may either be dusted with a brush on the everted lids once a day, or used as an ointment made with vaseline. The iodoform must be very finely powdered, or its crystals will cause mechanical irritation. Mr. Jennings Milles, house-surgeon at Moorfields, tells me that he finds an ointment of gr. xv to ^j a convenient strength for most cases. At the last Ophthalmological Congress at Heidelberg the strength advised was gr. xxx to ^j. I have not yet used iodoform enough to draw any conclusions. DISEASES OF CANALICULUS. The canaliculus is occasionally plugged by the growth in it of a mycelial fungus, which mingled with pus cells and mucus forms a yellowish, or greenish, putty- like concretion. These masses sometimes calcify, and are then called " dacryo-liths." 34. BANDAGES for the eyes may be of thin flannel or soft calico. A linen or knitted cotton bandage, about ten inches long, APPENDIX. 403 with four tails of tape, or a loop of tape embracing the back of the head (Liebreich's bandage), is very convenient after the more serious operations. An ordinary narrow llannel bandage is better when much pressure is wanted, or if the patient be unruly. When absolute exclusion of light is desired, it is best to use a bandage made of a double fold of some thin black material. Fine old linen is better than lint for laying next the skin in dressings after operations. 35. SHADES may be made of thin cardboard covered with some dark material, or of stout dark-blue paper, like that used for making grocers' sugar bags. Shades of black plaited straw are also very light and convenient. Shades, to be effectual, should extend to the temple on each side, so as to exclude all side light. 36. PROTECTIVE GLASSES : Various patterns of glasses are made for the purpose of. pro- tecting the eyes from wind, dust, and bright light. The glasses are either flat or hollow like a watch glass, and are colored in various shades of blue or smoke tint. The most effectual are the ones known as "goggles; " in these the space between the glass and the edge of the orbit is filled by a carefully fitting framework of fine wire gauze or black crape, by which side-wind and light are excluded. A small air-pad of thin India-rubber tubing makes the frame fit still more closely. Other forms, known as "horseshoe " or " D," and "domed " or " hollow," glasses are also in common use. 38. OPHTHALMOSCOPES : It is impossible to say that any ophthalmoscope is the best. When expense is not a great object it is always better to have one of the so-called "refraction ophthalmoscopes." In these a num- ber of small lenses are placed in a disk behind the mirror, the disk being made to revolve by the pressure of the finger against its edge so as to bring the lenses one after another opposite the sight-hole. The use of the lenses is explained at p. 75. For medical ophthalmoscopy it is not essential to have so many lenses ; about four concave and two convex will enable an erect image to be easily obtained in most cases. Liebreich's "small" ophthalmoscope and Oldham's ophthalmoscope are both very convenient forms for general use, and cost less than half as much as the refraction instruments. Of the refraction ophthalmoscopes there are now a great many patterns differing in the number and size of the lenses, the size of the mirror and lens-bearing disk, and other details. Usually the disk contains 20 to 24 lenses, and one empty circle. In the simpler forms about half the lenses are -f- and half . But in others the number of powers is immensely increased by combining lenses of different strengths, e.g., the disk may contain 24 + lenses, whilst a single movable lens, rather stronger than the 404 APPENDIX. highest -f- is placed behind the disk over the sight-hole; by using it alone or placing it in succession over the various -f- lenses a series of 25 powers, or 49 in all, will be obtained. In order to avoid the error caused by looking obliquely through a lens, some of the more elaborate instruments (Loring's, Couper's, Fox's, e. g.) are so arranged that the mirror can be sufficiently inclined to re- ceive the light whilst the lens-bearing disk remains at right angles to the observer's line of sight. Generally speaking, the English and American instruments are much better made than the French. Of the simpler forms, the one introduced by Dr. Gowers is in my experience (with one or two minor alterations) very convenient and efficient. Of the more expensive forms, an instrument lately introduced by Mr. "Webster Fox, late house-surgeon at Moorfields, is undoubtedly one of the best, both the design and the workman- ship being extremely good. In a good refraction ophthalmoscope the mirror should be thin and the sight-hole perforated ; the lens- disk thin and working as close to the back of the mirror as pos- sible ; the lenses evenly mounted, centred truly, easily accessible for cleaning, and not less than 5 mm. in diameter. INDEX. ABBREVIATIONS, 13 Abscess of cornea, 117 episcleral, 146 of lachrymal gland, 89 sac, 92 orbital, 159, 280 Abrasion of cornea, 164 Accommodation, examination, 44 errors of, 287 in myopia, 296 influence of age, 317 refraction, 317 paralysis of, 329, 375 relative, 45 spasm of, 290 Accommodative asthenopia, 244, 301 Acuteness of sight, 27 Albinism, 202 Albuminuric retinitis, 207, 215 Alcohol amblyopia, 242, 380 Amaurosis (blindness without visible changes in any part of the eye; also applied to blindness from optic or ret- inal atrophy), 238 Amblyopia (defective sight with- out visible changes; also from haze of media and optical de- fects), 238 alcohol, 242, 380 from defective images, 239 suppression, 238 hysterical, 244 pctatorum, 380 tobacco, 241, 380 Ametropia (any permanent error of refraction of the eye), 287 Anisometropia (unequal refrac- tionin the two eyes), 316 Anterior focus of eye, 26 polar cataract, 174, 175 staphyloma, 148 Apparent size of objects, 45 Arcus senilis, 132 inflammatory, 133 Artificial pupil, 354 Asthenopia (weakness of eyes: eyes that cannot be used for long. See also Hyper- metropia, Myopia, Ambly- opia.). accommodative, 244, 301 muscular, 244, 300 retinal, 244 Astigmatism, 308 measurement by ophthalmo- scope, 76 traumatic, 164 Atrophy of optic disk (see also Neuritis), 232 clinical aspects, 234 local causes, 233 primary, 235 progressive, 235 with spinal disease, 236, 390 choroid, 190 retina, 210, 221 Atropine for examination of eye, 61, 66, 400 effects on tension, 119, 267 in cataract, 182 corneal ulcers, 122, 123 glaucoma, 267 iritis, 141 irritation, 103 Axis, optic, of eye, 33 principal, 17 secondary, 17 visual, 26 ( 405 ) 406 INDEX. BANDAGES, 402 Bandaging in iritis, 142 ophthalmia, 100 suppuration after cataract ex- traction, 185 ulcers of cornea, 122 Basedow's disease (see Goitre). " Black eye," 158 Blennorrhcea of conjunctiva, 95 Blepharitis, 81 Blepharospasm (spasmodic clos- ure of eyelids), 112 Blindness of one eye, undiscov- ered, 240 Bloodvessels of eye, external, 35 retina, 203 Blows on eyeball, 161 Brain (see Cerebral). Burns of eye, 165 CANALICULI, disease, 91 Can thus, section of, in blepharo- spasm, 121 Cataract, 171 anterior polar, 175 atropine in, 182 choroidal changes with, 200 concussion, 180 congenital, 180 cortical, 172, 178 diabetic, 172, 382 diagnosis, 176 discission, 182 dotted cortioal, 173 extraction, 182, 362 glasses, 186 hard, 172 lamellar, 173, 178, 186, 393 mixed, 172 Morgagnian, 181 nuclear, 172, 177 operations for, 182, 362 over-ripe, 183 posterior polar, 175, 178 primary, 175 prognosis, 181 pyramidal, 173 secondary, 175, 187 sight after removal, 186 soft, 171 solution, 182 Cataract, suction, 183 symptoms of, 175 traumatic, 180 treatment of, 182 zonular (see Lamellar;. Catarrhal ophthalmia, 99 Caustics, injuries by, 165 Cellulitis of orbit, 159, 395 Central scotoma, 241 Centre of movement of eye, 26 Cerebral tumors, neuritis in, 388 syphilis, 389 Cerebritis, neuritis in, 389 Chalazion (Meibomian cyst), 84 Chancre of eyelid, 87, 373 Chemosis (oedema of the ocular conjunctiva, either passive or inflammatory), 96 Choked disk, 226 Cholesterine in vitreous, 253 Choroid, appearances in health, 189 in disease, 190 atrophy, 190 colloid disease, 195 coloboma, 202 congestion, 201 diseases, 188 exudation, 194 hemorrhage, 195, 196, 201 myopic changes, 199 rupture, 195 sarcoma, 283 tubercle, 194, 286 Choroidal disease with cataract, 200 Choroiditis, central, 199 disseminata, 197 in hydrocephalus, 390 senile, 199 syphilitic, 194, 197, 374 unclassed or anomalous, 201 Chronic ophthalmia, 109 Ciliary congestion (see Conges- tion). muscle, paralysis of, 163, 329 region, diseases of, 145 Cold in iritis, 143 Color blindness, 235, 248 defect in amblyopia, 241 perception, 249 INDEX. 407 Color perception, examination, 45, 249 of railroad employes, 47 Coloboma of choroid (congenital cleft in choroid), 201 of iris (cleft in iris usually restricted to the congenital form, but sometimes applied to the cleft made by iridec- tomy), 144, 355 "Commotio retince," 164 Congenital absence of iris, 144 cataract, 180 coloboma (see Coloboma). dermoid cyst, 275 tumor, 277 nbro-fatty growth, 277 irideremia, 144 ptosis, 88 Congestion, ciliary, 37, 112, 134 circumcorncal, 134 cboroidal, 201 conjunctiva!, 38 episcleral, 38 of optic disk, 206, 226 retinal, 206 Conical cornea, 124 Conjunctiva, diseases, 95 burns and scalds, 165 epithelioma, 277 growths, 275 Conjunctivitis (see Ophthalmia). Convulsions and lamellar cata- | ract, 393 Coredialysis (separation of iris from its ciliary attachment), 162 Cornea, abrasion, 1G4 abscess, 117 diseases of, 110 ulceration, 111 atropine, 122, 123 eserine, 123 fomentation, 122 iridectomy, 123 iritis in, 117 paracentesis, 123 phlyctenuiar, 113 recurrent vascular, 115 serpiginous, 116 suppurating, 117 Cornea ulceration, treatment, 119 examination, 30 lead deposit ou, 133 transverse calcareous opacity of, 131 Corneal disease, seton for, 121, 129 section for ulcer, 123 Cortical cataract, 172, 177 Crescent, myopic, 199, 292 Croupous ophthalmia, 101 Cupping of disk in glaucoma, 258, 260 Cutaneous horn, 85 Cyclitis, 149, 151 traumatic, 151 Cyclo-iritis (see Sclero-). keratitis (see Sclero-). Cycloplegia ( paralysis of ciliary muscle), 163, 329 Cysticercus in eye, 254, 387 Cvstic tumors in lids and orbit, 277 Cysts of iris, 286 lymphatic, of conjunctiva, 276 DACRYO-CYSTITIS (inflammation of the lachrymal sac), 92 Dacryo-lith, 402 Dacryops (cystic distention of one or more ducts of the lachrymal gland), 90 "Dangerous region," 167 zone, 152 Decentred lens, 23 Dermoid cysts of eyebrow, 275 tumor of eyeball, 277 Detachment of iris, lt>2 of retina, 162, 211, 255, 382 Diabetes, diseases from, 382 Dioptre, 28 Diphtheria, diseases from, 376 Diphtheritic paralysis of accom- modation, 377 ophthalmia, 101 Diplopia (seeing two images oj the same object), 33 binocular, 33 crossed, 322 homonymous, 322 in locomotor ataxia, 391 408 INDEX. Diplopia in meningitis, 391 uniocular (double sight with one eye), 33 Direct examination, 63, 72 Dislocation of lens, 162, 187 Disseminated choroiditis, 197 Distichiasis (double row of eye- lashes, lashes displaced and di- vided into two rows by distor- tion of edge of lid), 108 Dry heat in iritis, 142 ECHINOCOCCUS in orbit, 387 Ectropion, 338 Eczema of eyelids, 82 Embolism of retinal artery, 218 Emmetropia, E. (the refractive condition of the normal eye with accommodationrelaxed; paral- lel rays focussed upon the ret- ina), 25, 287 Emphysema of orbit, 158 Endemic nyctalopia, 247 Entozoa in eye, 387 Entropion, organic, 108, 335 spasmodic, 334 Epicanthus, 88 Epiphora (watery eye, tears How- ing over edge of lid), 82, 90 Episcleritis (inflammation, usu- ally localized, of the tissue be- tween the sclerotic and conjunc- tiva), 116, 145 Epithelial tumor of iris, 286 Epithelioma of conjunctiva, 277 Erysipelas, conjunctiva in, 101 optic atrophy from, 395 Eserine, effect on tension, 268 in corneal ulcer, 123 glaucoma, 268 mydriasis, 395 irritation, 103 Examination by focal light, 60 by ophthalmoscope, 62, 73 of bloodvessels of eye, 35 color-perception, 45, 249 cornea, 30 field of vision, 40 mobility of eye, 31 pupil, 40 Examination of tension, 30 Excision of eye in sympathetic affections, 155, 156 for injury, 167, 170 "Exclusion " of pupil, 137, 139 Exophthalmic goitre, 395 External examination of eye, 30 Extraction of cataract, 182 Eyelids, diseases of, 81 chancre on, 87 lupus on, 87 ulcers on, 86 syphilitic disease of, 87 FACIAL nerve, paralysis, 90, 394 False image, 322 Far-point, 44 Feigned blindness, 25 Fibro-fatty congenital growth, 277 Field of vision (see Vision). Fifth nerve, herpes, 267 influence on tension, 393 injury to, causing amaurosis, 388 paralysis, 267, 393 Flittering scotoma, 387 Fusion power of ocular muscles, 24 Focal illumination, 60 Focus, anterior, of eye, 26 conjugate, 18 principal, 17, 18 virtual, 19 Fomentation in corneal ulcer, 122 Foreign body in eyeball, 168, 170 in orbit, 160 on cornea, 164 Fovea centralis, 71, 204 Frontal sinus, distention, 279 Functional night blindness, 246 Fundus of eye, appearances, 66 definition, 64 Fungus in canaliculi, 402 GELATINOUS exudation in ante- rior chamber, 135 General diseases causing eye dis- ease, 373 INDEX. 409 General paralysis of insane, 391 Giddiness from ocular paralysis, 328 Glaucoma, 256, absolute, 260 acute, 256, 259 after extraction of cataract, 272 cases for operation, 270 causes, 264, 266 chronic, 257 corneal changes in, 131 from anterior synechia, 273 intraocular tumor, 284 fulminans, 260 hemorrhagic, 274 in sympathetic ophthalmitis, 154 malignum, 272 operations for, 268, 355 premonitory stage, 257 primary, 256 remittent, 259 second operations in, 272 secondary, 256, 273 to iritis, 139, 386 simplex, 258 subacute, 258 theory of iridectomy, 268 Glaucomatous cup, 258, 260 Glioma of retina, 282 Goitre, exophthalmic, 395 Gonorrhceal ophthalmia, 95 rheumatism, iritis from, 385 Gout, diseases in, 385 Gouty cyclitis, 150 iritis, 140 Granular ophthalmia, 103 Granuloma, 286 Graves' disease (see Goitre). Gunshot injuries, 166 HEMORKHAQE, choroidal, 194, 196, 201, 293 into anterior chamber, 135, 161 optic nerve, 219 intraocular, 163 retinal, 208, 379 secondarv, after iridectomy, 360 Hemorrhagic glaucoma, 274 Hard cataract, 172 Heart disease, eye diseases from, 383 Hemeralopia (day sight, term applied to cases where sight is especially defective at night, night-blindness), 247 Hemianopsia or Hemiopia (half sight, any condition causing loss of one-half of the visual field), 243 Hereditary amblyopia, 241 disease of retina, 222 syphilis, eye diseases in, 375 Herpes, cornece, 113 zoster, 393 Homonymous diplopia (see Di- plopia). Hyalitis (inflammation of vitreous (see Vitreous). Hydatid in orbit, 387 Hydrocephalus choroiditis, 390 optic atrophy, 390 Hyperaesthesia of retina, 244 Hypermetropia H. (refractive condition in which the retina lies in front of principal focus), 299 acquired, 300 haze of disk in, 206 how to measure, 305 measurement by ophthalmo- scope, 75 Hyphaema (blood in lower part of anterior chamber), 135 Hypopyon (pus in the lower part of the anterior chamber), 117 in iritis, 139 Hysterical amaurosis, 243 amblyopia, 243 ICE-BLINDNESS, 247 Idiopathic phthisis bulbi, 150 Images formed by lenses, 19, 20 size of, in relation to object, 20 retinal, influence of lenses on, 26 Indirect examination, 62, 64 Inflammatory glaucoma, 258 35 410 INDEX. Injuries of parts around eye, 258 eyeball, 161 Insufficiency of internal recti, 298, 323 Intraocular tumors, 282 hemorrhage, 163 lodoform, 402 Iridectomy (cutting out a piece of iris), 355 exciting glaucoma in other eye, 267 for glaucoma, 267, 355 in corneal ulcer, 123 in iritis, 143 Irideremia (absence of iris), con- genital, 143 Irido-choroiditis, 140, 149 Irido-cyclitis, traumatic, 168 Iridodesis, 355 Iridoplegia (paralysis of iris), 329 Iridotomy or Iritomy (incision of iris, 356 Iris, color, 38 diseases of, 134 cyst, 286 epithelial tumor, 286 in health, 38 granuloma, 286 paralysis, 329 sarcoma, 286 tremulous, 162 Iritis, 134 atropine in, 141 chronic, 140 cold in, 143 dry heat in, 142 glaucoma secondary to, 139, 386 gouty, 140, 385 heredito-gouty, 140, 386 in corneal ulcer, 117 interstitial keratitis, 125 iridectomy in, 143 leeches in, 141 paracentesis in, 142 pupil in, 136 recurrent, 139 results of, 138 rheumatic, 139, 385 serous, 149, 154 Iritis, "spongy" exudation in, 135 sympathetic, 151 syphilitic, 139, 373 traumatic, 140, 143, 164, 185 Ischtemia of disk, 226 of retina, 220, 378 Ivory exostosis, 279 KEKATITIS (inflammation of cor- nea), 110 interstitial, 125 iritis in, 125 marginal, 113 parenchymatous, 125 punctatd, 130, 149, 154 secondary forms, 130 strumous, 125 syphilitic, 125, 129, 374 Keratoscopy, 77 Kidney disease, eye in, 382 LACHRYMAL diseases, 89 canaliculi, alterations, 91 gland, abscess, 89 inflammation, 89 obstruction, 90 punctum, alterations, 90, 402 sac, diseases, 91 abscess, 92 stricture, 342 Lachrymation, 90 Lamellar cataract, 173, 178, 186, 393 Lamina cribrosce, 69, 77 Lead deposit on cornea, 133 optic neuritis, 380 Leeches in iritis, 141 Lens,flaws in, preceding cataract, 173 senile changes in, 171 Lenses, decentred, 23 definition, 16 deviation by, 16 influence of, on size of retinal image, 26 siscns for convex and concave, 28 spectacle, table of, 29 Lenticular ganglion disease. 331 Leucocythaemic retinitis, 383 INDEX. 411 Leucoma (a patch of dense opac- ity of cornea), 111 Lice on eyelashes, 86 Lime-burn, 165 Lippitudo (eversion with rawness of the edge of the lid, usually the result of severe ophthalmia tarsi), 82 Locomotor ataxia, cycloplegia, 391 diplopia, 391 iridoplegia, 391 optic atrophy, 235, 390 Lupus, conjunctival, 275 of eyelid, 87 Lymphatic cysts of conjunctiva, 276 Macula lutea, 71 Magnet for removing iron from eye, 168 Malarial fevers, diseases from, 378 Malignant tumors (see Tumors). Malingering, 247 Marginal keratitis, 113, 115, 127 Measles, diseases from, 378 Megalopsia, 247 Megrim, eye symptoms, 387 Meibomian concretions, 85 cyst, 84 Membranous ophthalmia, 101 Meningitis, epidemic cerebro- spinal, disease in, 379 neuritis in, 389 recovery with optic atrophy, 390 syphilitic, 389 tubercular, 389 Micropsia, 247 Mobility of eye, examination, 31 Molluscum contagiosum, 85 Moon-blindness, 246 Morgagnian cataract, 181 Mucocele (chronic inflammation and distention of lachrymal sac), 92 Muco-purulent ophthalmia, 99 Muscae volitantes (small moving specks in visual field), 247 Muscular asthenopia, 300 Mydriasis (persistent dilatation of pupil), 39 from blow, 163 paralytic, 327, 329 Myopia, 288 accommodation in, 391 choroidal changes in, 199 crescent, 292 from conical cornea, 298 incipient cataract, 298 measurement by ophthalmo- scope, 76 traumatic, 164 treatment, 295 Myosis (persistent contraction of pupil), paralytic, 394 spinal, 391 of eyelids, 275 Nasal duct, diseases, 91 Near-point, 44 Nebula (a faint localized opacity of corned), 111 Neuralgia preceding glaucoma, 388 neuritis, 388 dimness of sight in, 388 Nerve, facial, paralysis, 90, 399 Neuritis, optic, appearances, 227 causation, 164, 231, 388 cerebritis, 389 intracranial tumor, 389 lead, 380 meningitis, 389 orbital, disease, 231 peripheral, 231, 240 recovery from, 228 retrobulbar, 231, 240 sight in, 229 syphilis, 375 Neuro-retinitis, 320 Neurotomy, optico-ciliary, 350 Night-blindness, 220, 246 Nitrate of silver in corneal ulcer, 120 in ophthalmia, 98, 99 staining of conjunctiva, 133 Nodal point of the eye, 25 Nuclear cataract, 172, 177 Nyctalopia, 220 412 INDEX. Nystagmus (rapid small oscilla- tory movements of eyeball, involuntary or but slightly under control), 332 in disseminated sclerosis, 392 miners', 832 OBLIQUE illumination, 60 Occlusion of pupil, 138, 139 Ocular paralysis, 320 causes, 330 Onyx (accumulation of pus in layers of cornea ; should be re- stricted to cases where the pus has sunk to lowest part of cor- nea), 118 Opaque nerve fibres, 205 Operations, 333 for abscess of orbit, 159 abscission of eye, 349 artificial pupil, 354 canthoplasty, 340 cataract, 361 causes of failure, 184 after operations, 186, 368 extraction, 361 needle, 370 solution, 370 suction, 371 distended frontal sinus, 279 division of canthus, 340 ectropion, 338 entropion, organic, 335 spasmodic, 334 epilation, 333 eversion of eyelid, 333 excision of eye, 348 foreign body on cornea, 350 inspection of cornea in photo- phobia, 334 iridectomy, 355, 357 iridodesis, 355 iridotomy, 356 lachrymal abscess, 92, 341 stricture, 342 Meibomian cyst, 333 paracentesis of anterior cham- ber, 352 peritomy, 340 ptosis, 340 sclerotomy, 360 Operations, slitting canaliculug, 341 strabismus, 343, 347 trichiasis, 335 readjustment, 347 lachrymal, 341 on cornea, 350 on eyelids, 333 iris, 354 Ophthalmia after exanthems, 100 catarrhal, 99 chronic, 109 croupous, 101 diphtheritic, 101, 377 follicular, 104 from atropine, 103 cold, 101 eserine, 103 irritants, 101 gonorrhceal, 95 granular, 103 impetiginous, 101 in eczema, 101 erysipelas, 101, 395 herpes zoster, 101, 393 schools, 101, 105 membranous, 101, 377 muco-purulent, 99 neonatorum, 95 pblyctenular, 113 purulent, 95 pustular, 113 tarsi, 81 Ophthalmitis, sympathetic, 151 Ophthalmoplegia externa, 328 interna, 330 Ophthalmoscopes, 403 Ophthalmoscopic examination, 62 Optic disk, atrophy, 232 congestion, 206, 226 in health, 68 nerve, disease of, 224 disease from syphilis, 375 pathological changes, 224 tumors of, 281 neuritis from blows on eye, 164 Optical outlines, 13 Orbit, abscess, 159 cellulitis, 395 emphysema of, 158 INDEX. 413 Orbit, foreign bodies, 160 hydatid, 387 node, 282 tumor, 278 wound, 160 PANNUS (extensive superficial , vascularity of cornea), 107 phlyctenular, 115 trachomatous, 107 Panophthalmitis, 140, 151 Papilla optica, 224 Papillitis (inflammation of optic disk), see Neuritis. Papillo-retinitis, 214 Paracentesis for corneal ulcer, 123 in glaucoma, 272 iritis, 142 Parallactic movement, 212 Paralysis of external ocular muscles, 320, 391 ciliary muscle, 329 facial nerve, 90, 394 'fifth nerve, 267, 394 fourth nerve(superior oblique), 326 internal ocular muscles, 329 iris, 329, 391 sixth nerve (external rectus), 325 sympathetic nerve, 394 third nerve, 327, 391 Parasites, 254 Pediculus pubis, 86 Perimeter, 41 Peritomy, 108 Pernicious anaemia, retinitis, 383 Persistent pupillary membrane, 144 Phlyctenular affections, 113 pannus, 115 Photophobia (intolerance of light), 112 Physiological cup, 69 Pinguecula, 276 Pigment on choroid, 192, 201 in retina, 192 Plastic iritis, 140, 154 Polyopia uniocularis (seeing sev- eral images of the same object) , 176 Polypi, lachrymal, 92 Posterior polar cataract, 175, 178 staphyloma, 199 synechia, 134 total, 137, 139 Preliminary iridectomy, 364 Presbyopia, 316 table, 319 Primary optic atrophy, 234 Prism, 14 Prisms, uses of, 22 Progressive optic atrophy, 234 Projection, 15 Prolapse of iris (protrusion or inclusion of iris in a perforat- ing wound of cornea), 185 Proptosis, 34 in orbital disease, 89, 158, 264, 280 Protective glasses, 403 Pterygium, 276 Ptosis (falling of upper eyelid), congenital, 88 from granular lids, 108 paralytic, 327 traumatic, 159 Pulsation, retinal, in aortic dis- ease, 383 glaucoma, 383 Punctum proximum, 44 remotum, 44 Pupil (see also Iris, Synechia), examination, 39 exclusion, 137, 139 in optic atrophy, 234 Pupil in optic neuritis, 232 iritis, 136 influence of size on sight, 27 occlusion, 138, 139 total posterior synechia, 137, 139 why black, 62 Pupillary membrane, persistent, 144 Purpura, retinal hemorrhage, 353 Purulent ophthalmia, 95 Pustular ophthalmia, 113 Pyaemia, disease in, 379 Pyramidal cataract, 173 35* 414 INDEX. QUININE amblyopia, 381 RECURRENT vascular ulcer, 115 Eefraction of light, 13 of the eye, 25 determination by ophthalmo- scope, 73 retinoscopv, 78 errors of, 287 Refractive index, 13 Relapsing fever, diseases from, 378 Relative accommodation, 45 Renal retinitis, 207, 383 Retina, diseases of, 203 appearances in disease, 205 in health, 70, 203 atrophy, 208 bloodvessels of, 203 concussion, 164 congestion of, 205 detachment, 162, 211, 255, 382 embolism of, 213 functional diseases, 246 glioma, 282 hyperaesthesia, 244 hemorrhage, 208, 379 in disease of choroid, 188 disk, 211 pigmentation, 208, 221 Retinal image, size in hyperme- tropia, 300 in myopia, 289 Retinitis, 206 albuminuric, 214, 382 apoplectic, 217 hemorrhagic, 217 pigmentosa, 220 pernicious anajmia, 383 lead, 380 leucocythsemic, 383 malarial, 378 renal (see Albuminuric). syphilitic, 213, 374 Retrobulbar neuritis, 231, 240 Retinoscopy, 78 Rheumatism, disease in, 384 Rodent ulcer, 86 Rupture of choroid, 162, 195 eyeball, 161 SAEMISCH'S operation, 123 Sarcoma of choroid, 283 ciliary body, 283 iris, 286 sclerotic, 278 Scalds of eye, 165 Scarlet fever, diseases from, 376 Scleral ring, 69 Sclero-iritis, 147 Sclero-keratitis, 147 Sclerotic, rupture of, 161 ' ' Sclerotico - choroiditis poste- rior," 199 Sclerotitis, 145 Sclerotomy, 268 Scotoma (a defect or blind patch in field of vision, caused by localized opacity of media, disease of fundus or optic nerve), central, 241 flittering, 387 Scrofulous sclerotitis, 147 Scurvy, retinal hemorrhage, 379 Secondary cataract, 175, 187 keratitis, 130 glaucoma, 256, 273 operations for cataract, 186, 369 squint, 32, 328 Senile changes in accommoda- tion, 316 choroid, 199 lens, 171 failure of vision, 43 Serous iritis, 149, 154 Seton in corneal ulcer, 121 syphilitic keratitis, 129 Shades, 403 Sight (see Vision). after cataract operations, 186 in optic atrophy, 234 neuritis, 229 Size, apparent, of objects, 45 of retinal image, influence of lenses on, 26 Smallpox, eye diseases in, 376 Snow-blindness, 247 Soft cataract, 186 Solution of cataract, 182 Sparkling synchysis, 254 Spasm of accommodation, 290 INDEX. 415 Spectacles in hypermetropia, 304 astigmatism, 315 myopia, 295 presbyopia, 318 unequal eyes, 316 prismatic, 298 Spectacle lenses, table of, 29 "Spongy exudation" in iritis, 135 " Spring-catarrh," 115 Squint (see Strabismus). Staphyloma, anterior, 148 posterior, 199, 292 Stillicidum lacrymarum, 90 Strabismus, definition and varie- ties, 32, 320 alternating, 303 apparent, 33 causes of, 323 concomitant, 303 \ convergent, 32, 302 ) divergent, 32, 290 examination for, 32 in hypermetropia, 302 myopia, 290 paralytic, 324 periodic, 303 primary, 33, 328 secondary, 32, 328 Stricture of nasal duct, 90 Strumous eye diseases, 130, 386 Stye, 83, 84 Suction of cataract, 183 Suppression of retinal image, 238, 323 Sycosis tarsi, 81 Symblepharon (adhesion between palpebral and ocular conjunc- tiva), 165, 276 Sympathetic inflammation, 151 irritation, 151, 153 nerve, paralysis, 394 ophthalmitis, 151, 153 Syndectomy, 108 Synechia (adhesion of the iris), anterior (iris adherent to cornea), 165, 272 causing glaucoma, 139 posterior J(iris adherent to cap- sule of lens), 137 Syphilis, acquired, eye diseases, 373 Syphilis, brain disease, 389 choroiditis, 194, 197 cyclitis, 151 hereditary, eye diseases, 375 iritis, 139 keratitis, 125 ocular paralysis, 374 optic neuritis, 375 atrophy, 375 orbital disease, 374 retinitis, 213 tarsitis, 276 ulcers of eyelid, 87 TAT'S choroiditis, 200 Teeth in lamellar cataract, 393 hereditary syphilis, 395 Tension of eye, examination, 30 diminished, 151 in glaucoma, 256, 258 iritis, 136 paralysis of fifth, 267 Test-types, 43 Tinea tarsi, 81 Tobacco amblyopia, 241, 381 Toxic amaurosis, 376, 380 Trachoma (granular ophthal- mia), 103 Trachomatous pannus, 107 i Traumatic astigmatism, 164 cataract, 167, 180 cycloplegia, 163 irido-cyclitis, 140, 151, 168 iridoplegia, 163 iritis, 140, 143, 164, 185 myopia, 164 panophthalmitis, 141, 151 ptosis, 159 Tremulous iris, 162 Trichiasis (irregular growth of eyelashes, some of them rubbing against the cornea), 108 Tubercle of choroid, 194, 286 Tuberculosis, diseases in, 384 : Tumors, 275 intraocular, 282 of eyelids, 275 front of eyeball, 275 orbit, 278 fluctuating and cystic, 280 pulsating, 280 416 INDEX. Typhus, diseases from, 376 ULCERS of cornea, 112 eyelids, 86 Undiscovered blindness of one eye, 240 Unequal refraction in the two eyes, 316 Ursemic amaurosis, 376 Vence vorticosce, 189 Vision (see Sight). acuteness of, testing, 43 field of, 40 optical conditions of clear, 27 Visual angle, 26 axis, 27 field for colors, 250 in glaucoma, 258 optic atrophy, 235 Vitreous, cholesterine, 253 disease of, 149, 251 in glaucoma, 255 Vitreous, diseases of, in choroi- ditis, 254 myopia, 254, 293 hemorrhage, traumatic, 254 spontaneous, 254 humor, examination, 73 WATERY eye, 90 Wart, conjunctival, 275 marginal, of eyelid, 85 Waxy disk, 221 Whooping-cough, diseases from, 378 Woolly disk, 229 Wounds of eyeball, 166 eyelids, 160 orbit, 160 XANTHELASMA palpebrarum, 86 YELLOW spot, 71, 204 ZONTJLAR cataract, 173, 178, 186 CATALOGUE OF BOOKS PUBLISHED BY HENRY O. LEA'S SON & CO. (LATE H E N R Y c. L E A .) 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