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Fourth Enlarged Edi- tion. Price, $6.00. Tomes's System of Dental Surgery. Second Enlarged Edition. Price, $5.00. Richardson's Mechanical Dentistry. Second Edition, much En- larged. Price, $4.50. Beale's Use of the Microscope in Practical Medicine. Fourth Edition. 500 Illustrations. Preparing. MANUAL OF THE DISEASES THE EYE. OPINIONS OF THE MEDICAL PRESS. From the London Medical Times and Gazette, Aug. 14, 1869. " We have been fully supplied in the last two or three years with sys- tematic treatises on diseases of the eye. But there seems still to be room for a clear, brief, and concise yet practically full manual on modern oph- thalmic medicine and surgery, such as might serve for a text-hook fur stu- dents and a companion for the busy practitioner. This Mr. Lawson ha.s supplied, and supplied admirably well. Of his qualifications for the ta-^k of producing such a work it would be superfluous to speak. He is a ' Past Master' on the subject, and while any work of his is sure of a favorable reception, he has taught the profession to judge him by a high standard of excellency, and so judged the book we now notice will certainly not disappoint its readers. Necessarily brief and concise as to details, it is admirably clear and eminently practical. The reader feels that he is in the hands of a teacher who has a right to speak with authority, and who, if he may be said to be positive, is so from the fulness of knowledge and experience, and who, while well acquainted with the writings and labors of other authorities on the matters he treats of, has himself practically worked out what he teaches." From the British Medical Journal, Jnli/ 24, 18(59. " We congratulate Mr. Lawson on the production of such an excellent work on ophthalmic diseases as this. Without depreciating the large and valuable treatises on this subject that have recently appeared, we have long felt that a manual was wanted which would serve as a teat-hook for stndetits, and also should form a trustworthy guide for practitioners in dealing with diseases of the eye. AVell has Mr. Lawson supplied this want. He has described the various aflfeutions of the eye, briefly but j-et clearlj', and from the large experience he has acquired as surgeon to the Royal London Ophthalmic Hospital, Moorfields, he has made his work thorongkly ■practical. The profession will find this manual just the sort of work they want on eye diseases, while to the student it will be invalu- able as a text-book.'' From the Practitioner, August, 1869. "This handy and beautifully printed volume is as good in the quality of its contents as it is attractive to the eye. Mr. Lawson has long been known as an ophthalmic surgeon, he has enjoyed a long experience, and he has the faculty of telling his story clearly. He has here given us a manual of moderate size, in which the practitioner will find ,«hort and clear descriptions and directions for the treatment of every kind of eye disease. The work is sure to become very popular, and to enjoy a large circulation.'' DISEASES AND INJURIES THE EYE: MEDICAL AND SURGICAL TREATMENT. GEORGE LAWSON, F.R.C.S., SUROEON TO THE ROYAL LONDON OPHTBALMIC HOSPITAL, MOORFIELDS, AND ASSISTANT-SCROEON TO TUB MIDDLESEX HOSPITAL. PHILADELPHIA: LINDSAY & BLAKISTON. 186 9. CAXTON PRESS OF SHERMAN ft CO I Go PREFACE. In this Manual is comprised a brief account of all the medical and surgical affections of the Eje, with the treatment essential for their relief. Each subject is discussed in a separate section, under its own peculiar heading. In the description and treatment of the various dis- eases, I have not o\\\j given the results of mj^ own ex- perience, but I have carefully recorded special points in the practice of my colleagues at the Roj'al London Ophthalmic Hospital, and have made frequent reference to the labors of the Continental ophthalmic surgeons. The scope of this work forbids profusion of detail. Wh^n, therefore, fuller information is required, I must refer the reader to the " Treatise on the Eye," by Mr. Soelberg Wells, or to the "Natmal and Morbid Changes of the Human Eye," by Mr. Bader. At the end of the book I have added a Formulary of Prescriptions, and also a page of Test-types, reduced from those designed by Dr. Orestes M. Pray, of New York, to aid in the diagnosis of astigmatism. In the 1* VI PREFACE. original, each letter is two inches square, and is com- posed of either vertical, horizontal, or oblique lines set at different angles. To my friend Dr. Workman I return my warmest thanks for the help he has kindl}- given me in revising the proof-sheets before they passed through the press. 12 Harley Street, Cavendish Square, "W. June, 1869. CONTENTS. CHAPTER I. DISEASES OF THE CONJUNCTIVA. PAGE Catarrhal Ophthalmia — Chronic Ophthalmia — Pustular Oph- thalmia — Purulent Ophthalmia of Newly-born Infants — Purulent or Contagious Ophthalmia — Gonorrhoeal Ophthal- mia — Diphtheritic Ophthalmia — Granular Lids — Syndec- tomy — Pterygium — Pinguecula — Dermoid Tumors of the Conjunctiva — Cysts of the Conjunctiva — Warts of the Con- junctiva — Injuries of the Conjunctiva — Ecchymosis of the Conjunctiva — Lacerations of the Conjunctiva, . . 13-42 CHAPTER II. DISEASES OF THE CORNEA AND SCLEROTIC. Corneitis — Chronic Interstitial Corneitis — Strumous Corneitis — Diffuse Suppurative Corneitis — Hj-popion — Onyx — Ab- scess of the Cornea — Marginal Corneitis — Phlyctenular Ophthalmia — Corneo-Iritis — Ulcers of the Cornea — Super- ficial Ulcers of the Cornea — Superficial Nebulous Ulcers — Superficial Transparent Ulcers — Deep Ulcers of the Cor- nea — Sloughing Ulcers — Crescentic or Chiselled Ulcers — Chronic Vascular Ulcers — Fistula of the Cornea — Nebula of the Cornea — Leucoma of the Cornea — Opacity of the Cornea from Lead — Conical Cornea — Kerato-globus — Sta- phyloma of the Cornea, partial and complete — Ciliary Sta- Vlll CONTENTS. PAUE pbylbma — Cyclitis — Episcleritis — Injuries of the Cornea and Sclerotic — Foreign Bodies on the Cornea — Abrasions of the Cornea — Penetrating Wounds of the Cornea and Scle- rotic — Kupture of the Eye through the Sclerotic, . . 43-93 CHAPTER III. DISEASES OF THE IRIS AND VITREOUS HFMOR. Iritis — Classification of — General Symptoms of — Syphilitic Iritis — Eheumatic Iritis — Serous Iritis — Suppurative Iritis — Traumatic Iritis — Cysts of the Iris — Cysticercus on the Iris — Melanotic Sarcoma or Carcinoma of Iris — Functional Derangements of the Iris — Mydriasis — Myosis — Calabar Bean — Operations on the Iris — Iridectomy — Artificial Pupil —1. "With a Broad Needle and Tyrrell's Hook— 2. By Iri- dodesis or Ligature of the Iris — 3. By Incision of the Iris — 4. By Excision of a Triangular-shaped piece of Iris — In- juries to the Iris — Hemorrhage into the Anterior Chamber — Coredialysis — Prolapse of the Iris — Irido-Choroiditis — Choroido-Iritis — Sympathetic Ophthalmia — Glaucoma — The Acute and Subacute Inflammatory Glaucoma — The Chronic or Simple Glaucoma — The Consecutive or Second- ary Glaucoma — How to ascertain the Tension of the Globe — Tremulous Iris — Coloboma of the Iris — Diseases of the Vitreous — Hj-alitis — Muscje Yolitantes — Opacities of the Vitreous — Sparkling Synchysis — Fluidity of the Vitreous — Foreign Bodies in the Vitreous — Hemorrhage into the Vitreous, 93-148 CHAPTER IV. DISEASES OF THE CRYSTALLINE LENS. Cataract — Causes of — Classification of — Hard and Soft Cata- racts — Congenital or Infantile Cataract — Involuntary Os- cillations of the Globe — Operations for Soft Cataract — Oper- ation by Solution — Linear Extraction — Suction Operation CONTENTS. IX PAGE — Hard Cataracts — Varieties of — Nuclear, Striated, Black, and Senile Cataracts — Operations for Hard Cataracts — Flap Extraction Operation — Accidents which may happen in Flap Extraction of Cataract — Remarks on Flap Extraction — The Traction Operation — Von Graefe's modified Linear Extraction — Mooren's Extraction Operation — Jacobson's Extraction Operation — Pagenstecher's Operation for ex- tracting the Lens in its Capsule — Macnamara's Operation for Cataract — Treatment of the Eye after an Extraction of the Cataract— The Casualties which may occur after an Ex- traction of a Hard Cataract — Capsular Cataract — Capsulo- Lenticular Cataract — Diabetic Cataract — Fluid Cataract — Traumatic Cataract — Secondary Cataract — Capsular Opaci- ties — Treatment of — Dislocations of the Lens — 1. Into the Anterior Chamber — 2. Into the Vitreous — 3. Beneath the Conjunctiva — Partial Dislocations of the Lens, . . 149-195 CHAPTER V. DISEASES OF THB RETINA, CHOROID, AND OPTIC NERVE. Hyperaemia of the Retina — Retinitis — Retinitis Albuminurica — Retinitis Syphilitica — Retinal Apoplexy — Retinitis Pig- mentosa — Detachment of the Retina — Embolism of the Cen- tral Artery of the Retina — Tumors of the Retina — Glioma of the Retina — Cysts of the Retina — Diseases of the Choroid — Disseminated or Exudative Choroiditis — Sclerotico-Cho- roiditis Posterior — Suppurative Choroiditis — Deposits of Bone on the Choroid — Tubercles in the Choroid — Hemor- rhage from the Choroid — Injuries of the Choroid — Hemor- rhage between the Choroid and Retina — Hemorrhage be- tween the Choroid and Sclerotic — Hemorrhage into the Vitreous — Tumors of the Choroid — Sarcoma of the Choroid — Medullary Cancer of the Choroid— Diseases of the Optic Nerve — Descending Optic Neuritis — Neuro-Retinitis — At- rophy of the Optic Nerve — Amaurosis — Causes of — Am- blyopia — Hemeralopia — Snow-blindness — Color-blindness — To ascertain the Field of Vision — The Ophthalmoscope — How to work with the Ophthalmoscope — Lateral or Focal Illumination of the Eye, ...... 19-J-260 CONTENTS. CHAPTER VI. ANOMALIES OF REFRACTION AND DISEASES OF ACCOMMODATION. PAGE Accommodation — Myopia — Ophthalmoscopic appearances of a Myopic Eye — Treatment of Myopia — Degree of Myopia — General Rules for Selection of Glasses — General Directions for Myopic Patients — Hypermetropia — Treatment of Hy- permetropia — To ascertain the degree of Hypermetropia — Peculiarities of the Hypermetropic Eye — Presbyopia — Treatment of Presbyopia — Astigmatism — Irregular Astig- matism — Regular Astigmatism — Asthenopia — Causes of — Treatment of Asthenopia, 2G0-282 CHAPTER VII. STRABISMUS. Strabismus — Causes of — To ascertain the Degree of — Con- vergent Strabismus — Causes of — Divergent Strabismus — Causes of — Treatment of Strabismus — The Moortields Ope- ration for Strabismus — Von Graefe's Operation for Strabis- mus — Liebreich's Operation for Strabismus — Treatment of Strabismus after the Operation — Divergent Strabismus fol- lowing division of the Internal Recti Muscles — Operation for bringing forward the Internal Rectus Muscle — Paralysis of the Ciliary Muscle — Spasm of the Ciliary Muscle — Diplo- pia — Homonymous Diplopia — Crossed Diplopia — The Ac- tion and Uses of Prisms — To ascertain the presence of Binocular Vision — To test the Strength of the Muscles of the Eye — To wear as Spectacles to correct Diplopia — Para- lytic Aflcctions of the Muscles of the Eye — Causes of — Paralysis of the Third Nerve— Paralysis of the Fourth Nerve — Paralysis of the Sixth Nerve — Treatment of Para- lytic Affections of the Muscles of the Eye, . . . 282-312 CONTENTS. XI CHAPTER VIII. SPECIAL INJURIES OF THE EYE. PAGE Foreign Bodies within the Eye — Injuries of the Eye from Escharotics — Injuries from Mortar, Lime, and Plaster — Burns and Scalds of the Eye — Injuries from Strong Sul- phuric and Nitric Acid — From Vinegar, dilute Acetic Acid, or any of the weak Acids — Injuries from Percussion Caps, Gunpowder, and Small Shot — Excision of the Eye — Arti- ficial Eyes — Directions for wearing Artificial Eyes, . 313-326 CHAPTEPv IX. DISEASES OF LACHRYMAL APPARATUS. Epiphora — Causes of — Chronic Inflammation of Lachrymal Sac — Treatment of — Stricture of Lachrymal Canal — Sites of Stricture of — Treatment of — Acute Inflammation of the Lachrymal Sac — Treatment of — Fistula of the Lachrymal Sac — Epiphora from Mechanical Obstruction by Tumors — To slit up the Canaliculus — Obliteration of the Lachrymal Sac — Removal of the Lachrymal Gland — Diseases of the Lachrymal Gland — Inflammation of the Lachrymal Gland — Cysts of the Lachrymal Gland — Fistula of the Lachrymal Gland — Chronic Enlargement of the Lachrymal Gland — Treatment of, 327-341 CHAPTER X. DISEASES OF THE EYELIDS. Tinea Tarsi — Hordeolum — Eczema of the Lids — Trichiasis — Distichiasis — Operation for the Removal of the Eyelashes — Entropion — Spasmodic Entropion — Chronic Entropion — Causes of — Treatment of — Ectropion — Causes of — Treat- ment of — Paralytic and Spasmodic Aftections of the Eye- lids — Ptosis — Complete and Partial — Paralysis of the XU CONTENTS. PAGE Orbiculiiris Muscle — Blepharospasm — Ulcerations of the Eyelids — Syphilitic Ulcers of the Eyelid — Treatment of— Kodent Cancer of the Eyelid — Epithelial Cancer of the Eye- lid — Treatment of Epithelial and liodent Cancer — Tumors of the Eyelid — Tarsal Cysts — Naevus of the Eyelid — Seba- ceous or Dermoid Cysts — Epicanthus — Injuries of the Eye- lids — Ecchymosis of the Eyelid — Abscess of the Eyelid — "Wounds of the Eyelid — Kesults of Injuries and Ulcera- tions of the Eyelids — Anchyloblepharon — Treatment of — Syrablepharon — Treatment of, 342-378 CHAPTER XI. DISEASES OF THE ORBIT. Abscess of the Orbit — Acute and Chronic — Treatment of — Fractures of the Bones of the Orbit — Foreign Bodies in the Orbit — Effects of — Treatment of — Penetrating Wounds of the Orbit — Periostitis of the Orbit — Treatment of — Ne- crosis and Caries of the Orbit — Aneurism of the Orbit — True and False Aneurism of Orbit — Diffuse or Consecutive Aneurism of Orbit — Aneurism by Anastomosis of Orbit — Exophthalmic Goitre — Treatment of — Tumors of the Orbit — 1. Those which originate within the Orbit — 2. Those which commence within the Eye — 3. Those which have their Origin beyond the eye or Orbit — Treatment of Tu- mors of the Orbit — Acute Inflammatory Exudation into the Orbit — Distension of the Frontal Sinus — Anatomy of Frontal Sinus — Causes of Distension of Frontal Sinus — Treatment of Distension of Frontal Sinus, . . . 379-414 Formulary of Prescriptions, ....... 415 Page of Test-Types for Astigmatism, 427 MANUAL DISEASES OF THE EYE. CHAPTER I. DISEASES OF THE CONJUNCTIVA. Catarrhal Ophthalmia — Acute Conjunctivitis — is an inflammation of the conjunctiva covering the eye and lining the lids. It may come on without any apparent cause, or it may be produced by rapid alternations of tem- perature, or by exposure of the eye to cold. Catarrhal ophthalmia will sometimes assume an epidemic character, and large numbers in the same locality will suffer from it ; or it will attack every member of a family in succession, notwithstanding that due precautions have been taken to prevent its spreading by direct communication. Symptoms. — A feeling of grittiness, as if dust or fine sand were in the eye, wath some stiffness of the lids. The conjunctiva becomes red, and this increase of vascularity generall3^ commences from the circumference of the globe, and fades as it approaches the cornea. In the advanced stage of this affection the white of the ej^e becomes of one uniform red color. The redness is superficial, and of a brighter and darker shade than that caused by inflamma- 2 14 DISEASES OF THE CONJUNCTIVA. tioii of the deeper structures of the eye, for which it can hardly be mistaken. There is an increased secretion from the surfaces of the eye and lids ; at first only of mucus, but afterwards of muco-pus, small quantities of which will collect in little beads over the caruncle at the inner angle of the eye, or form little scabs on the edges of the lids by caking on the eyelashes. If the lower lid be drawn down by the finger, one or two streaks of pus or lymph will be pften seen in the oculo-palpebral fold. The patient com- plains that the lids are sticky, and that in the morning they are gummed together by dried secretion. On look- ing at the eyes, there is a peculiar sticky and gummy ap- pearance which is quite characteristic of the disease. There is often associated with these symptoms chemosis of the conjunctiva and swelling of the lids. The con- junctiva looks blown np from the serous effusion into the subjacent cellular tissue, sometimes to an extent sufllcient to make the cornea appear sunken below it. The cornea is clear, and the pupil is active. The rapid action of the pnpil will at once decide that the inflammation is super- ficial, and that the iris is not affected by it. Catarrhal ophthalmia usually commences in both eyes simultaneousl}' , or one eye may be attacked a little in ad- vance of the other, but it is seldom that this disease is limited to only the one eye. In this respect catarrhal oph- thalmia oflers a -marked difference from gonorrhoeal oph- thalmia, which is generall}^, in the first instance, strictly confined to the one eye. (See Gonorrhceal Ophthalmia, page 22.) Prognosis. — This affection is usually very amenable to proper treatment, and the eye& will recover without a trace of the disease remaining. But if no treatment be adopted, or unsuitable remedies be used, the conjunctival inflammation may extend to the cornea, and corneitis, with superficial or deep ulcerations, may follow. CHRONIC OPHTHALMIA. 15 Treatment. — The ej^es should be bathed every two or three hours, or oftener if the case is severe, with a lotion of alum, or sulphate of zinc and alum (F, 38, 39, 40), taking care that with each application a little is allowed to flow into the eyes. In the intervals between the times for using the lotion, the ej^es may be bathed with cold water, to keep them free from the discharge. A solution of nitrate of silver, gr. 1 or gr. 2, ad aquae ^ 1, is very useful in catarrhal ophthalmia, and especially in those cases where there is chemosis of the conjunctiva and swelling of the lids. Two or three drops should be dropped into the ej^e twice a daj'^, and every two or three hours, or oftener if necessary, the eyes should be cleansed from discharge by bathing them with cold water. To pre- vent the gumming together of the eyelids during sleep, a little unguent, cetacei should be smeared along their tarsal borders every night. At the commencement of the attack the bowels should be acted on by some pui-gative ; and if the patient is hot and thirsty, an alkaline or effervescing draught (F. 53, 55) may be prescribed, but, as a rule, tonics, such as bai'k, quinine, or iron, will be required; and these are given with most benefit after the first febrile symptoms which often usher in an attack of catarrhal ophthalmia have passed away. Chronic Ophthalmia may be consequent on catarrhal ophthalmia, the acute disease subsiding into a chronic form; but this is quite exceptional. Chronic ophthalmia generally occurs in patients who are below the standard of health, and in those who have to earn their living by the long-continued use of their eyes at fine work. Symptoms. — The eye has a reddish and irritable appear- ance ; it will not face the light without a sense of discom- fort and watering. The caruncle and edges of the lids often look red and prominent, and the secretion of the IG DISEASES OF THE CONJUNCTIVA. mucous surfaces of the lids and globe is slightly increased. Reading or fine work soon tires the e^^e, and causes it to flush up. The patient is generallj' more or less out of health ; oftentimes used up from Avant of rest. Treatment. — When there is reason to believe that over- use of the eyes has been the exciting cause of the disease, rest must be strictly enjoined. Close reading, the casting up of figures, and all fine work should be forbidden. The state of the patient's health should be improved, and an}^ irregularity in the discharge of the functions of the differ- ent organs of the bod}^ should be, as far as possible, cor- rected. Local AjjjMcations. — When there is any extra secretion from the mucous surfaces of the lids or eye, mild stimu- lating drops or lotions do good. Two or three drops of the guttse argenti nitratis (F. 16), or of zinci sulphatis (F. 20), may be dropped into the eye twice a da^'. Lo- tions Avith alum, or with alum and sulphate of zinc com- bined (F. 39, 40), are very efficacious. A weak solution of the acetate of lead (F. 42), provided there is no abra- sion of the cornea, will be often found very useful. The tarsal edges of the lids should be anointed at night Avitli a little unguent, cetacei, to prevent their gumming to- gether; or if there is much secretion from the Meibomian follicles, the unguent, hydrarg. nitratis dilut. (F. 102) may be advantageously used. When there is much dread of light, stimulating applications to the e^'e fail to do good, and are apt to excite considerable irritation. In chronic ophtlialmia, counter-irritation will be frequently found beneficial. A small blister of emplast. cantharidis, or a piece of Brown's tilistering tissue of the size of a shilling, may be applied to the temple, or behind the ear, and repeated in two or three nights if necessary'. If the remedies named fail to afford relief, a seton in the temple of a single or double thread of thick corded PUSTULAR OPHTHALMIA. 17 silk will occasionally do good. The setoii should not be allowed to remain more than three or four weeks, or the ulceration at the entrance and exit of the thread may cause an viusightly scar. In cases of persistent chronic ophthalmia the lids should be everted and carefully ex- amined for granulations, as, if the conjunctiva has become granular, the ophthalmia will continue until the granula- tions are cured. (See Granular Lids.) Pustular Ophthalmia is a mild form of inflammation of the conjunctiva, characterized by the formation of small elevations about one or two lines from the margin of the cornea. They are generally of a reddish color at their base, and of a yellowish-white on their somewhat flattened summits. They have been called pustules, but they do not really contain pus ; if pricked, onl}^ a little watery fluid will exude from them. The conjunctiva in their vicinity is more or less reddened, and sometimes one or two small red vessels may be seen coursing towards them. There may be only one of these so-called pustules, or there mu}^ be as man}' as three or four of them. There is no intolerance of light, and the patient seldom com- plains of more than a feeling of grittiness in the eye. One peculiarit}^ of pustular ophthalmia is that it is very apt to recur. This attection is quite distinct from the true phlyctenular ophthalmia described in the chapter on Diseases of the Cornea. Treatment. — Attention must be paid to the general health of the patient, and, if necessary, a mild aperient prescribed. As a local application, any mild stimulant will do good. A little calomel, dusted into the qjq on to the pustules with a camel's hair brush every or every other day for a few times, will be found a very eflScient remedy. It has also the credit of preventing a recur- rence of the disease. Lotions of the acetate of lead (F. 2* 18 DISEASES OF THE CONJUNCTIVA. 42), or of sulphate of zinc, ma}' be also used with good effect. Purulent Ophthalmia of Newly-born Infants — Ojyhthalmia neonatorum — is one of the most important diseases of the 63^6 which the surgeon can have under his care. When rightly treated it is one of the most remedi- able, but when neglected, or, what is often worse, when unsuitable and improper remedies are used, it is one of the most disastrous of all the inflammatory affections of the eye. The responsibility of any one undertaking a case of purulent ophthalmia who is not thoroughly' ac- quainted with its nature and treatment is very great. Many a useful life has been blighted in the first mouth of its existence by irreparable blindness, which might have been prevented if the simple means, which seldom fail to arrest this formidable disease, had been rightfull}- applied. Purulent ophthalmia usually commences from the second to the seventh day after birth. Both eyes are commonly atfected simultaneously', but to this there are occasional exceptions ; thus one eye only ma}'^ be involved, or the first eye may sufier twelve or twenty-four hours in ad- vance of the second. Symjitoms. — The first indication of the disease is usu- ally detected by the nurse, who notices that there is a slight discharge from the eyes, and that the edges of the lids are glued together during sleep. In a short time, often within a few hours, the discharge increases greatly in quantity and changes in quality ; it first becomes muco- purulent, and ultimatel}', if the case is severe, is converted into almost pure pus. The eyelids now become red and swollen, and their tarsal margins, caked together, pen up the discharge, which accumulates behind the lids, and streams over the cheeks when the e^'es are opened. The quantity of pus which literally pours from between the I'UKULENT OPHTHALMIA OF INFANTS. 19 ej^elids in a bad case, and the rapidity with which it is secreted, are verj' remarkable. In the slight cases of puruleut ophthahnia the discharge is of a whitish color with scarcely' a tinge of j^ellow, and it is not ver}^ abundant iii quantity. In the very severe forms of the disease the discharge is of a deep yellow color and very profuse. Between these extremes there are many gradations. Prognosis. — When a child suffering from purulent oph- thalmia is seen sufficiently early, and proper remedies are rightly applied, recover}^ is almost certain. It should, however, be remembered that cases occasionally occur of so severe a nature that all treatment is unaA'ailable to ar- rest the progress of the disease, and one or both ej^es are rapidly and irrecoverably destroj-ed. In such instances it will generally be found that the discharge was of a deep yellow color, very copious, and that it commenced on the first or second day after birth. It will also be probably ascertained, on inquiry, that the mother had gonorrhoea at the time of her confinement, or leucorrha^a of so severe a type that the discharge was yellow and puriform. Treatment. — The indications for treatment are to wash away the discharge from the ej^e as often as it collects, and to use some astringent lotion to arrest the re-secretion of the purulent matter. Lotions of alum, or of sulphate of zinc and alum (F. 38, 40), and drops of nitrate of sil- ver, are the most useful astringents in purulent ophthal- mia. The lotion which I generally use is one of alum (F. 38). The mode, however, of applying the remedies is of as much importance as the remedies themselves. The lotion should be gently squirted into the eye with an India-rubber S3'i'inge with an ivory nozzle, or with a small glass S3'ringe, ever}" half-hour or hour, according to tlie severity of the case, the object being to thoroughh^ cleanse 20 DISEASES OF THE CONJUNCTIVA. the eye from all discharge as often as it is re-secreted. This treatment should be pursued by night as well as by daj^ The intervals between the use of the lotion ma}- be increased as the discharge decreases in quantity. The carrying out of these iusti'uctions should be intrusted solely to the nurse, as the mother, so soon after her con- finement, is unfitted for the duty, and rest is also essen- tial for her in order to insure a due suppl}- of milk for the child. The easiest way of applying the lotion is as follows : The nurse should lay the child on her laj:), turning its head a little to one side or the other, according to the eye she is going to wash out. "With the thumb and finger of her left hand she geutl}' separates the lids, whilst with the right hand she squirts a stream of the lotion into the e3'^e from the nasal side, allowing it to run away from be- tween the lids on to a soft napkin, which she has placed under its head to receive it. If the case is very severe, the surgeon should see the child once or twice a day himself, and having washed the eye thoroughly from all discharge with a stream of cold water, he should drop into it two or three drops of a solu- tion of nitrate of silver gr. 2 ad aqua^ 5 1, and order the alum lotion to be continued as directed during his ab- sence. In some cases, where the nurse is verj' awkward, and cannot rightly- use the lotion with a syringe, it may be efficiently applied by means of a soft camel's-hair brush. From time to time a little unguent, cetacei should be smeared on the edges of the lids, to prevent their sticking together. Evil Results of Purulent Ophthalmia. — The great danger in this disease is lest the inflammation, which was originally confined to the conjunctiva of the lids and globe, should extend to the cornea. When this happens, acute corueitis follows ; the cornea becomes at firs-t hazy, PURULENT OPHTHALMIA. 21 then ulcerates either superficially or deeply, or, if the case is very severe, a large portion of it may slough. As the result of such casualties, we get nebula, leucoma, or staphyloma of the cornea. Each of these subjects will be found fully treated of under their respective head- PuRULENT Ophthalmia — Contagwus Ophthalmia To this disease xevy many names have been ai)ijlied, but the two mentioned are sufficient to indicate its nature. This form of ophthalmia is both purulent and contagious. It has been called Egi/jjfian Ophthalmia^ from its being ever present in Egypt, where the severest types of the disease are to be constantly found. In its mild form it closely resembles catarrhal ophthal- mia, for which it may be mistaken ; but in the worst cases it almost equals in severitj^ the gonorrho^al aflection of the eyes. Purulent ophthalmia commences with a slight discharge from the ej^e and swelling of the lids. The discharge soon increases in cpiautity and becomes puriform, the conjunc- tiva gets chemosed, and the lids grow red, shining, and oedematous. If the disease progresses unchecked, the cornea first becomes cloiidy, then ulcerates, or portions of it slough, and the e}' e is destrojed. The peculiar ten- dency of purulent ophthalmia is to attack masses of people who are congregated together, and living without due attention to cleanliness and ventilation. Hence it is that the disease has frequently broken out amongst sol- diers in barracks, amongst the poor in workhouses, and in large pauper schools in the country. Although purulent ophthalmia is undoubtedl}^ propa- gated by inoculation, yet there is abundant evidence to show that it may be epidemic, and spread without any di- rect conve3'ance of the purulent secx'etion from e3'e to eye. 22 DISEASES OP THE CONJUNCTIVA. I think myself that the ordinary catarrhal ophthalmia may, and frequently does, assume a contagious form, and that it is liable to do so whenever it attacks members of a community who are living in violation of the laws of health. Treatment. — A mild case of purulent ophthalmia should be treated in the same way as catarrhal ophthalmia, page 13 ; but if the case is severe the plan of treatment recom- mended for gonorrhoeal ophthalmia, page 23, should be adopted. After the severit}^ of the disease has been ar- rested, there is apt to remain a muco-puruleut discharge, which will obstiuatel}^ resist all treatment for many weeks, or even months. Upon everting the lids, it will be often found that this chronic discharge is due to a granular condition of the palpebral conjunctiva induced by the disease. (See Treatment of Granular Lids, page 32.) In all outbreaks of the disease sanitarj'^ precautions should be taken to prevent it spreading, and the bad cases should be kept apart from the others. A daily inspection should be also made to treat each fresh case as soon as the earh'^ symptoms show themselves. Results of Purulent Oplithalmia. — 1st. If the disease resists all treatment, the ej^e may be lost from ulceration or sloughing of the cornea. 2d. The eyQ maj^ recover, but w^ith a nebula of the cornea, or a leiicoma, to the inner surface of which the iris is frequently attached, causing a distortion of the pupil. 3d. A granular state of the lids, with a chronic muco-purulent discharge. GoNORRHCEAL OPHTHALMIA is au acutc spccific inflam- mation of the conjunctiva of the lids and globe, induced by the inoculation of some gonorrheal matter into the eye. It is characterized b}" a profuse purulent discharge from between the lids, which is of a yellow color, and ex- GONORRHCEAL OPHTHALMIA. 23 actly corresponds iu appearance with that which flows from the urethra. The disease is rapid in its progress and very destructive ; unless it is soon checked, the eye is lost. Synijitoms. — Acute inflammatory action usually com- mences in from six to eighteen hours after the inoculation has been efiected. The earlj^ symptoms resemble those of catarrhal ophthalmia, but they are more severe. A slight thin discharge first begins to ooze from between the lids, accompanied bj' a sense of heat and fulness of the eye. The conjunctiva of the globe grows red, swollen, and che- mosed, often rising above the level of the cornea, which will appear as if it were partiall}' buried below it. The lids are swollen, red, and shining, and completely closed over the e^^e. The discharge has now become excessive in quantity, of a thick consistence and yellow color, and streams over the cheeks from between the lids. The cor- nea is almost certain to become involved ; and if the in- flammation be not quickly subdued, ulceration and slough- ing of its structure will surely follow. The patient suffers severel}^ from the pain in the eye and around the orbit, with an oppressive feeling of heat and fulness of the lids and globe. The disease is usually confined to the one eye. When the second becomes afiected, it is generall}^ on ac- count of due precaution not having been taken to shield it from the danger of inoculation. Treatment. — A few years ago the treatment consisted in excessive bleedings from the arm, and in the use of strong depressing medicines. Experience has shown the error of such proceedings, and by now adopting a directly opposite course, a far larger proportion of cases recover with good and useful eyes. In gonorrhoeal ophthalmia the treatment must be constitutional and local. Constitutional Treatment. — From the very commence- ment of the attack the strength of the patient must be supix»rted by tonics, diffusible stimuli, and a liberal diet. 24 DISEASES OF THE CONJUNCTIVA. The whole histoiy of gonorrhoeal ophthalmia is of a de- pressing character. The patient, generally suffering from gonorrhoea at the time the e3e becomes inoculated, is, from the nature of his complaint and the treatment adopted to cure it, below the standard of health. The disease itself is also ver}' exhausting; but the prospect of loss of vision, with the utter annihilation of all future prospects, adds to his sense of loneliness and despair. The fact that the patient is suffering from a severe urethral discharge, will not forbid the free use of tonics and stimulants. The danger of ulceration and sloughing of the cornea is in- creased in proportion as the vital powers are depressed. Having therefore first acted freelj' on the bowels by a moderate purgative, quinine, in 2 gr. doses, or the min- eral acids with cinchona (F. Gl), should be giA'en CA'ery four hours. If there is much pain or irritabilit}', opium should be prescribed, either in small quantities frequently repeated, or in one full dose at bedtime. "When there is heat of skin, with thirst and a furred tongue, an efferves- cing mixture with ammonia (F. 53) may be advantage- ously ordered before prescribing the direct tonics. The diet should be one of meat or beef tea, with a certain amount of wine or brand}", according to the strength of the patient. Local Treatment. — The best applications are nitrate of silver, lotions of alum, or of sulphate of zinc and alum, and cold. 1st. Nitrate of Silver. — This is best used in the form of solution, varj'ing in strength from gr. 10-gr. 30 ad aquse ^ 1, according to the severit}' of the case. The lids should be everted, and the conjunctival surfaces painted over with a camel-hair brush with the solution, which should be allowed to remain a few seconds so as to whiten the parts, and be then washed off with a stream of cold water from an India-rubber bottle. GONORRHEAL OPHTHALMIA. 25 This should be repeated once daily ; and, in very bad cases, a second application may be necessary. For the mode of applying the solution of the nitrate of silver, see TreaTxMent of Granular Lids, page 32. When the lids are so swollen that they cannot be everted, two or three drops of a weaker solution of nitrate of silver, from gr. 2- gr. 10 ad aquae § 1, may be dropped twice a day into the eye, after it has been first cleansed by syringing away the discharge with cold water. 2d. Lotions of Alum, or Alum and Sulphate of Zinc (F. 38, 40), should be used at least once every hour, to wash away the discharge as often as it accumulates. The lotion should be gently injected over the surface of the globe by a syringe or India-rubber bottle, so as to thor- oughly wash away all purulent matter at each applica- tion. 3d. Cold is very grateful to the patient, and may be applied, during the intervals between using the lotion, by placing a fold of lint wet with iced water over the ej^elids and changing it as often as it becomes hot or dry. The patient may als6 be allowed to wash away the discharge with a piece of linen dipped in the iced water as fast as it exudes from between the lids. By a steady perseverance in this line of treatment, the best chance of saving the eye is afforded to the patient ; but the disease is frequently of so virulent a character, that, in spite of all remedies and the most judicious man- agement, the cornea sloughs, and the eye for all useful purposes is irretrievably lost. There is a form of gonorrhoeal ophthalmia consequent on the virethral discharge, but which is not produced by inoculation. The two eyes are affected simultaneously within a few days or a week after the appearance of the gonorrhoea. It closely resembles a very severe attack of catarrhal ophthalmia. I have had one gentleman under 8 26 DISEASES OF THE CONJUNCTIVA. m}' care who has had three attacks of this form of inflam- mation of the eyes, coming on each time shortly after he had contracted a fresh gonorrhoea. The purulent dis- charge from the eyes was at one time so copious that I thought it must have been caused by inoculation, but its reappearance in both eyes with each recurrence of the urethral discharge has now convinced me that it was due to other causes. I should add that this patient, with each attack of gonorrhoea, suffered severely from gonorrhoeal rheumatism. It is possible that this form of ophthalmia may be due to the same absorption of the poison as that which induced the rheumatism, and that the discharge from the ejes is an attempt to eliminate it through the mucous surfaces of the globe and lids. Another explana- tion is, that in some people there exists a peculiar sym- pathy between the mucous membranes of one part of the bod}^ with those of another ; thus, it is not vmcommon to find in common catarrh the whole mucous lining of the body more or less aflected at one time ; and in one gen- tleman with whom I am acquainted a severe catarrhal at- tack is frequentl}^ accompanied by a discharge from the urethra. Treatment. — The same as for the gonorrhoeal ophthal- mia caused by inoculation ; but as the symptoms are less severe, so the strength of the remedial applications to the eye may be reduced. The patient should be prescribed a good nutritious diet, with a moderate allowance of stimu- lants. Diphtheritic Ophthalmia is a disease which is almost unknown in England. It was first described b}' Y. Graefe,* who has witnessed several epidemics of this peculiar affec- tion. * Archiv. f. Opbthal. p. 1G8. 1854-5. DIPHTHERITIC OPHTHALMIA. 27 Sym2:)toms. — The disease usually commences suddenly in the upper eyelids, which become red, swollen, and rigid from fibrinous effusion into the subcutaneous tissues. The conjunctiva of the lid is found, on eversion, to be smooth, dry, and pale from constriction of the palpebral vessels. The lower lid then becomes similarly affected, and the conjunctiva of the globe chemosed, not, as in ca- tarrhal ophthalmia, from serous effusion, but from exuda- tion of fibrin. As the disease advances, the swelling and redness of the lids increase ; there is great pain and heat, and a thin discharge with flocculi of 13'mph oozes from the eye. This, after a few days, becomes purulent, and the rigidity of the lids begins to subside. During the prog- ress of the disease, fibrinous exudations will occasionally take place on the conjunctival surfaces of the lids and globe, either as- small isolated gray patches, or else as a continuous membrane, which may be peeled off. The cornea is speciall}'- apt to suffer in this disease. It first becomes hazy, portions of its epithelium are then de- tached, and an ulcer is formed, which nia}^ lead to perfo- ration and prolapse of the iris, or parts of the cornea may slough. During the process of repair, which afterwards follows, the fibrinous exudations on the lining membrane of the lids are thrown off, and the conjunctiva appears almost bared of its epitheUum. Cicatrization and con- traction now set in, and not unfrequently cause some in- version or eversion of the lid. Treatment. — At the commencement of the disease. Yon Graefe recommends a strictly antiphlogistic treatment ; and if the health of the patient admits of it, he places him quickly under the influence of mercurj^ As local ap- j^lications, he relies chiefly upon iced compresses to the eye and leeches to the temple, the latter being frequently used in large numbers. In the second stage, when there is a purulent discharge, 28 DISEASES OF THE CONJUNCTIVA. he advises the conjunctival surfaces of the lids to be touched with the solid mitigated nitrate of silver (F. 5, No. 2); or, if j^referred, they may be painted with a solu- tion of the strength of gr. 10-gr. 20 ad aquffi ^ 1. After the nitrate of sih'er has been applied, either by stick or in solution, thirty or forty seconds should be al- lowed to elapse, and then a stream of cold water, or weak salt and water, should be directed over the parts, to wash away any surplus of the drug which ma}' remain, and prevent its affecting injuriously the cornea. When the lids cannot be everted, either on account of the swelling or pain, a solution of the nitrate of silver, gr. 1 — gr. 5 ad aquae ^ 1, may be dropped twice daily into the eyes ; or they may be washed out with an astringent lotion (F. 39, 40) thrown beneath the lids by means of a syringe. Granular Lids — Granular Ophthalmia; Trachoma; Granulations These terms have been applied to a rough and granular state of the lids, which induces a chronic muco-purulent discharge from the conjunctiva, and pan- nus of the cornea. Granulations are usually the result of purulent or contagious 0])hthalmia, or of some long-cou- tinued conjunctival inflammation. There is, however, one form of granular lids produced by vesicular granulations, which may originate without an}- previous severe or pro- longed aflection of the conjunctiva. Granulations ma}' be divided into two classes — the true and the vesicular. The true granulations are those which arise from puru- lent ophthalmia, or from any chronic irritation of the con- junctiva. The inner surfaces of the lids lose their bright polish and smoothness, and become rough from the growth of numerous small vascular projections. These granula- tions are ^tartly produced by an hypertrophy of the papillae of the lids, but partly also by an inflammatory GRANULAR LIDS. 29 exudation into the connective tissue of the conjunctiva, to which is principall}' clue the subsequent cicatricial changes. During the earl}^ stages the granulations are red, highly vascular, and l)leed easily on being pressed or rubbed with the finger. The mere effort of everting the lids, which are usuall}^ somewhat thickened, is sufficient to make them bleed. In the later stages the granulations become paler and fewer in number, and the conjunctiva between them grows anjemic and shrunken, with a bright tendinous lustre like cicatricial tissue. At the commence- ment of the disease there is fulness and hyperemia of the palpebral conjunctiva, whilst at its termination there is anaemia and consolidation. The appearances of the gran- idations vary considerably, according to the severity of the inflammation which produced them, the stage at which they have arrived, and the treatment to which they have been subjected. In some cases the palpebral conjunctiva is coA'ered with small, red, villous-looking granulations of a nearly uniform size ; in others, with red granulations varying in size and shape ; whilst frequently the granula- tions are pale, flabb}", and scattered, with the spaces be- tween them apparent!}' occupied by cicatricial tissue. Vesicular Gi-anulations. — These appear as small, round, whitish bodies, scattered on the conjunctiva of both the upper and lower ej'clids, slightl}'^ projecting from the sur- face, and usualty in the greatest numbers about the oculo- palpebral fold of the upper lid. They have been likened to boiled sago-grains, or to frog's spawn, or to the vesi- cles of an herpetic eruption. They look as if the}^ con- tained a little semi-transparent fluid, but the}' are solid growths, and so firml}^ implanted that it is very difficult to remove them, as when punctured they will not easily shell out from the subconjunctival tissue in which thej'^ are imbedded. The}^ are met with both in children and adults, but they are most liable to occur amongst masses 3* 30 DISEASES OF THE CONJUNCTIVA. of people who live iu a crowded atmosphere, with neglect of all sanitary arrangements. Hence it is that they are so frequently seen amongst the children in workhouses, the poor Irish in large towns, and amongst soldiers in baiTacks. Vesicular granulations are contagious, and due to malarious influences ; and, from the constant irri- tation they keep up, are very apt to lead to the formation of the true conjunctival granulations. They may exist for some time without giving any greater anno3-ance than a slight sense of pricking, and a little stickiness about the lids in the morning. In most cases, however, there is lachrymation, with a constant feeling of grittiness of the eye, and a slight muco-purulent discharge ; and if the disease is advanced, a nebulous and vascular condition of that portion of the cornea which is subjected to the fric- tion of the upper lid over it. The severity of the symp- toms vary, but they are always increased by exposure to glare or to cold winds. Symptoms. — A feeling of constant grittiness and a sense of heat in the eye, with some photophobia, and a muco-purulent discharge suflicient to cause the lids to gum together in the morning. There is redness of the caruncle and tarsal margins, and in advanced cases the upper lid droops as if it hung heavily over the eye. As the disease progresses, the cornea suflers from the con- stant friction of the roughened palpebral conjunctiva.' It becomes vascular and nebulous, its surface grows uneven, and at points frequently ulcerates. This vascular con- dition of the cornea, dependent on granulations, has been termed " trachomatous j^ojinus,^^ to distinguish it from that pannus which is the result of corneitis induced from other causes. In some cases the pannus is confined to the upper half of the cornea, the part which is under the cover, and, consequently, subjected to the friction of the tipper lid ; but in granulations of long standing, the whole GRANULAR LIDS. 31 surface of the cornea becomes vascular, every portion of it being pervaded with bloodvessels. All these symptoms are greatly increased if the eyes are overworked, or ex- posed to cold winds or bright lights. Occasionally the eyes will become acutely inflamed, constituting the con- dition described as Acute Granidai" Ojjhthalmia; the lids are then red, swollen, and spasmodically closed from the excessive photophobia, and any attempt to open them is foUow^ed by a gush of hot tears, with some muco-purulent discharge. Under treatment, these acute symptoms will gradually subside, and the eyes will again relapse into their previous state of chronic irritability. Prognosis Judicious management, coupled with the reparative power of time, will generally succeed in oblit- erating the granulations and restoring a smooth surface to the palpebral conjunctiva. If the disease has been slight, or of only short duration, there is good reason to hope that the eye will so recover from the irritation to which it has been subjected, that it will regain the greater part, if not the whole, of the sight it had lost. If, how- ever, the granulations have been severe and long-con- tinued, they will probably have i^roduced mischief which neither time nor remedies will ever completelj'^ eradicate. The conjunctiva will frequently become changed, both in appearance and structure. Although its surface may have grown smooth, yet it will be more contracted and dense than formerly, and have acquired in different parts a whitish, glistening aspect, closely resembling cicatricial tissue. This contraction of the palpebral conjunctiva is the most frequent cause of entropion and distichiasis. (See articles on each of these subjects.) The cornea, from the constant friction of the rough- ened lids against it, will often become so uneven, vascu- lar, and cloud^', that for all useful purposes the eye will be practically blind. 32 DISEASES OF THE CONJUNCTIVA. Treatment. — The object to be accomi^lislied is to re- store a smooth surface to the lining membrane of the lids by the obliteration of the granulations ; but in endeavor- ing to gain this end, care must be taken to avoid the use of all strong remedies which will destro}' the conjunctiva, and produce deep cicatrices. The treatment from which I have found the greatest benefit has been the application to the palpebral conjunctiva of a strong solution of the nitrate of silver, var3dng in strength according to the severity of the case, from gr. 5 — gr. 20 ad aquse | 1. This should be applied in the following manner : The patient is to be seated in a chair, and the surgeon, standing be- hind him, with a probe everts the upper lid so as fully to expose the palpebral conjunctiva, over the surface of which he paints, Avith a camel's-hair brush, the solution of the nitrate of silver, taking care to appl}' it thoroughly to the reflection of conjunctiva which forms the oculo-palpe- bral fold. After waiting for about half a minute, he then, with a syringe, gently squirts over the granular surface a stream of cold water, or, what is better, a solution of com- mon salt of about the strength of gr. 10 ad aquie 5 1, to wash away and neutralize all the surplus nitrate of silver, so as to prevent its irritating the eye, or blackening the ocular conjunctiva, — a misfortune I have seen occur when strong solutions of the caustic have been frequentl3' used without taking these precautions. This application should be repeated every second or third day, and in the inter- vals the patient should frequently- bathe the ca'cs with cold water, and every night and morning drop into them a little of a weak solution of the chloride of zinc (F. 19), or some other mild astringent. The nitrate of silver ma}' be also conveuientl}- applied to the granulations by using the diluted nitrate of silver points (F. 5). Suljiihafe of Cojyjier, or a combination of this salt with alum, " lapis divinus," or " greenstone," as it is com- GRANULAR LIDS. 33 raonly called (F. 4), are excellent astringents in granular lids. Every second or third day the lid should be everted, and having first dried the surface with a piece of linen, the granulations only should be freely touched with the sulphate of copper or greenstone, taking as much care as possible to prevent the caustic from affecting the con- junctiva. Between the applications a few drops of the guttfe cupri sulphatis (F. 21) should be dropped twice a day into the eye. Acetate of Lead is a useful remedy when there is ex- cessive roughness from the whole palpebral conjunctiva being covered with red granulations of varying sizes, but unattended by any acute inflammatory symptoms. The acetate of lead should be finel}^ powdered and laid over the granulations, and, after waiting one or two minutes, the surplus should be washed off with a stream of cold water. This application does good, first, b}' rendering the surface more smooth by filling up the chinks between the granulations, and afterwards hy its astringent powers causing them to shrink. It may be repeated three or four times, at intervals of from three to six days. Liquor Potassee. — Mr. Dixon speaks very highl}' of the benefit to be derived from the local application of liq. potassae to the granulations. He says : " The fluid is dabbed upon the everted lids, so as to be thoroughly brought into contact with the whole surface." And fur- ther on he remarks: "It may be applied at intervals of a few days ; and in some cases I have seen the granulations removed, and much of the original clearness of the coi:nea restored, in the course of six weeks."* When there are severe inflammatory sjTnptoms, as in " acute granular ophthalmia," it is best to postpone the use of astringents until they have partiall}" subsided. In * Dixon on Diseases of the Eye, third edition, p. 56. 34 DISEASES OF THE CONJUNCTIVA. sTich cases great relief is often derived from applying a slight compress and bandage (F. 2) over the closed lids, and onl}^ removing it for the purpose of bathing the eyes three or four times during the twenty-four hours with the lotio belladonnse (F. 32), or the lotio belladonnas cum alumine (F. 33). If, however, as sometimes happens, the compressing bandage should ])rove hot and uncomfort- able, it should be given up, and in its place a fold of lint wet with the lotio belladonna cum alumine (F. 33) should be suspended over the eye by a piece of broad tape tied round the forehead. As soon as the swelling and redness of the lids have sufficiently abated to allow of their being everted without much pain, a weak solution of the nitrate of silver should be painted once daily over the palpebral conjunctiva, and in the intervals between the applications the belladonna lotion may be continued. Even in cases of granular lids, where there are no severe inflammatory s^'mptoms, but where the photophobia and lachr3-mation are excessive, I have often found benefit from the use of the compressing bandage, as by it the eye is kept com- pletely at rest, and the friction between the lids and the cornea is prevented. Inocidation wdth purulent matter for the cure of severe granular lids is a most successful mode of treatment. It requires, however, great caution in the selection of cases fitted for this procedure, and also in the choice of the pus with which to inoculate the eyes. The whole, or certainly two-thirds, of the cornea should be so permeated with vessels as to render it semi-opaque, as the purulent oph- thalmia established bj'^ the inoculation is xevy liable to in- duce sloughing in anj^ portion of it which is quite trans- parent. The pus should be chosen from the e3'e of an infant suflTering from purulent ophthalmia. Its strength may be determined, firstly, l)y the color, and, secondly, by the severity and duration of the inflammation it has GRANULAR LIDS. 35 excited iu the eye from which it is takeu. The yellow pus is always more active than the whitish discharge seen in slight cases of purulent ophthalmia. The period of the disease at which the pus is taken influences materially the amount of inflammation and suppuration it is capable of setting up. Pus from the eye of an infant in the early and most acute stage of purulent ophthalmia will produce more serious effects than that taken from the same eye at a later period of the disease, after it has undergone some treatment and is on the decline. If one e3'e only is to be inoculated, the other should be tied up so as to protect it from contagion. Mr. Bader, who has had great experi- ence in inoculation for granular lids, advises that a la^er of Canada balsam or gum mastic should be spread over the skin of the closed eyelid and adjacent side of the nose, and upon this should be placed sutficient wadding to fill up the hollow to a level with the bridge of the nose, and over the whole a single turn of a light bandage should be fastened.* Great care and cleanliness will be required during the whole of the treatment to prevent the other eye from becoming infected ; the bandage should be changed dail}", and readjusted as often as it becomes loose. To inoculate the eye, a single drop of pus should be taken with a small scoop, or the end of the little finger, from the eye of an infant with purulent ophthalmia, and placed on the conjunctiva of the lower lid. In from eight to twentj^-four hours the first symptoms of purulent oph- thalmia will begin to show themselves, and will rapidly increase until the disease has reached its height. The ac- tivity of the inflammation usually lasts from eight to ten days, but the discharge will not completely abate for six * Bader on the Natural and Morbid Changes of the Iluman Eye, p. 115. 36 DISEASES OF TUE CONJUNCTIVA. or eight weeks. As soon as the discharge becomes pro- fuse, the patient should be allowed to wash the eyes with cold water every hour, or even oftener if he desires it, and if there is much pain he may use iced-water, and when lying down keep a fold of lint wetted with it over the eyelids. No astringent application should be given to check the discharge, but the disease must be allowed to run its course uninterruptedly. The danger to be ap- prehended is sloughing, or ulceration of a portion of the cornea. During the progress of the inflammation it is often very difficult to decide whether the cornea is still entire, as from its red and swollen A'illous appearance it is difficult to even distinguish it from the surrounding vascular conjunctiva. The only test, then, is to notice its curvature ; and, if this remains unchanged, and there is no depression in one part with a lump of swollen granu- lations in another, no anxiety need be felt. The patient should be allowed a liberal meat diet, with a fair amount of stimulants, during the whole period of treatment. If his appetite or strength fail, quinine or bark (F. 61, 64) should be prescribed ; and if from the pain his nights are disturbed, opiates may be given at bedtime. It should be remembered, that although inoculation will obliterate the granulations from the lids, and the vessels from the cor- nea, yet it will not efface previously existing nebulosities. Some operation is often afterwards required to alter the shape of the pupil, so as to bring it opposite that por- tion of the cornea which is most transparent. The re- sults of my experience of inoculation in severe cases of granulai" lids have been most brilliant. I have seen pa- tients practically blind for years, and condemned to the workhouse, regain sufficient sight to resume their former occupations. Syndectomy — Peritomy This operation was first SYNDECTOMY. 37 practised b}' Dr. Furnari, of Paris, in 1862.* It consists in excising a band of conjunctiva and subconjunctival tissue of about one-eighth of an inch in width from around the cornea and close up to its margin. It may be performed in the following manner: The patient being placed under chloroform, and the lids widely separated with a spring speculum, a fold of conjunctiva is to be seized with a pair of finely-toothed forceps, and with a pair of blunt-pointed curved scissors an incision is to be carried through that membrane around the cornea, and at about one-eighth of an inch distant from it. The band of conjunctiva surrounding the cornea is now to be dis- sected off, and all the subconjunctival tissue and vessels between it and the sclerotic care full}' removed close up to the corneal margin. The operation being now com- pleted, the lids are to be closed and covered with a wet compress and a bandage. Dr. Furnari recommends that after the excision of the band of conjunctiva and submucous tissue, the exposed surface should be freely touched with the nitrate of silver; but this is a most daugerous proceeding, and in the few cases in which it has been tried in this country, has pro- duced very prejudicial results. After three or four days, the wound will be found covered with lymph, and in a few weeks it will be perfectly closed, partl}^ from contrac- tion of the surrounding conjunctiva, but partly also by the formation of a smooth cicatrix tissue. This operation is well suited for severe cases of pannus which continue after the granulations of the lids have been obliterated ; but my experience of it, for the cure of granulations, is that it is unsuccessful. I have, on several occasions, per- formed syndectomy as a preliminary to inoculation, and allowed the eye to recover from all effects of the opera- * Gazette Medicale, Nos. 4-6, 8, &c., 18G2. 4 38 DISEASES OF THE CONJUNCTIVA. tion before introducing the pns. The virulence of the purulent ophthalmia seemed to have been materially di- minished by the removal of the portion of conjunctiva, and by the broad cicatrix which it had produced around the cornea. For a detailed account of these cases, see "Roj^al London Ophthalmic Hospital Reports," vol. iv, page 182. Pterygium is a peculiar morbid growth of the conjunc- tiva and subconjunctival tissue. It is of a triangular shape, with its base usually at the semilunar fold close to the inner canthus, and extending outwards it gradually tapers to a rounded end w^hich is implanted on the sur- face of the cornea, generally reaching to a point oj^posite the inner margin of the pupil, and sometimes spreading halfway across it. I have never seen the pupil com- pletely occluded by the growth. A pterj-gium is more or less vascular, and one or two large conjunctival ves- sels may be frequently seen coursing along it. In some cases it is red, fleshy, and prominent, whilst in others it is pale and membranous, and so thin as to be almost translucent. A pterygium is almost invariably a single growth con- fined to the inner half of the eye, although to this there are occasional exceptions, and cases have been reported where there have been two pter3'gia, one on each side of the cornea, and also where the}' have occurred in the up- per and lower parts of the eye, in lines corresponding with the superior and inferior recti muscles. The disease may be limited to one e3'e, or both may be affected by it. I have seen man}^ cases in which a pterj^gium existed in both eyes ; in all of them the growths were symmetrical. Patients about the middle age are most liable to ptery- gium, and especially those who have served long in trop- ical climates. It is seldom seen in the young. The dis- PTERYGIUM. 89 ease is of slow and almost imperceptible growth, and it is not until it lias attained a considerable size that it causes any annoj-ance. When it extends partially over the pupil it interferes with vision. Treatment. — There are only two ways of efficiently dealing with a pterygium. It may be excised, or its apex may be transplanted from the cornea to a part of the conjunctiva, where, even if it were to grow, it would cause no impairment of vision. No local application to the eye will be of any benefit in eradicating the disease. 1. Excision of the Pterygium. — The lids being sepa- rated by a spring speculum, the pterygium is to be seized from above downwards by a pair of forceps and drawn slightly from the eye. With a pair of fine scissors or a Beer's knife, its attachment to the cornea is to be sepa- rated, and then, with a few snips of the scissors, the greater part of the pterygium, or the whole of it, if it be small, is removed. If the base of the growth is large, no attempt should be made to excise the whole of it, as the too free removal of the conjunctiva will cause a tight cicatrix, which will greatly impair the outward movements of the eye. After the pterygium has been removed, the cut edges of the conjunctiva should, if the gap is not too wide, be drawn together with one or two fine sutures. 2. Transplantation of the Pterygium. — This operation was first suggested and practised by Desmarres. I have tried it myself on many occasions, and have been well satisfied with the results. The operation may be per- formed as follows : The lids having been separated by the spring speculum, the extremity of the pterygium is to be seized with a pair of forcejis close to the cornea, and its union with that structure carefully parted by a few snips with a pair of fine scissors. One cut is then to be made with the scissors through the conjunctiva along the upper. 40 DISEASES OF THE CONJUNCTIVA. and another along the lower border of the pterj-gium. At the point of the lower free cut edge of the conjunc- tiva, to which it is desired to plant the apex of the growth, a smaU nick is to be made with the scissors, and into this the cone of the pterj^gium is to be fixed by a single fine thread suture. The pterygium, now separated completely from the cornea and implanted into the conjunctiva, generally wastes, and becomes so shrunken that it ceases to draw attention to the e^^e. Such has been the result in the cases in which I have performed this operation. The great advantage which transplantation offers over excis- ion of the pterygium is, that as there is no removal of a portion of the conjunctiva, there is afterwards no dense cicatrix to cause a drawing in of the eye, or to limit its movements outwards. Pinguecula is a term applied to a small j-ellowish patch which is frequently seen on the eye near the mar- gin of the cornea, and is apparently in the substance of the conjunctiva. In a specimen examined by Desmarres, the growth was found to be composed exclusively of h^^pertrophied conjunctival epithelium. It creates annoy- ance sometimes from its being a little conspicuous, but it is perfectly innocuous. If its presence worries the patient, it may be removed b}^ seizing hold of it with forceps, and snipping it off with a pair of fine scissors. Dermoid Tumors generally spring from the margin of the cornea and the adjacent sclerotic. The}- are usu- all}^ smooth, light-colored growths, covered with con- junctiva and with a few hairs sprouting from their sur- face. They are congenital, and consist of elastic and con- nective tissue and fat. Treatment. — The only waj' to get rid of these tumors ECCIIYMOSIS. 41 is by excision. Whilst operating, care must be taken not to dissect deeply into the sclerotic and cornea, even though the origin of the tumor should apparently be be- low their surfaces. Cysts of the Conjunctiva are generally the simple serous cysts. They usually appear as small round or oval translucent bodies, and occasion inconvenience only by their size or their position. Their most frequent site is in the fold of conjunctiva which is reflected from the lower lid on to the globe. They are easily removed by first seizing them with a pair of finely-toothed forceps, and then with a pair of scissors snipping through the portion of conjunctiva which holds them. Warts of the Conjunctiva usually grow from near the tarsal margins of the lids, but they may spring from other portions of the conjunctiva, and even cover a large portion of the globe. They may either be pedunculated or sessile. The proper treatment is excision. INJURIES OP THE CONJUNCTIVA. EccHYMOSis OF THE CONJUNCTIVA — Subconjunctival Hemorrhage — may be caused by a blow on the eye, by coughing, or by any violent exertion. The effused blood at first appears as a bright red mark, abruptly limited to a portion of the conjunctiva, but, during the process of absorption, the color loses its intensity, and passes through a variety of shades which diffuse themselves over the front of the eye. Treatment A few days' rest is generally all that is required. Cold applications are grateful, and may be used either by allowing the patient to sponge his eyes 4* 42 DISEASES OF THE CONJUNCTIVA. thi;ee or four times a day with cold water, or by prescrib- ing for him some cool evaporating lotion (F. 31, 41). Lacerations of the Conjunctiva covering the eye, but without any other injury to the eye or eyelids, are generally occasioned either by the patient striking his eye against some sharp projecting object which catches the conjunctiva and tears it as the head is moved away ; or else by some second person running a shutter, or a pole, or whatever he ma}^ be cariying, against the eye. The injury is usually followed by swelling of the lids and conjunctiva, often sufficient to render it difficult to make a thorough examination of the eye a few hours after the accident. Treatment. — The eye should be closed, some water- dressing should then be laid over the lids, and fastened in its place b}^ one turn of a roller. It is very rarely necessary to apply any sutures to keep in situ Uie torn edges of the conjunctiva, as they usually fall together of their own accord ; and there is seldom afterwards any sufficient strain to draw them apart or prevent union. An exceptional case might occur, in which sutures would be called for ; thus, if a flap of the conjunctiva was torn from the globe, so that it was reflected back on itself, one or two fine stitches would be required to hold it, after it had been restored to its proper position. When all the swelling of the lids and conjunctiva has completely subsided, if there is some muco-purulent discharge, two or three drops of a lotion of sulphate of zinc (F. 20) may be dropped into the eye twice a day. For diseases and injuries of the conjunctiva of the e^'e- lids, see section Diseases of Eyelids. COKNEITIS. 43 CHAPTER 11. DISEASES OF THE CORNEA AND SCLEROTIC. "CoRNEiTis — Keratitis — Inflammation of the Cornea — is a disease of impaii'ed nutrition most frequently seen in children and young people. It is met with in the pale and half-starved, as well as in the OA^er-fat and improp- erly fed child ; or it may be caused from some constitu- tional taint, such as struma or inherited syphilis. The two latter, however, present peculiarities which distin- guish them from the simple form of corueitis we are now considering. True or simple corneitis is a disease which extends itself over an uncertain period of time, runs a definite course, and with a strong tendency to get well if not thwarted by the injudicious use of drops and nos- trums, suggested by the zeal of the surgeon or the rest- lessness of the patient. Corneitis may be confined to the one e^'e, but both are generally affected. It usually com- mences in one eye, and steadily progresses until it has reached a certain stage, when the second eye becomes attacked, and passes through exactly the same series of symptoms. Both eyes are now affected, but the one in which the disease began is in advance of the other, and is the one first to recover. The interval which elapses before the second eye is involved is very variable, in some cases it may only be a few weeks, in others as long as three or four months. The progress of the disease towards recovery is verj^ slow ; it may vary, according to the acuteness of the attack, from six months to one and a half or two j^ears, dating from the commencement of the attack in the first eye to the ultimate recovery of that 44 DISEASES OF THE CORNEA. in the second. With the knowledge of these facts, the prognosis of the surgeon ought to be guarded. Synvptoms. — The disease usually commences with a pinkish redness of the ciliary region, shading off and be- coming lost in the general whiteness of the eye. This redness will occasionally be at first confined to one or more vascular patches around the margin of the cornea, or there may be present from the very beginning a dis- tinct pinkish tinge of the whole ciliary zone. The eye is irritable and shirks the light. The cornea now begins to look hazy and the sight is dimmed. As the corneitis ad- vances, the haziness of the cornea, the vascularity of the eye, and the intolerance of light increase. The brilliancy of the cornea becomes so dulled that it looks like a win- dow-pane which has been breathed on, or like a piece of ground-glass. One part of the cornea is frequently more deeply affected than another, and a patchy appearance is thus given to the cloudiness. There is generally consid- erable lachrj-mation, and oftentimes a good deal of pain in and around the eye, with a sense of grittiness of the lids. The disease having reached its height, the process of repair sets in. The vessels around the margin of the cornea shoot into the substance of the corneal tissue and give to the part of that structure which they invade, a red velvety appearance. In ver}" severe cases this condi- tion of pannus will extend over the greater part of the cornea. It is quite distinct in appearance from the vas- cular cornea, which is induced by the friction of granular lids. Gradually this excessive vascularity subsides, and, as the bloodvessels disappear from sight, patches of cor- nea again become transparent, until at length the repara- tive process is completed. Such is the course of a simple uncomplicated case of corneitis, which, having run through the various stages of the disease has terminated favora- bly. The disease, however, may not progress so satis- CORNEITIS. 45 factoril}^, aucl ulcers may form either at the margin or central portion of the cornea, which will considerably retard recovery. (See Ulcers of the Cornea, p. 58.) BesuJfs of Corneitis. — The ej'e may corapletel}' recover, the cornea regain its transparency, and the sight be re- stored. Generally, however, even in favorable cases, the acnteness of vision is diminished, either by a haziness so diffused and slight as not to be noticed by an ordinary observer, or else by a faint nebula which slightly invades the region of the cornea opposite the pupil. When the corneitis has induced ulceration or sloughing of the cor- neal tissue, there will always remain a more or less dense nebula or leucoma. Chronic Interstitial Corneitis, or inflammation of the cornea dependent on hereditary syphilis, was first accurately described b}^ Mr. Jonathan Hutchinson in his work on Sj'philitic Diseases of the Eye and Ear, pub- lished in 1863. Patients suffering from this affection usuall}^ present marked signs of constitutional syphiUs, or evidence can be obtained from the parents of their having had, during infancy, some specific symptoms. Mr. Hutchinson states that in almost all cases the subjects of this disease " present a ver^y peculiar physiognomy^ of which a coarse flabby skin, pits and scars on the face and forehead, cicatrices of old fissures at the angles of the mouth, a sunken bridge to the nose, and a set of perma- nent teeth peculiar for their smallness, bad color, and the vertically notched edges of the central upiper incisors, are the most striking characters." * He also notices the facts that this disease is frequently accompanied or preceded by iritis, and followed by such changes in the choroid as are often seen in heredito-syphilitic patients. * Syphilitic Diseases of the Eye and Ear, p. 30. 4G DISEASES OF THE CORNEA. Symptoms. — The disease usually commences in one eye •with a diffuse haziness near the central part of the cor- nea, which, when carefully examined, is found to consist of dots of opacity in the substance of the corneal tissue. These interstitial deposits increase in number and size, whilst some of them coalesce with others, gradually ren- dering the whole cornea opaque, with the exception of a circumferential band which commonly retains more or less of its transparency. The cornea loses its brilliancy, and ultimately assumes a dull ground-glass appearance; but the cloudiness is seldom uniform, patches of it being of deeper density than the rest. There is intolerance of light, var3-ing in intensity, but generally not ver}^ severe. There is supra-orbital pain and redness of the ciliary zone of vessels around the cornea. After a time the opacity of the cornea begins to clear, and gradually its transpa- rency and ijolish are either partially or entirety restored. It is, however, very rare that the recovery is complete ; patches of nebulosity remain which impair vision in ac- cordance with their situation and density. The second eye usualty becomes affected from one to three months after the first one, and runs through a similar course. In this disease ulcers of the cornea seldom occur. The duration of an attack of chronic interstitial corneitis from its commencement in one eye to its termination in the other, is general^ from twelve to eighteen months. The time will, however, necessarily vary with the extent and severity of the disease. Strumous Corneitis resembles, in its general charac- ters, the simple corneitis already described. The patients are usually children or young persons, who exhibit all the characteristics of struma. There is great photopho- bia and lachrymation, and a peculiar tendency to ulcera- tion, which may take place at one or more points on the CORNEITIS. 47 surface of the cornea. The disease is very tedious, and generally both eyes are aifected, but like most forms of corneitis one e3'e is attacked some weeks in advance of the other. General Treatment of Corneitis, — As this affection naturally extends over a long space of time, it is well to remember that the effects of remedies are slow, and that judicious treatment consists rather in guiding the disease to a favorable termination than in the endeavor to cut it short bj^ the use of powerful agents, which generally exert a prejudicial influence. Constitutional Treatment. — At the commencement of the attack the bowels should be cleared out by a purga- tive (F. 123, 124, 128); and if the attack is acute, and the dread of light severe, a saline mixture (F. 107), or one containing small doses of tartarated antimon}^ (F. 108), may be prescribed ; but these must, in a few da^'s, give way to tonics of the mineral acids with cinchona (F. 110), or to some of the preparations of iron, quinine, or both combined. During the continuance of the attack, the state of the health should be carefully attended to, and medicines should be prescribed or omitted as the case may seem to demand. Where there is great intol- erance of light and lachrymation, or where the patient is restless and sleeps badly at night, opiates are of great service, taking care that during their administration the bowels act regularly. Small doses of tinct. opii, or tiuct. belladonnse (F. 112), may be given with the bark mix- ture every four hours during the day ; or a larger dose of the opiate maj^ be ordered ever3' night. In children of two or three years of age, a powder of pulv. ipecac, comp. cum potass, nitrat. (F. 120), at bedtime, is often very useful in allaj'ing the excessive irritability and restless- ness which is so frequently seen in corneitis. 48 DISEASES OF THE CORNEA. In all cases of inflammation of the cornea, or indeed of an}' of the tissues of the eye in which there is a dread of light, the eyes ought to be protected from painful expo- sure to glare. In the house this is best effected by draw- ing down the blinds, or partially closing the shutters, and b}' shading both eyes with a broad light shade; but out of doors dark-colored glasses should be used. The neu- tral tint glasses are far more efficient in affording relief from glare than those of a cobalt-blue color. The}- may be obtained of any shade. In making a selection, those neutral tints should be chosen which do not contain much j-ellow. The cobalt-blue glasses, from being less un- sightly, are generall}' preferred b}' the patient, and in the slight cases of photophobia answer their purpose exceed- ingly well. The best form of spectacles are those with large curved glasses ; they sufiiciently protect the eye from light and wind, whilst they do not make it hot. The popular s^'stem of tying up the eye with a hand- kerchief to exclude it from light, is essentially wrong, and should not be allowed. In the Chronic Interstitial Coriieitis, Mr. Hutchinson recommends "the cautious use of mercurials and iodides, at the same time supporting the system b}' tonics and a liberal diet." He adA'ises a little of the mild mercurial ointment to be rubbed in behind the ear, or beneath the axilla, ever}' night, but a strict icatch should be kept to prevent the patient from becoming salivated. Inter- nally, the syrup of the iodide of iron (F. 114), or the mist, potassii iodidi cum ferro (F. 115), may be ordered; but should these medicines disagree, or the patient be very feeble, tonics of iron, quinine, or bark may be sub- stituted. In strumous children^ cod-liver oil and the syrup of the iodide of iron in small doses do much good. Where there is a tendency to rickets, the phosphites and hypophos- CORNEITIS. 49 phites of iron and lime, either singly or combined (F. 117), are often of service. But the greatest benefit will be derived from bracing country or sea-side air, strict cleanliness, and a well-regulated nutritious diet, in which pure milk and^ew-laicl eggs form a part. Local Applications. — In corneitis, sedatives to the eye give great relief, and of these belladonna is the most effi- cacious. When there is great irritability, a warm fomen- tation of belladonna (F. 8) may be applied to the closed lids bj^ means of a cupped sponge ; or, if cold is more agreeable to the patient, the eye may be frequently splashed with cold water, or a fold of lint wet with the belladonna lotion (F. 32) may be tied over the lids, and moistened as often as it becomes dry. A few drops of a solution of atropise sulph. gr. 2 ad aquae ^ 1 may be dropped two or three times a day into the eye when the dread of light is very severe. Thus frequently applied, it acts as a direct sedative to the ciliary nerves, and also paralyzes the accommodative power, and places the eye in a state of rest. It is, however, very difficult to use atropine drops in j^oung children, as the struggling which ensues whenever the attempt is made to put them into the eye often does more harm than the remedy is likely to do good. In such cases the compound belladonna ointment (F. 98), rubbed in over the brow night and morning, or the belladonna liniment smeared over the brow, will probably act beneficially. Stimulating appli- cations to the eye almost invariably do harm ; the^^ are very painful, and increase the irritation. Counter-irritation is often of great benefit. The brow and integument of the upper ej^elid may be painted with the linimentum iodi, taking care not to paint it too thickly on the upper lid. A stick of nitrate of silver moistened with water, drawn twice or three times across the slvin of the upper lid, is a good counter-irritant, and sometimes 50 DISEASES OF THE CORNEA. does rauch good in relieving excessive photopliobia. It must be applied cautiously, as when it is laid on too thickl}', it will blister, or even produce a slough of the skin, and, in addition, it is very painful. If the appli- cation of the iodine or the nitrate of silver affords relief, it ma}' be repeated at intervals of a few days or a week. Diffuse Suppurative Corneitis is generallj- the re- sult of an injury, such as a contused or lacerated wound of the cornea, but it may also come on from constitu- tional causes. It may follow an}^ operation on the eye in which the cornea is involved ; and it is one of the most fatal terminations of the operations for cataract. The state of health of the patient at the time of the injury de- termines very much the form of the inflammation which may arise from it. A simple incised wound or an abra- sion of the cornea, from which a strong healthy person would probably- recover, without an untoward symptom, in a few days, may be sufficient to induce in an unhealthy patient a diffuse suppurative corneitis which will destroy the e^'e. Symptoms. — The cornea grows dull and steamy; pus is effused between its lamellae, at first only in a small quan- tity at one sjjot ; but it soon increases and ditluses itself throughout the corneal structure. In severe cases I have seen the whole tissue of the cornea pervaded with pus, but in the slighter ones it is geuerall}' confined to one part. The eye is hot and painful ; there is great congestion of the conjunctival and sclerotic vessels, dread of light, and lachr3'matiou. The deeper parts of the e3'e partici- pate in the inflammation, the iris loses its mobility, the aqueous becomes seroiis, and pus is efiused into the ante- rior chamber (hypopion). The pus between the la^'ers of the cornea now makes CORNEITIS. 51 an exit for itself, and this it does by progressive ulcera- tion either anteriorly towards the surface, or posteriorly into the anterior chamber. In the majority of cases the corneal abscess bursts anteriorly, and a sloughing-looking ulcer is left. BesuUs of Suppurative Corneitis. — If the whole cornea has been involved in a diffuse suppurative inflammation, and pus has been effused throughout the whole or greater part of the corneal tissue complete loss of the eye must follow. If, however, the abscess of the cornea has been limited in extent, the eye may recover, but a leucoma will remain, which will impair the sight in proportion to its size, density, and position with respect to the pupil. It will be well to explain here the meanings of the terms hypopiou, onyx, and abscess of the cornea, as con- siderable confusion prevails amongst students as to their right application. Hypopioyi is an effusion of pus into the anterior chamber. Onyx is often indefinitely used to signify a collection of pus between the lamellae of the cornea ; but it is only applicable to those small effusions at the lower pai't of the cornea, from the fancied resemblance of which to the pos- terior end of the finger-nail it has derived its name. Abscess of the Cornea and Onyx are, by many, regarded as synonymous terms ; but as the word " onyx " indicates the appearance and locality of the disease rather than the disease itself, the term " abscess " should be considered as applicable to those larger effusions of pus between the corneal lamellae into which onyx occasionally passes, or to the diffused purulent infiltrations which are the result of diffuse suppurative corneitis. Treatment. — Warm fomentations of belladonna (F. 8), or of poppy-heads to the eye ; and, in the intervals, be- tween using the fomentations, a fold of linen wet with the 52 DISEASES OF THE CORNEA. belladonna lotion (F. 32) maj^ be laid over the closed lids. It will be useless to attempt to evacuate the pus from between the corneal laniellix?, it is so thick and iiifdtrated that it will not escape through any external incision. Parace»tesis of the cornea, or tapping the anterior cham- ber with a broad needle and letting the aqueous slowly escaj^e will often be of service, and may be repeated at intervals of one or two daj'S if it gives relief. Paracentesis of the Cornea may be performed as fol- lows : A broad needle is made to puncture the cornea towards its lower margin, the point being kept well for- wards towards the cornea to avoid wounding the lens, when, by suddenly turning the flat of the blade on to its edge so as to render patulous the opening it has made, the aqueous is allowed to nin off. As soon as the iris closely approaches the cornea, which it will do when the aqueous has nearly escaped, the blade of the needle should be again turned on the flat, and quickl}^ with- drawn from the eye. For the constitutional treatment, the patient should be supported with a liberal diet and a fair allowance of wine or beer. Diffusible stimulants (F. 54) and tonics (F. 63, 64) are the most suitable medicines ; and if there is much pain or inability to sleep, oj^iates should be given either in small doses during the da}', or in one full dose at bed- time. Attention should be paid to the regular and healthy action of the bowels, and, if necessary, some mild purga- tive or alterative be prescribed. Marginal Corneitis. — This name is well applied to a low form of inflammation which commences at the ex- treme border of the cornea, and creeps on slowly, slightl}' invading the corneal tissue for a short distance, but sel- dom, if ever, involving the whole of its structure. Sijmptoms. — It commences with slight dread of light, CORNEITIS. 53 lachrymation, and grittiness of the eye, which increase in intensity as the disease advances. On examining the eye, there will be found at one spot close upon the cor- nea a vascular patch, and the corneal edge which corres- ponds to it looks swollen and softened. This condition may involve a third or even more of the margin of the cornea, but it seldom includes the whole of its circumfer- ence. In a few days a small diffused haze will be noticed near the margin of the cornea, and this will gradually ex- tend, sometimes so as to include the part which is oppo- site the pupil, but it rarely invades the whole cornea. Occasionally this form of corneitis is accompanied with one or more small marginal herpetic ulcers, so as closely to resemble the phlyctenular ophthalmia. The disease is tedious ; it may be acute at the onset, but, in its dura- tion and recovery, it is generally chronic. It is also very recurrent. The patients who are most liable to marginal corneitis, are those who are in a low 'state of health. It is, consequentl}', met with amongst the anxious and over- worked, and in mothers who are enfeebled from over- lactation ; or it may be brought on by any exhausting disease, such as leucorrhoea or menorrhagia. Tr-eatment. — The eye should be shaded from strong lights, and rested, as far as practicable, by the avoidance of reading, writing, and all kinds of close work. If there is much dread of light, gutt. atropire (F. 13) maybe used once or twice daily ; or the Qje, may be bathed frequently with a lotion of atropine (F. 31), or of belladonna (F. 32). If the marginal corneitis is apparently dependent on overwork or close confinement to business, change of air and recreation are the most powerful curative agents. The medicines which do the most good are tonics of bark or iron, combined with the mineral acids, or with small doses of liq. strychnise, or tinct. nucis vomicae (F. 59, 60, 61, 68, 70). 5* 54 DISEASES OF THE CORNEA. Phlyctenular Ophthalmia — Scrofulous Ophthalmia — is most frequent in young children from two years old and upwards ; but it is seldom seen in patients after the age of puberty. It is characterized by intense intoler- ance of light ; the photophobia is greater in this than in an}' other disease of the eyo.. In severe cases the child is commonly seen with the lids tightly closed, and with a fist over each eye, or Avith his face buried in the dress of the nurse who is carr3'ing him. An}- attempt to look at the e3'es is met by violent spasmodic contraction of the lids, and if, after severe struggles, the lids are parted, the globe is found to be so turned upwards that it is impos- sible even to see the cornea. The exposure of the ej'e to the slightest light often brings on a fit of rapid sneez- ing. In such cases, when it is desired to see the 63-6, the child should be given a few sniffs of chloroform, suf- ficient to dull his sensibility, without putting him com- pletely under its influence. An examination can then be made without any struggling, but, in addition to this the chloroform often exerts, by its sedative influ- ence, a very beneficial effect on the e3'e, and the child awakes from his sleep with a decided diminutioji of the photophobia. It will be often found that the severit}^ of the s3'mptoms is quite out of proportion to the apparent disease ; frequently there is but little to be seen except one or more small phl3ctenulre close upon the margin of the cornea. These phlycteuulffi are, however, of an her- petic nature, and run a course somewhat similar to an herpetic eruption on other parts of the bod3\ At first the}^ appear as small vesicles, the contents of which soon become turbid; the vesicles then burst and form small superficial ulcers, which eventuall}' heal without leaving any visible scars to show where the3^ have been. The whole ej^e, in some cases, is much bloodshot, whilst in other instances, when the lids are first opened, the con- PHLYCTENULAR OPHTHALMIA. 55 jnnctiva is found to be scarcely tinged, but it soon flushes up on exposure to the light. Occasionally a leash of red vessels may be seen running up to one or two of the phlyctenule. Scrofulous ophthalmia is more frequent amongst the poor than the rich ; the strumous child is the most liable to it, but the impure air of dirty, confined lodgings, com- bined with an insufficiency of sunlight, improper diet, and want of care, will induce the disease in children who, under more favorable circumstances, would not sutTer from it. This form of ophthalmia is frequently associated with eczema, impetigo, sores about the nose and lips, and with enlarged cervical glands, indeed with all those kin- dred complaints which are so frequently met with amongst the poor scrofulous children in a London hospital. Scrof- ulous ophthalmia is tedious in its progress, and very re- current. Treatvient. — During the early and acute stage of the disease, when the photophobia is very intense, the vinum antimoniale, in doses of from njjlO to Tt)2 20 every four hours, often exercises an almost speciiic effect in reliev- ing the dread of light. If, however, it fails to do decided good in three or four daj^s, it should be discontinued. Sedatives will sometimes prove of great service, and small doses of tinct. hyoscyami, succus conii, tinct. bella- donna?, tinct. opii, or sol. morphite muriat., may be given singly at short intervals during the day ; or they may be combined with bark, or with the mineral acids, or with an}^ other medicine which the state of the patient may suggest. Where there is much debility with languor, and restlessness at night, mist, cinchonse (F. 110, 111), may be prescribed during the day, and pulv. ipecac, comp. cum potass, nitrate (F. 120), in doses of gr. 3 or gr. 4, according to the age of the patient, at bedtime. The preparations of iron are very valuable in scrofu- 56 DISEASES OF THE CORNEA. lous ophthalmia, but they should not be coutinued for too long, or be ordered with a hot skin and furred tongue. In decidedly scrofulous children, the syrup, ferri iodid. or the syrup, ferri hypophosphit. in doses n)j 15 to tijj 20, twice a day in water, are of much benefit. Where there is simply anaemia, the ferrum redactum gr. ^ to gr. 1, or the ferri carl), cum saccharo, in doses of from gr. 1 to gr. 5, are the best. Cod-liver oil may be often advantageously prescribed with the iron ; it is especiallj^ serviceable where there are evidences of failing nutrition. The regular and healthy action of the bowels should be strictly attended to, and purgatives ordered when necessary. If the child suffers from ascarides, means should be taken to rid him of them. This is best done by an injection of two or three ounces of infusion of quassia into the rectum ; or, if this fails, an injection with a few minims of tinct. ferri sesquichlorid. to the ounce of water may be used. After the injection, a powder of cal. cum scammon (F. 127, 128) should be given. Local apjMcations may be considered under two head- ings : a. Sedatives to the eye. /3. Counter-irritants. a. Sedatives to the Eye. — Of these the most useful is the sulphate of ati'opia, a solution of which gr. 1 ad aquae ^ 1 may be dropped into the eye three or four times daily. Unfortunately the use of this remedy is very often im- practicable, from the resistance the child offers to every attempt to put the drops into the 63*6. When there is much struggling the drops ought to be discontinued. Much comfort is frequently obtained from bathing tlie eyes with the belladonna lotion (F. 32), and, when the child is asleep, applying a fold of linen wet with the lo- tiou over the closed lids ; or iced water may be used in a similar manner. The belladonna liniment of the British Pharmacopeia rubbed into the brow Avill occasionally aflbrd ease ; or the unguent, belladonna} comp. (F. 98), CORNEO-IRITIS. 57 may be applied over the brow and temple, and allowed to remain on dnring- the daj^ When there is eczema of the lids, the best application is the lotio boracis (F. 48). /?. Counter-irritants. — 1. A stick of nitrate of silver moistened with water may be drawn once or twice across the skin of the npper lid. It is a painful application, but it frequentl}' gives marked relief. 2. The liuimentum iodi may be painted over the brow and upper eyelid, taking care that none of it runs between the lids into the e^-e. Over the integument of the lid it must be painted lightly, as it soon blisters. 3. Small blisters, the size of a sixpence or shilling, ap- plied to the temple. If the emplast. cantharidis is used, the blisters should be removed at the expiration of four hours. For children, the best and least painful blister is Brown's cantharidine or blistering tissue. Corned-Iritis is an inflammation of the cornea and iris. The disease usually commences in the cornea, and after- wards extends to the iris. It mostly occurs in patients enfeebled by disease or excessive work, and in those who have previously suffered from sjphilis. Symptoms Haziness of the cornea, ciliary redness, a sluggish and irregular pupil, pain in the eye and around the orbit, and frequently great photophobia and lachry- mation. Treatment The pupil should be kept dilated with the guttae atropiae (F. 13), dropped twice dailj' into the ej'e, or the lotio belladonnje (F. 32) may be frequently' used. If there be much pain in the eye and around the brow, a little of the unguent, hydrarg. cum belladonna (F. 99), rubbed into the temple night and morning, often affords relief. As the patient is generall}' in a low state of health, tonics of quinine and iron (F. 65, 66), or bark with the mineral acids {F. 61), should be prescribed. When, how- 58 DISEASES OF THE CORNEA. ever, there is a distinct sj'philitic history, the mist, potass, iodid. (F. 74), or the mist, potass, iodid. cum ferro (F. T3), should be given. It is seldom advisable to give mer- cury internally in these cases. The disease is one of low power, and all the benefit lil^ely to be gained from mer- cury will be obtained by the inunction of the unguent, hydrarg. cum belladonna into the temple. ULCERS OF THE CORNEA. Ulcers of the Cornea may be caused by seA^ere in- flammation of the conjunctiva or cornea, and may occur during the progress of the attack. They are thus fre- quentl}^ seen in purulent and gonorrhoeal ophthalmia, and in corneitis, especially in the strumous and diffuse sup- purative forms of the disease. There are, however, some special ulcers which seem to originate in the cornea, and not to be secondary to active inflammation of either that structure or of the conjunctiva. Ulcers of the cornea are always indicative of impaired health, and are conse- quently met with in the feeble, the overworked, the stru- mous, and the rheumatic patient. The}^ are alwaj's ac- companied with i^ain and grittiness of the eye, photopho- bia and lachrymation. The cornea, except in the imme- diate vicinity of the ulcer, may retain its transparency^, but the conjunctival surface of the globe is usually more or less reddened, and rapidly flushes on undue exposure of the eye to light. Ulcers of the cornea may be either acute or chronic, superficial or deep. Superficial Ulcers of the Cornea are most fre- quently met with in young people, and especially in deli- cate children. The disease may be confined to one eye, or both may be affected, or they may be attacked alter- nately. There is considerable photophobia and lachry- ULCERS OF THE CORNEA. 59 mation, with a sense of heat and grittiness in the e3'e. There are two forms of superficial ulcers of the cornea : the nebulous and the transparent ulcer. The Superficial Nebulous Ulcer may occur at any part of the cornea, either towards its periphery or its centre. Carefully examined, it appears as a small, irregular, ill- defined, grayish-looking ulcer. The edges of the ulcer are frequently slightly raised, and of a darker gray tinge than the central portion, which will be found occasionally almost transparent. The ulcer having been formed, it may remain almost stationary for a short time, and then begin to heal. This is the course which such superficial ulcers usually run ; it is exceptional for them to penetrate deeply the corneal tissue and to lead to perforation and prolapse of the iris. As the ulcer advances towards re- covery, it first assumes a more opaque appearance ; the central excavation then becomes filled in and its edges bevelled. Frequently one or more red vessels may be seen running to it from the margin of the cornea ; these are vessels of repair, and ought, when they have accom- plished their duty, to become so reduced and contracted as to cease to be visible, or to interfere with the normal transparency of the cornea. Graduall}^ the opacity of the healing ulcer is reduced, and day by day the parts slowly become clearer, until at length complete or partial trans- parencj is restored. These ulcers of the cornea are gen- erallj^ acute at their onset, but they will often drift into the chronic state. Superficial Transparent Ulcers of the Cornea. — The symptoms which accompany the formation and progress of these ulcers, resemble those of the nebulous ulcer just described, and they occur amongst the same class of pa- tients. There is the same photophobia and lachrymation, with redness of the eye on exposure to light ; the only characteristic diff"erence being the appearance of the ulcer. 60 DISEASES OF THE CORNEA. On gently raising the lids so as to examine the eye, the epithelium of the cornea seems as if it were abraded or scratched off at one or more points. The transparency and polish of the cornea at this stage of the disease is unimpaired, and each ulcer, if there be more than one, is seen as a glistening facet. The first indication of a heal- ing action in these ulcers is shown b}^ their losing their transparency and becoming gray and cloudy, the cloudi- ness often extending beyond the margin of the ulcer. Their clear outline is soon lost, their slight excavation filled in, and the even surface of the cornea is restored. If the ulcer has not penetrated below the epithelium, transparency is regained ; but if it has extended into the true corneal structure, a nebula or semi-transparent leu- coma will be afterwards left. Treatment. — Soothing applications to the eye, which may be used either hot or cold in accordance with the feelings of the patient. Fotus papaveris, lotio belladonnae (F. 32), or, if there is great irritability^, the gutt£e atropias (F. 13), dropped into the eye three or four times dail}'. All stimulating drops or lotions are injurious. In chil- dren, an alterative powder of hydrarg. cum creta cum rheo (F. 122, 123), given ever}' second or third night, is very beneficial. If the skin is hot and the tongue furred, the mist, salin., or mist, antimonii tartarati (F. 10*7, 108), should be ordered ; but as soon as the secretions have become healthy, bark, the mineral acids, preparations of iron, and cod-liver oil, are the most suitable remedies. Deep Ulcers of the Cornea. — The superficial ulcers described in the preceding paragraphs may become deep, and so be rightl}^ included under this heading ; but this is not the course they usually pursue. There are, how- ever, certain ulcers, the tendency of which is to extensive destruction of corneal tissue, leading frequently to per- ULCERS OF THE CORNEA. 61 foration and prolapse of the iris, and to these the term " deep " is fitly applied. They may be seen in patients of all ages, and unless produced by injury, are usually dei:)endeut on some constitutional defect. Generally they proceed from want, but occasionally from excess. Sloughing Ulcers of the Cornea may be the result of a diffuse suppurative corneitis, induced either by in- jury or disease, the pus between the lamellae of the cor- nea having worked its way to the surface by progressive ulceration. Thej^ may also occur amongst the half-starved and overworked, as well as the drunken and dissipated. They must be then regarded as evidences of failing nu- trition and want of nervous power. A sloughing ulcer of the cornea usually presents an irregularly excavated sur- face, with a whitish yellow, sloughy appearance, and with its margins shelving and ill-defined. Around the ulcer the cornea is hazy. These ulcers often lead to complete destruction of the e3^e for all visual purposes ; but even when they yield to treatment and the eye recovers, it is always a more or less damaged organ. Sometimes they will perforate the cornea, and prolapse of the iris will follow ; or occasionally they will penetrate the true cor- neal tissue, but their further progress will be stopped by the postei'ior elastic lamina or Descemet's membrane. An aperture is then seen in the cornea, the bottom of which is closed by a transparent membrane (Descemet's), which projects slightly into the wound. In this condition I have seen the eye remain for man^^ weeks ; the corneal wound may then begin to granulate and heal, but gener- ally the posterior elastic lamina in the end gives way, the iris prolapses, and cicatrization follows. During the heal- ing process, the cornea in the immediate vicinity of the ulcer becomes more cloudy, red vessels are seen invading its substance and running towards the ulcer, and in some 6 G2 DISEASES OF THE CORNEA. cases in such numbers as to present a perfect pannus ; but these disappear from sight as soon as cicatrization is completed. The cornea in the locality of the ulcer may- resume its transparency, but the new material which has replaced that lost by ulceration will be more or less opaque and leucomatous. Treatment (see Treatment or Diffuse Suppurative CoRNEiTis). — There are, however, a few points to be spe- cially noticed. All stimulating applications to the ulcer, as a rule, do harm. The touching the ulcer with a stick of the diluted nitrate of silver, as recommended by some, is, I believe, in most cases, positively prejudicial. When there is severe pain in the eye, paracentesis of the cornea will often afford mucli relief. In a sloughing ulcer of the cornea, with increased intraocular tension, an iridectomy ; is of the greatest service. I have, in .my own practice, seen the whole train of distressing symptoms immediately relieved by the operation ; the ulcer has taken on a heal- ing action, and the eye has rapidly recovered. Crescentic or Chiselled Ulcers of the Cornea. — This is one of the worst and most intractable forms of ulceration to which the cornea can be subjected, but, for- tunately, it is one of the most rare. I have called these ulcers "crescentic," from their shape, and "chiselled," from their peculiar characteristic appearance, as if a poi*- tion of the epithelium and true corneal tissue had been cut away with a chisel, or scooped out with the thumb- nail from the margin of the cornea. The}' alwa3'S occur at the extreme edge of the cornea, but they are strictly confined to that structure, and do not in the slightest de- gree encroach upon the sclerotic. In their progress they follow exactly the. curve of the rim of the cornea, by which they are abruptly limited, the circumferential edge of the ulcer being cut sharply and deepl}'. They spread ULCERS OF THE CORNEA. 63 rapidly and increase both in length and depth. There may be two or even three of these ulcers at different parts of the margin of the cornea, and, unless their progress be arrested, thej^ may spread and unite, and so insulate the central portion. At the commencement of the dis- ease, the ulcei's are perfectly transparent. It is during their healing stage that they grow nebulous. They fre- quently perforate the cornea, and cause extensive pro- lapse of the iris ; or, as in the sloughing ulcers, the ad- vance of the ulceration may be stopped b}^ the posterior elastic lamina of the cornea ; but this usually, in the end, gives way, and prolapse of the iris ensues. During the reparative process, they become first cloudy, then of a grayish-white color ; vessels shoot into them from their sclerotic border, and they are ultimately filled in with a semi-opaque cicatricial tissue. These crescentic ulcers are the source of great pain in the eye and around the orbit, accompanied with photophobia and lachrymation on the slightest exposure to light. They do not seem to be connected in any way with an}^ constitutional taint, such as syphilis or struma. The patients whom I have seen affected by them have alwa3's been in that state of health which is best described as " being thoroughly out of condition." Treatment. — These ulcers are so intractable, and so many means have been tried without success to check their progress, that it is difficult to saj' what is the wisest course to pursue. My own experience is, that it is best to leave the ulcers alone, and to apply either hot fomen- tations or cold lotions of belladonna (F. 8, 32) to the eye. If these do not give relief, the gutt. atropiae (F. 13) may be used two or three times daily, and a compress band- age (F. 2) be applied over the closed lids so as to keep the eye as much as possible at rest. All exposui'e to strong light should be strictly avoided b}' obliging the 64 DISEASES OF THE COKXEA. patient to shade his ej-es, and to keep the room in which he lives darkened. A liberal diet and tonics with diffu- sible stimuli should be ordered, and if there is nnieh pain opiates ma}' be given either in small doses at short inter- vals, or in one full dose at bedtime. In two cases I have seen a partial syndectomy performed by excising close up to the margin of the cornea a portion of the conjunctiva and subconjunctival tissue, about ith inch in width, and in a line exactly corresponding with the ulcer, but in both it failed to do any good, Mr. Bowman, however, relates one case in his private practice in which he performed this operation with most marked success. The ulcer, which had before resisted all treatment, at once took on a healing action, and soon cicatrized. Chronic Vascular Ulcer of the Cornea. — This name has been applied to what is generalh' rather a vascular nebula than an ulcer. It is the remains of an ulcer which has become filled in, but in which the vessels originally destined for its repair have, from some cause, become sta- tionary, and by their presence keep the eye in a state of constant irritation. Sijmpfoms. — Continued irritability of the eye, with lachrymation and dread of light varying in intensit}', but never entirely absent. The historj- is generally that of an ulcer of the cornea which had recovered up to a cer- tain period, from w hich date the eye had ceased to mend, and had since been more or less irritable. On examina- tion, a small nebula will be seen on the cornea at a short distance from its margin, with one or more vessels — some- times a regular bundle of them — running up to it from the sclerotic adjoining the corneal edge. It frequently happens that the patient has been under treatment for many months, and sometimes even for two or three j'ears, during which time he has persistently dropped drops into FISTULA OF THE CORNEA. 65 tlie eye, both stimulating and sedative in turn, but with- out gaining the slightest benefit from either. Treatment. — Omit, for a time, all applications to the eye, and insert a double silk thread seton into the skin of the temple. The seton should be placed so high on the' side of the temple as to be almost amongst the short hairs, as there will then be no noticeable cicatrices from the ulceration at the points of ingress and egress of the thread. Care, also, should be taken to avoid wounding the branch of the temporal artery, which is in this lo- cality. The seton should be worn for about three or four weeks, but it may be continued longer if it acts benefi- cially on the e3'e, and does not excite too great an irrita- tion. In conjunction with the seton, other remedies may be tried. The lids of the attected eye may be kept closed, and a compress bandage (F. 2) applied over them, so as to give the e3"e, for a time, absolute rest ; or, if the patient should find the compress hot and uncoiufortable, it may be given up, and a cool lotion (F. 35, 3*7), or iced water, or a cold douche may be used, with the lids closed, three or four times daily. The state of the patient's health should be carefulh' looked after, and any irregularity should be corrected. In order to give the treatment every possible chance of success, the patient should, if his circumstances will permit of it, abstain from all work with the sound eye, and enjoy, for three or four weeks, rest with recreation. A Fistula or the Cornea is a small opening in the cornea which has little or no tendenc}^ to close, and through which the aqueous humor is constantly oozing. Causes. — 1st. A perforating ulcer of the cornea, which from some cause has been imperfectly healed. 2d. A contused or lacerated wound of the cornea, after which there has not been perfect union. 6* 66 DISEASES OF THE CORNEA. 3d. A wound of the cornea with wound of the lens. The swollen lens pressing on the iris may keep up such constant irritation of the eye, as to retard the union of the edges of the corneal wound. 4th. A glaucomatous state of the eye following a per- forating wound of the cornea. 5th. The presence of a foreign body within the eye ; the wound through which it entered having failed to completely unite. Si/mptoms. — A shallow or scarcely perceptible anterior chamber, with a minute oj^ening in the cornea, through which drops of the aqueous humor may be seen to exude. One useful method of diagnozing a fistula of the cornea is, to separate the eyelids with the fingers from the globe, and, having dried the suspected spot of the cornea with a piece of blotting-paper, to notice if the surface again becomes moist whilst the e^^e is kept open. Treatment. — When dependent on a perforating ulcer, or a wound of the cornea, the fistulous orifice maj' be touched with nitrate of silver. This is best applied by a fine camel's-hair brush, which has been first moistened with a little water, and then drawn a few times across a stick of nitrate of silver. This application may be re- peated three or four times, at intervals of two days, if it does not excite undue inflammation. If this treatment should fail, an iridectomy should be performed ; the spot at which it is made is not of much consequence, as in any part it will equall}^ succeed in promoting the closure of the fistula. When the fistula is due to a cataractous lens pressing on the iris, and by the irritation it excites preventing the perfect union of the corneal wound, the lens should be removed. If, however, the maintenance of the fistula is caused by a glaucomatous state of the eye, an iridectoni}' should be made. Lastl}', if all other means have failed, CLOUDINESS OF THE CORNEA. 67 the edges of the fistula may be pared with a broad needle, and united by a single fine silk suture. Nebula or Cloudiness of the Cornea may be caused by inflammation or superficial ulceration of the cornea, or by an injury which has induced a traumatic corneitis. It may be limited to a portion of the cornea, or it may be irregularly diffused over its whole surface. In some cases the nebula is due to an interstitial deposit of lymph in the true corneal tissue ; whilst, in other instances, it is produced by a layer of fine semitransparent cicatricial tissue, formed during the healing process of a superficial ulceration. Treatment. — When the eye is free from all irritation, some mild stimulating application will occasionally do good, by exciting the absorbents of the cornea to an in- creased activity ; but there are no specific remedies for the cure of nebula. The applications from which I have found the most benefit are the following : 1. Lotio hydrarg. perchlorid (F. 46). Two or three drops to be dropped into the eye twice a da}^ This remedy is often a powerful irritant, and should be dis- continued if the eye becomes inflamed or painful. 2. Guttae ol. terebinth, cum ol. oliv;e (F. 23). At first these drops should be used very weak, but their strength may be increased if the eye is tolerant of them. 3. Dusting calomel into the eye every or every other day for a short time. 4. Guttae zinci sulphatis (F. 20), or ziuci chlorid (F. 19) may be prescribed. 5. A solution of the iodide of potassium (F. 18) dropped twice a day into the eye is thought by many to do good. 6. Sulphate of soda. Mr. Powers speaks favorably of the general results he has obtained from the use of this drug in corneal opacities. He says that, " in the employ - 68 DISEASES OF THE CORNEA. ment of this salt, the quantity that should be introduced at one time into the eye, should not exceed one or two grains, and the most convenient mode of application con- sists in everting the upper lid, and brushing the powder lightl}^ over the surface with a camel's-hair brush." * T. The late Dr. Mackenzie, of Glasgow, recommended the vapor of hydrocyanic acid.f Leucoma of the Cornea. — A leucoma is a dense white opacity of the cornea, caused by a loss or destruction of a part of its substance, the gap thus made being replaced by cicatrix tissue, which is opaque and white, instead of transparent and colorless like healthy cornea. It may be the result of an injury, but, more frequently, it is oc- casioned b}' inflammation and deep ulceration induced by other causes. It is irremediable. With the leucoma there is often some alteration in the shape of the pupil, from a portion of the iris having become adherent to the cicatrix. In such cases the ulcer, which had caused the leucoma, had penetrated the cornea, and the iris had either been dragged into the wound as the aqueous es- caped, or else, falling forwards, had contracted adhesions to the granulations, which were afterwards to be con- verted into the cicatrix tissue. One of the evils which frequently results from a leu- coma is, that the normal curvature of that portion of the cornea which remains transparent, is changed in one or more of its meridians, and the eye rendered astigmatic ; a defect which may be neutralized, to a great extent, by a properly-fitted cylindrical glass. * Power on Sulphate of Soda for removing Opacities from the Cornea. The Practitioner, vol. i, p. 155. f Mackenzie on the Diseases of the E^^e, 4th edition, pp. 639 and 428. CONICAL CORNEA. 69 Opacity of the Cornea from Lead is caused b}- the use of a lead lotion when the cornea is ulcerated or abraded ; the lead is deposited on the surface as a carbonate, producing a milky-white patch, which is often sufficiently opaque to occlude either the portion of iris or the pupil which lies behind it. The treatment consists in removing the la3-er of lead deposit which has coated the abraded surface of the cornea. This may be done with a small knife curved convexly on it.s cutting edge, as in Fig. 1. The lids being separated b}^ a speculum, the operator with one hand fixes the eye with a pair of forceps, whilst with the other he gently scrapes the whitened surface of the cornea, until, having detached the epithelium, he comes down to the thin coating of lead; steadily but gentl}' scraping, he will generally succeed in detaching all that is required. Having completed the operation, a few drops of olive oil should be dropped into the 63^6, and a fold of wet lint laid over tlie closed lids. Conical Cornea is a staphylomatous bulging of the middle portion of the cornea, caused by a thinning of that structure in its central region. The disease comes on very imperceptibly, and progresses without pain. It first manifests itself to the patient by a change in the focus of the eye, which becomes irregularly myopic ; and this defect grows worse as the bulge increases, until, in severe cases, the sight is so much impaired as to render the eye almost useless. Usually there is no undue vas- cularity of the globe, but, in some instances, where the conicity is rapidly' advancing, there is slight ciliary red- ness. After the cone has attained a certain size, its ajiex loses its transparency and becomes nebulous or semi- 70 DISEASES OF THE CORNEA. opaque, with its epithelial surface roughened. One or hoth eyes may be affected ; but, when both are involved, the conicity is generally much greater in one eye than the other. The disease will frequently advance rapidl}" in one eye, whilst it remains stationary in the other. Biagnotiis. — In the advanced stage, conical cornea is easily recognized, but, at the commencement of the dis- ease, it is often difficult to diagnose, and its presence may be easily overlooked. The cornea is best examined by looking at the eye from its outer side, so as to see the cone, if one exists, in profile. In a paper by Mr. Bow- man, on " Conical Cornea," in the Royal London Oph- thalmic Hospital Reports, vol. ii, he saj'S : " Soon after the immortal invention of Helmholtz, I found the oph- thalmoscope very useful in detecting slight degrees of conical cornea. For this purpose the concave mirror only is to be used without a convex lens. On turning the mirror so as to throw light at different angles, the side of the cone opposite to the light is darkened." In speaking of conical cornea, Bonders remarks : " High degrees strike the eye at once. Slight degrees, on the contrary, are often enough overlooked. The disturbance of the power of vision frequently suggests the idea of amblyopia combined with myopia." .... Further on, he recommends the use of the ophthalmoscope as a means of diagnosis in slight cases of conical cornea, and ob- serves that, " in the inverted image where there is a tol- erably wide pupil, we overlook at the same time a rather large portion of the fundus oculi ; the image, therefore, of one part or other, for example, of the optic disc, re- mains in the field of vision, both on moving the head of the oltserver and on shifting the lens before the observed eye. At the same time, however, the raj's which, pro- ceeding from the optic disc, strike the eye of the ob- CONICAL CORNEA, 71 server, pass each time tlirougli other parts of the cornea. Now, if its curvature is irregular, the result is, that the form of the disc each time alters, it shortens in this di- rection, extends in that direction, and, moreover, is never seen acutely in its integrity."* Pathology of Conical Cornea. — It is very difficult to as- cribe any cause for the structural changes in the cornea which give rise to the staphylomatous bulging. The ten- sion of such eyes is seldom, if ever, in excess ; indeed, it is more frequent to find them slightly soft. All that we ai'e at present able to sa}^ of conical cornea is, that from some cause, possibly failing nutrition, the central portion of the cornea becomes thinned and its power of resist- ance diminished, so that it yields before the normal pres- sure from within the eye, and bulges conically. The bulg- ing may increase until the apex of the cone seems to be on the verge of bursting, but this is an accident which seldom, if ever, occurs spontaneously. Mr. Bowman thinks that this fact may be thus explained : " As the cornea becomes thinner, the escape of the aqueous humor by exosmose is facilitated, and thus the internal pressure is reduced so as to be no longer in excess of the dimin- ished resisting power of the cornea." The following is an account of a microscopical exami- nation made by Mr. Hulke, of a conical cornea taken from an eye which had been excised by Mr. Bowman during an operation for the removal of a large sebaceous cyst from the orbit : " The central conical nebulous portion was much thin- ner than the transparent periphery of the cornea, where the curve was natural. This thinning began at the base of the cone, and progressively increased towards the apex, * Di-inders on the Accommodtition aiul Refraction of the Eye, pp. 550-551. 72 DISEASES OF THE CORNEA. where it reached its niaximuni. At this point tlie mean depth of several vertical sections was only one-third of that of the ])eripheral region. The continnity of the an- terior elastic lamina was perfect, but upon the cone this structure was much thinner than elsewhere, and wrinkled ; it was underlaid by a stratum of crowded, elongated, club-like nuclei, and beneath these the normal lamellar tissue was placed by a web of caudate and nuclear fibres, amongst the meshes of which clusters of large oval and fusiform cells were packed. The structure of the ti'ans- parent peripheral region was perfectly normal, and, at the base of the cone, there was a gradual transition from the healthy to the diseased tissue, the interlamellar cor- puscles becoming more plentiful, branched, and drawn out into fibres, which, in many instances, coalesced with those from neighboring corpuscles. The posterior elastic lamina and the epithelium, both on the front and on the back of the cornea, were unchanged." " The changes I have described," adds Mr. Hulke, " were confined to the laminated tissue of the cornea and the anterior elastic lamina. The substitution of a web of nuclear fibres and cells for the regular lamination of the cornea, explains the nebulosity of the cone and the lia- bility to bulge."* Treatment. — When conical cornea is in its earliest stage, it is possible, that by judicious prophylactic treat- ment, its progress may be retarded ; but, when the cone is steadily advancing, I know of no help except by opera- tion which is likely to be of any avail. A)^ preventive treatment, all work Avhich strains or reddens the e^'es should be avoided. The cold or tepid douche, whichever is the more pleasant, may be used three or four times dail3\ When there is axiy ciliarj^ red- * Koyiil London Opbtluihnic Ilosjntal Keports, vol. ii, j). 154. CONICAL CORNEA. 73 ness, two or three leeches ma}' be advantageously applied to the temple. If the patient is feeble, tonics of quinine, iron, «fec., should be ordered. Except in the very com- mencement of the disease, but little, if any, benefit will be derived from either concave, spherical, or cylindrical glasses. The astigmatism produced by the conicity is so irregular that it cannot be sufficiently corrected by lenses to afford much improvement of sight. Occasionally a stenopaic slit placed behind a concave spherical lens is found of decided service, and, when this is the case, the patient may be provided with similar spectacles, but with the understanding that they must be laid aside if they fatigue the eyes. Operative Tr-eatment. — 1. To better the sight of the palieut, the position of the pupil must be so changed that it is brought opposite to that portion of the cornea which is the least affected b}^ the conicity. 2. To arrest the progress of the disease, it is desirable to slightly lessen the tension of the eye, so as to compen- sate for the diminished resisting power of the cornea. When this is satisfactorily accomplished, the cone will cease to increase, and in some of the recorded cases it has actually receded. Mr. Bowman first suggested the making a slit-shaped pupil by performing the operation of iridodesis twice in the same eye, but at an interval of several daj's. He first drew a piece of the iris downwards and tied it, and after a few da3's he repeated the operation in the upward di- rection, and fastened it in a similar manner, thus convert- ing the pupil into a vertical slit. (See Operation of Iridodesis.) The improvement which followed the first iridodesis was very decided, but that which ensued after the second was very doubtful. I have done this oi^era- tion several times, but found no increased benefit from the second iridodesis. Von Graefe has for a long time 7 74 DISEASES OF THE CORNEA. practised iridectomy for the relief of conical cornea, with the view of lessening the tension of the e^e, whilst, at the same time, he altered the position of the pupil. The success which has followed this mode of treatment, has induced Mr. Bowman to adopt it in preference to his own operation. The iridectomy should be made rather small, and either directly upwards, or upwards and inwards, unless special circumstances call for it in a different position. The defoi-mity of the pupil will be then so covered by the upper lid as to be scarcely noticeable. Von Graefe has lately adopted a new operation for the relief of conical cornea.* It consists in the establishing an ulceration on the apex of the cone wuth a view to its producing a general flattening of the cornea by the con- traction which always accompanies the cicatrization of the wound. The operation is as follows: The patient having been placed under chloroform, and the lids sep- arated b}' a spring speculum, a small flap of about one line in width is to be made with a fine cataract knife through the superficial la3ers of the cone, taking care that the point of the instrument does not penetrate the anterior chamber. Should this accident happen, the operation must be at once stopped and postponed to a future da^^ The flap of cornea is now to be seized with a pair of forceps and cut off with a pair of scissors. On the following day the cut surface is to be gently touched Avith the diluted nitrate of silver (F. 5), and this applica- tion is to be repeated every two or three days until an ulcer with some surrounding corneal haze is produced. Tlie e3'e is now to be kept closed with a compress and bandage until the ulcer has healed. A solution of atro- pine (F. 13) should be dropped dail^' into the eye to keep the pupil dilated and allay irritation. During the healing * Archiv fur Oplithahnologie, vol. xii, 2, 215. KERATO-GLOBUS. 75 of the ulcer, a general contraction of the surrounding cornea takes place towards the cicatrix, and the conicity is thus sensibly diminished. If the leucoma, which is thus produced, should so oc- clude the pupil as to interfere with sight, a new pupil should be made by a small iridectomy opposite to that portion of the cornea which presents the most normal curvature. Kerato-globus — Hydrophthalmia — is a uniform en- largement of the anterior half of the globe, which often attains to such dimensions as to prevent the lids from closing over it. Both eyes are usually affected, although one may be more seriously involved than the other. It is sometimes congenital, and may possibly be due to some hereditary s^q^hilitic taint; but it may also come on after corneitis. It most frequently occurs in young children. The peculiar amazed stare which this deformity of the eyes gives to the patient is very unsightly. The cornea will sometimes be seen of almost double its normal pro- portion. In some cases it is slightly cloudy, whilst in others its transparency is unimpaired. The adjacent sclerotic is thinned and of a bluish color from the subja- cent choroid shining through it. The anterior chamber is large and deep, and the iris is pushed backwards, fre- quently tremulous, and so greatly stretched that its ciliary attachment is occasionally drawn within the ante- rior chamber. The pupil is usually rather dilated and sluggish, and sometimes oval or pear-shaped. The sight is always very defective, and in the worst cases com- pletely destroyed. The disease is usually slowly progres- sive. Treatment. — Unless the disease is steadily increasing, and the sight diminishing, I believe it is best to leave h^'drophthalmic eyes alone. Their powers of repair are 7(3 DISEASES OF THE CORNEA. enfeebled, and they stand operations badly. I have cer- tainly seen an iridectomy occasionally do good, bnt, on the other hand, I have seen cases in which it did yjositive harm. Stenopaic spectacles may be tried, and, if they improve the sight, they may be worn. If one eye is quite blind, and suffering from not being fully protected b}' the lids, it may be excised. A Staphyloma of the Cornea is a projecting for- wards or bulging of the Avhole or a i)art of the cornea, or of the new tissue which supplies its place when a part or the whole of it has been destro^'cd by injury or disease. A staphyloma of the cornea may be either partial or complete; that is to saj^, it maybe limited to a small por- tion, or it may involve the whole of the cornea or the new structure which re2)resents it. Partial Staphyloma or the Cornea. — When a por- tion of the cornea has been destroyed by sloughing or ulceration, its place is made good by cicatricial tissue, which is more or less white and opaque, and in many cases incapable of resisting the normal outward pressure of the parts within the e3'e. Slowly yielding, it bulges and forms an unsightl}^ prominence on the cornea. Treatment. — The objects to be accomplished are, 1st, to arrest the progress of, and, if possible, to diminish the bulge; and, 2d, to restore some of the lost sight to the eye. Both of these conditions may be often attained by the operation of iridectomy. The removal of a piece of the iris by iridectom}' exer- cises an important influence in diminishing the tension of the globe, and thus frc(iuently prevents any further increase of the staphyloma; and in a few instances which have come under my notice, the bulging has decidedly receded. But, in addition to this, by the excision of a STAPHYLOMA. 77 portion of the iris opposite to that part of the cornea which is in the most healthy state, an artificial pupil is made ; and if the fundus of the e}"e is sound, and the transparency and curvature of the cornea opposite the new pupil tolerabl}^ good? useful sight will be regained. Complete Staphyloma of the Cornea is a bulging of the entire structure which has replaced the original cornea after it has been destroyed b}^ ulceration or slough- ing. Progress of the Disease. — After the loss of the cornea, the exposed surface of the iris is soon coated with a film of lymph. This becomes organized and ultimately con- verted into a bluish-white cicatricial tissue, to which the iris is firmlj^ adherent. The eye will now either gradually shrink, or the new tissue will yield before the pressure from within and become staplndomatous. Treatment of Commencing Stajjhyloma If the patient is seen early, the first object in view is to prevent the formation of the staphyloma, and this is best accom- plished by the removal of the lens, if it has not already escaped from the eye. After the slough of the cornea has separated, the lens will be often seen Ijing in the centre of the pupil, perfectly transparent and projecting slightly forwards. It may then be removed by gently lifting it away with the point of a fine needle. If the eye is not seen until a later period, but when the staphylomatous bulging is still recent, and the new tissue which occupies the corneal space is yet but imper- fectly formed, the plan recommended by Mr. Bowman for the removal of the lens may be adopted. A broad needle is passed through the most prominent part of the staphyloma in the direction of the lens, so as to penetrate its capsule, and the lenticular matter is freely broken up. The needle is then withdrawn, and through the aperture 78 DISEASES OF THE CORNEA. it has made a curette is introduced, and as much of the leus matter as is sufficiently- soft and diffluent, is allowed to escape from the eye along its groove. The puncture made with the broad needle ma}' be repeated every two or three days until the prominence of the staphyloma is reduced. Treatment of Complete Staphyloma of the Cornea. — The eye being lost for all visual purposes, the object to be accomplished is to get rid of the unsightly staphy- lomatous bulging, and to enable the patient to wear an artificial ej'c. One of the following modes of treatment ma}^ be adopted : 1st. The staphjlomatous eye may be excised. 2d. The staphyloma ma^' be abscissed. 3d. The staph3'loma may be treated by seton. 1st. The Staph i/lomatou.-< Eye may he excised. — When the bulging is large and unsighth', and causes the patient annoyance from the obstruction it offers to the free move- ments of the lids over it, and there is reason to believe that the fundus of the e^'e is laihealthy, this is the best operation. The patient will recover from it more quickly than from any other, all chance of future troulile is avoided, and an artificial e3e can be worn, although the deception may not be quite so complete as after a suc- cessful case of abscission of the staphyloma. 2d. The Staphyloma may be abscissed. — There are two modes of thus dealing with a staphyloma. a. The bulging portion may be simply abscissed, and the sclerotic wound be left to close by granulation. /?. The staphyloma may be abscissed, and the edges of the wound of the sclerotic be brought together by su- tures, after the manner recommended b}' Mr. Critchett. (a.) For the simple abscission of the staphyloma, the lids should be first separated by a spring speculum, and a puncture made w-ith a broad needle at its margin, suf- ficiently large to admit one blade of a pair of scissors, STAPHYLOMA. 79 when, with a few snips around its circumference, the whole of tlie bulging portion is removed. Another way of abscissing the staph^-loma is, to transfix its base with a Beer's knife, and first cutting through its upper half, then to seize hold of the detached portion with a pair of forceps, and complete the abscission of the remaining segment, either with the kuife or with a pair of scissors. The speculum is then to be removed, and a pad of cotton- wool to be applied firml}' with a bandage over the closed lids. (i?.) Mr. Critchett's operation for abscission of the sta- phyloma was first described by him in the first chapter of vol. iv, of the " Ro^al London Ophthalmic Hospital Reports." The following is a brief abstract : " The patient being placed under the influence of chloroform, the staphyloma is freely exposed by means of a wire speculum ; a series of four, or rather five, small needles, with a semicircular curve, are passed through the mass about equidistant from each other, and at such points as the lines of incision are intended to traverse. " These needles are left in this position, with both ex- tremities protruding to an equal extent from the staphy- loma. " The next stage of the proceeding is to remove the anterior part of the staphyloma. " M}' usual plan is to make an opening in the sclerotic, about two lines in extent, just anterior to the tendinous insertion of the external rectus, with a Beer's knife. Into this opening I insert a pair of small probe-pointed scis- sors, and cut Oiit an elliptical piece just within the points where the needles haA'e entered and emerged. The needles, armed with fine black silk, are then drawn through, each in its turn, and the sutures are carefully tied, so as to approximate as closely as possible the di- A'ided edges of the sclerotic and conjunctiva. The opera- 80 DISEASES OF THE CORNEA, tion is now finished ; the specuhim may be removed so as to allow the lids to close, and wet lint may be applied to keep the parts cool." Unless this operation is carefully performed, there is apt to be a projecting corner at one or both of the ex- tremities of the cicatrix. Such a result is a serious im- pediment to the proper fitting of an artificial eye, and may require a second operation to remedy it. Abscission of the staphyloma should never be per- formed where there is reason to suspect pre-existing dis- ease of the choroid or retina, as deep hemorrhage is likely to follow the removal of the front of the globe, which may necessitate the immediate excision of the rest of the eye. Treatment of Staphyloma of the Cornea by Seton. — J'or the purpose of reducing the bulge of the staphyloma, so that an artificial eye may be worn, Von Graefe has rec- ommended that a silk thread seton should be passed through the staphyloma, with the view of inducing a sup- purative inflammation, and a subsequent shrinking of the globe.* In from sixteen to thirty-six hours after the introduc- tion of the thread, an acute suppurative choroiditis will be set up, with chemosis and enlargement of the globe, and the seton is then to be withdrawn. The acute symp- toms will gradually subside in from three to eight days, and atrophy of the globe will shortly follow. Ciliary Staphyloma — Anterior StajDhyloma of the Sclerotic — is a staphylomatous projection of the sclerotic in the ciliary region of the eye. It consists of a series of grape-like bulgings, with such a thinning of the sclerotic coat that the dark color of the ciliar}^ processes with which it is in contact is distinctly seen through it. It may * Archiv fur Oplitlial. vol. ix, part ii, pp. 106-109. STAPHYLOMA. 81 be limited to a part, or it may involve the whole of the ciliary region of the eye. Ciliary stai)hyloma may be the result of disease or in- jur3^ In the majority of cases it is dependent on a chronic irido-choroiditis, accompanied with a gradual wasting of the sclerotic in the immediate vicinity of the ciliary processes, so that it loses its normal power of re- sisting the outward pressure from within the eye, and, slowly yielding, a dark irregular nodulated prominence is developed. As the direct result of an injuiy, ciliary staphyloma may be produced by a rupture of the scle- rotic, and especially when there is also associated with it an extensive prolapse of the iris and choroid, Tlte jjrognosis of ciliary staphyloma is always most un- favorable ; even when slight, there is considerable impair- ment of vision ; but the danger to be apprehended is, that it will increase, and, as it enlarges, all sight will be destroj-ed. Treatment. — When a ciliary staphyloma is dependent on disease, no matter whether it has originated from con- stitutional causes or from some remote injury to the eye, it ma3' frequently, in its early stages, be arrested by the operation of iridectomy. It is the only remed}^ from which I can really feel satisfied that I have seen any de- cided benefit ; and, although in some cases it may fail in accomplishing the desired end, j-et it is certainly the most successful of all the remedial agents I have known prac- tised for the relief of this disease. By reducing the ten- sion of the eye, the tendency of the staphjdoma to in- crease is certainly diminished, and, in some instances, completely stopped. It should be remembered that, even though the tension of the eye, at the time of the opera- tion, may be normal, yet the resisting power of the scle- rotic has been lowered by disease, and that, by lessening 82 DISEASES OF tul: cornea. the tension which exists, the condition of the e^'e is im- proved. If, howeA'er, the ciliary staphyloma is produced hy a rupture of the sclerotic, I know of no remedy. The sight which such an eye retains, even when the staphyloma is small, is usually ver}- limited ; but, if the bulging is suf- ficientl}'^ large to interfere with the free movements of the lid, the eye is generally blind. When an e3'e, thus completel}^ lost for all visual purposes, is unseemly in ap- pearance and troubles the patient, the best treatment is to excise it. Cyclitis, or inflammation of the ciliary body, is sel- dom an independent or primar}- atlection, except in cases of wounds or some other injury in the vicinity of the ciliar}" region of the eye. It is usiiall}' produced b}' the inflammation in iritis spreading to the ciliary bod}' ; but it ma}' also arise, although less frequentl}', from an ex- tension forwards of the morbid action of an inflamed choroid. Cyclitis, like iritis, ma}' be either plastic, serous, or suppurative, according to the character of the inflam- mation of which it is the continuance. When, however, it is excited b}' an injury, it is nsuall}' either serous or suppurative. The injuries which are most liable to pro- duce cj'clitis, are, penetrating or incised wounds in the ciliary region, the lodgment of a foreign body within the eye, a dislocation of the lens, or the forcible removal of a piece of opaque capsule, especially if during the opera- tion an}^ drag has been made on the ciliary processes. Symptoms. — Pain in the ciliary region, with marked tenderness on pressure ; a pinkish zone around the cornea from distension of the ciliary vessels, photophobia and lachrymation, and turbidity of the vitreous from inflam- matory exudations into it from the ciliary processes. After wounds in the ciliary region, large masses of lymph CYCLITIS. 83 or pus may be frequently seen with the unaided eye, lying- behind and to one side of the lens. The iris usu- ally participates in the inflammation, even when the dis- ease originates in the ciliary body, its striae become in- distinct and its color changed, the pupil is sluggish or inactive, and posterior synechiae are formed ; tlie aque- ous grows serous and turbid, and there is frequentlj^ hy- popion. The sight is greatly impaired, and the tension of the globe is often increased. Prognosis. — When cyclitis is due to an extension of the inflammation from the iris, it will probably, under judicious treatment, subside ; but it must always be re- garded as a serious complication of the original disease. When, however, it arises from an injury, the prognosis is very unfavorable. If the inflammation subsides under treatment, the e3'e generally becomes soft, and partially shrinks, and all sight is destroyed. The great danger, however, to be feared, is lest while endeavoring to save the injured eye, the other should become sympathetically aflfected. Treatment. — When cyclitis is secondary and proceeds from iritis or choroiditis, the treatment recommended in the sections devoted to these diseases must be followed. When, however, it is caused by an injury, no special me- dicinal treatment will be of service. At the commence- ment of the attack, leeches should be applied to the tem- ple, and warm belladonna fomentations (F. 8) to the ej^e, and in the intervals between the applications the eye may be kept at rest by a slight compress and bandage. If this should fail to give relief, a fold of linen, wet with the bel- ladonna lotion, may be laid over the closed lids. The bowels should be freely acted on by a purgative, and, if the pain is severe, opiates should be given at bedtime. The strength of the patient must be maintained b}^ a liberal diet, and a moderate amount of stimulants may be 84 DISEASES OF THE CORNEA. allowed. If necessaiy, tonics of quinine or bark should be prescribed. The results, however, of cjclitls proceed- ing from injur}' are so unfavorable, both as respects the injured eye and the risk to which the sound one is exposed from sj^mpathy, that if the inflammation does not yield rapidly to treatment, I would strongly urge the removal of the globe, and this especially' if the accident be a wound in the ciliar}^ region. Episcleritis is a small diffuse swelling beneath the conjunctiva, iisuallj' on the temporal side of the cornea, and near the insertion of the recti muscles. It has a smooth surface, and is of a dusky red color, and is appa- rently caused b}' some plastic effusion on the sclerotic. There is geuerallj' some redness of the conjunctiva imme- diately over it, and sometimes chemosis. The dark hue of the swelling seems due to its being supplied by the deep subconjunctival vessels, which in some cases ma}' be seen running up to it. The affection appears to be local and confined to one side of the cornea. The degree of suffering it produces is very variable. In some patients I have seen considerable irritation, with severe neuralgic pain in the eye-, whilst in others the onl}' annoyance has been the disfigurement which the bloodshot appearance has produced. The disease is generally very tedious in its course, and frequently recurrent. For a time the swelling seems to increase in size and redness ; it then gradually fades in color, diminishes, and ultimatel}' dis- appears. Treatment. — When there is no irritation, a mild stimu- lating application to the eye does the most good, and the guttse zinci chlorid. (F. 19), or the guttte zinci sulphatis (F. 20), may be ordered twice a daj'. If, however, there is photophobia and lachrymation, the guttae atropite (F. 13), or the lotio belladonna, should be prescribed. The INJURIES OF THE CORNEA AND SCLEROTIC, 85 state of health should be carefully inquired into, and if any irregularity of the functions of any of the organs be detected, suitable medicines should be prescribed. In some cases I have found benefit from the administration of the iodide of potassium, given either with an alkali (F. 74) or with small doses of iron (F. 73), according to the requirements of the patient. injuries of the cornea and sclerotic. Foreign Bodies on the Cornea or on the Conjunc- tiva Lining the Lids. Symptoms. — Great irritability of the e3'e, accompanied b}' a copious flow of tears, an almost absolute inability to raise the upper e3'elid and face the light, and a dis- tinct feeling of grittiness as if something were in the eye. The suddenness of the attack, and the exposure to which the eye has been subjected, are also points to be noted. Treatment. — The cornea should be first well scanned over, turning the head of the patient in various directions so as to cause the light to fall obliquely on the eye first on one part of its surface and then upon another ; or by using a two-inch focus lens a column of light may be directed over the cornea, so as to illumine each portion of it in succession. Failing to find a foreign body on the cornea, the inner surfaces of the eyelids should be next examined ; and this is to be done by drawing down the lower lid and everting the upper one. If the foreign body is not deeply buried^ but merel}' lying on the surface, or sunk into the epi- thelium of the cornea or conjunctiva of the lids, it may be easily removed b}^ a spud (Fig. 2) or by a broad needle. iji^ If the foreign body is buried deep)ly in the cor- i i neal tissue, a broad needle should be passed into, iJLJ! but without penetrating, the cornea. Inserting it just by 86 INJUllIES OF THE CORNEA AND SCLEROTIC. the side of the object, it should be made to traverse the corneal lamellae until the broad part of the blade is behind the foreign body, when, b}' thus giving a firm su})port upon which to act, another needle may be fearlessly used to pick gently from the surface until it reaches the object, which can then be lifted away. Should, however, the for- eign body, have so deeply penetrated the cornea that it is feared any attempts to reach it from its surface ma}'^ end in pushing it into the anterior chamber, a broad needle should be passed into the anterior chamber, and pressed against the inner surface of the cornea immedi- ately behind the foreign body, and carefully and steadily held in this position, whilst the surgeon, with another needle, scrapes through the cornea, layer after layer, until he reaches it. Having removed the foreign body, one or two drops of olive or castor oil may be dropped into the eye. The eyes should not be used for two or three days, and if there is pain, or a continuance of the irritation excited by the foreign body, two or three leeches should be applied to the temple, and the eye fomented with hot water or de- coction of poppy-heads or belladonna (F. 8, 9). Abrasions of the Cornea. — An abrasion of the cor- nea is the forcible removal of a portion of the epithelium from its surface. It is always the result of an injury. Symj^foms. — Immediately after the accident there is photophobia, great lachrymation, and conjunctival red- ness, with a feeling as if a foreign body were in the eye. On examination of the eye before a good light, the abra- sion will be recognized by the glistening facet, which will be seen at the part where the cornea has been denuded of its epithelium. Proynosii< — Favorable in a healthy person ; but in a delicate or exhausted patient, ulceration of the cornea, ABRASIONS OF THE CORNEA. 87 diffuse suppurative corneitis, and ultimate loss of the eye, may be caused by this apparently slight accident. Abra- sions of the cornea frequently occur in mothers who are suckling ; the child unconsciously claws at the eye, and scratches off a little of the epithelium from the cornea. As the health of the mother during lactation is often very unfavorable for the repair of injuries, veiy troublesome results may follow. Treatment. — If there is a simple abrasion of the cornea, and the patient is seen soon after the accident, a drop of castor or olive oil, or cream dropped into the eye, will often give temporary relief, and may be repeated every two or three hours for the first day or two. Gently clos- ing the eye and applying over it a cotton-wool compress with a single turn of a soft roller will give great ease, by effectually excluding the e^^e from light, and by prevent- ing the up and down movement of the lid, which serves to irritate the abraded surface. If the ej'e is very pain- ful, the bandage may be removed three or four times during the day, whilst the eye is bathed with hot water, or with a decoction of poppy-heads, and two leeches may be applied to the temple. If untoward symptoms come on, such as ulceration or abscess of the cornea, warmth and soothing remedies are still best suited. A warm belladonna fomentation (F. 8) may be used, frequently appljdng it to the eye with a hollow sponge so as to steam it, and thus relax and soothe the inflamed parts. In ad- dition to this, two or three drops of a solution of atropine, gr. 1 ad aquse ^ 1, may be dropped twice a day into the eye. If the aqueous grows turbid, and hypopion follows, tapping the anterior chamber with a fine needle, and let- ting off the aqueous, will often do good. When abrasions of the cornea take on these unfavora- ble symptoms, as they frequently do, it is usuall}^ on ac- count of some condition of the patient's health si)ecially 00 INJURIES OF THE CORNEA AND SCLEROTIC. unfavorable for the repair of injuries. Too great plethora, anaemia, a constitution broken b}' drink and rough living, or one enfeebled from some exhausting cause, such as suckling, ma}^ retard recovery- or induce symptoms dan- gerous to the eye. Such conditions of sj'stem must regu- late our constitutional treatment. In the one class of cases moderate antiphlogistic treatment will be called for, Tvhilst in the other the patient must be propped up by stimulants, and all irritation be alla^'ed bj^ sedatives. Opiates in these cases are of the greatest service, and a few minims of the liq. opii sedativ. combined with llq. cinchonjB given three or four times a day will sometimes completelj" change the character of the inflammation, and induce a healthy action and a speedy recovery. If it should be preferred to give the opiate in one dose at night, it should be sufficient in quantity to produce sleep, as a single moderate dose will excite rather than tran- quillize. Penetrating Wounds of the Cornea and Sclerotic, — A small incised wound of either the cornea or sclerotic, provided none of the other textures of the eye are injured, is almost harmless ; it rapidly heals, and no after incon- A'cnience is experienced. We have evidence of this in the numerous operations on the eye^ and especially in those for cataract and iridectomy. Wounds, however, which are produced by accident, are generally compli- cated by either contusion, hemorrhage, prolapse, wound of the lens, or loss of vitreous ; and sometimes b}' all these casualties together. The danger of a corneal wound is immensely increased if it should extend into the ciliary region, as there is then great risk of the other eye be- coming aftected with sympathetic ophthalmia. I Wounds in the sclerotic are far more fatal to the eye I than similar wounds in the cornea; they are also some- PENETRATING WOUNDS. 89 times difficult to heal, and especially if the cut is at a distance from the margin of the cornea, and there has been loss of vitreous. They will generally remain patu- lous, and show no attempt at closing. This apparent incapacity to unite, is solely due to the peculiarly un- jdelding nature of the sclerotic, which prevents the lips of the wound from falling accurately together, when the contents of the globe have been suddenly diminished by a loss of vitreous. If, however, 3'ou can succeed in bring- ing the edges correctly in contact, union will at once take place. This fact has been proved on several occasions, by the rapid healing of such patulous wounds of the sclerotic after the}' have been closed by a single fine silk suture. Treatment. — The primary treatment must be soothing ; the patient should be kept in a subdued light, and the injured eye should be closed, and a compress bandage (F. 2) applied over the lids. Two or three leeches should be applied to the temple, thus anticipating rather than waiting for any excessive action which may arise, and one or two drops of a solution of atropine (F. 13) should be dropped into the eye twice a day, each time the com- press is readjusted. After a few days the compressing bandage may be discontinued, and warm or cold applica- tions to the eye may be substituted in accordance with the feelings of the patient. Belladonna may be used either in the form of a cold lotion or a warm fomentation. The Constitutional treatment will vary somewhat with the condition of the patient. It must, however, be re- membered that affections of the cornea, even though they are traumatic, will not bear much depletion. The in- flammation which follows such injuries is reparative in its action, and requires to be watched and kept from ex- ceeding its proper limits, rather than that means should be taken completely to check it, as the part may iierisli 90 INJURIES OF THE CUllNEA AND SCLEROTIC. from a waut of A'ital action, as well as from an excess of energy. If the patient is robust, a brisk purgative (F. 87, 88) may be prescribed, with some saline or diaphoretic medi- cine (F. .55, 52). A regular antiphlogistic course is sel- dom if ever required. A moderate, well-regulated diet, the avoidance of more stimulants than the case demands, and rest both to the eyes and body, place the patient in the condition most favorable for recovery. Pain in the e^'e suflicient to prevent sleep should be relieved by opiates, taking care at the same time that there is a regu- lar daily action of the bowels. In delicate and feeble patients it may be necessarj' to order from the very commencement a liberal diet and a certain amount of stimulants ; and to prescribe tonics, such as the mineral acids with cinchona, or quinine (F. 61, 64), combining a few minims of liq. opii with each dose, to allay the constant irritability which injuries to the cornea often excite in such patients; or the opiate maj' be given in one full dose at bedtime. For wounds of the cornea complicated with prolapse of the iris, or wounds of the lens, see articles Prolapse OP THE Iris, and Traumatic Cataract. Rupture or the Eye through the Sclerotic — This is the most severe injury that can happen to the eye. It either destroys the eye at once, or else so impairs it that it seldom sufficiently recovers to be of much ser- vice. It is usually caused bj* blows on the eye with the fist, or with some blunt or semi-blunt instrument, or by the patient falling and striking his eye against some pro- jecting object. The exact part at which the eye will burst depends partly on the situation of the point which re- ceives the force of the blow ; still the locality in which the rupture takes place is so frequently the same that RUPTURE OF THE EYE. 91 the coincidence must be due to more th/mptoms. — The early symptoms are those of iritis, from the first attack of which the patient may have re- covered ; but after one or more relapses the whole or the greater part of the margin of the pupil has become bound down by synechiae, and lymph has been effused on the capsule of the lens within the pupillar}' area. The iris is now gradually pushed forwards towards the cornea from an accumulation of the aqueous in the posterior chamber j. its striation is blurred and indistinct; its surface, dis- colored and hazy, is convex instead of being plane, and, if the disease has been of long standing, it is marked by irregular knotty bulgings from atrophic portions yield- ing to the pressure of the fluid behind it. At this stage there is frequentlj^ a difliised opacity of the vitreous with floating opacities. The vision is always greatly impaired, and especially in those cases where the iris is much arched forwards ; and occasionally there is considerable limita- tion of the field. The contracted pupil, opacit}' of the pupillary portion of the lens capsule, and hazy vitreous prevent the ophthalmoscope from affording much infor- mation as to the state of the parts at the fundus of the eye. This must be estimated partly by the general ap- pearance of the structures which can be seen, but chiefly by an accurate examination of the amount of sight and the extent of the field of vision. During the inflamma- torj' attacks the tension of the globe is apt to be greatly GUOROIDO-IRITIS. 123 increased, but in the later stages of the disease the eye becomes soft from atrophy of the structures within it, 2d. Choroido-iritis is an inflammation whicli com- mences in the choroid, and afterwards extends to the iris. It is a more severe affection than the preceding, and less amenable to treatment. Symptomi^. — The early symptoms are failing sight, a slightly dilated and sluggish pupil, and turbidity of the vitreous. There is nothing in the external appearance of the eye to account for the great impairment of sight. The disease at this stage is confined to the choroid, but after a time it gradually' extends itself to the iris, and symptoms of a low form of iritis are developed. The iritic sj'mptoms are of a subacute form, and ver}^ insid- ious in their progress. They are usuall}^ accompanied with some irritability and redness of the eye, especially in the ciliary region. The impairment of sight steadily increases, the field of vision becomes contracted, and por- tions of it are occasionally destroyed either from partial detachments of the retina, or from patches of atrophy of both the choroid and retina. The tension of the globe as a rule remains unaltered, until during the later stages of the disease, when atrophic changes in the recently in- flamed structures cause the eye to become soft. The Prognosis of irido-choroiditis is more favorable than that of choroido-iritis. In the former the defect of sight ma}^ be chiefl}- due to the centi-al opacity of the lens capsule, the vitreous being still clear, and the choroid but little affected. When such is the case, there is a good prospect of the eye under proper treatment regaining use- ful vision. In choroido-iritis the impairment of vision is usually great, and clearl}^ dependent on changes at the fundus of the eye. The most hopeful cases are those in which there is a fair field of vision, with an ability to read 124 DISEASES OF THE IRIS. large type, — and with tlie globe of the normal tension. When the eye is soft, the field much contracted, and there remains onl}^ an imperfect perception of light, the prog- nosis is ver}^ bad, for no benefit will be derived by any operative procedure. Treatment. — Although both irido-choroiditis and cho- roido-iritis may arise from many causes, yet a large num- ber of the cases of these diseases are dependent on syphi- lis. A careful inquir}^ should therefore be always made into the previous history of the patient, as if a syphilitic taint can be discovered, it forms a good ground upon which to found the treatment, and the prognosis is more favorable than when the source of the disease cannot be traced. If syphilis is the probable cause, the treatment recommended for Retinitis Syphilitica, should be fol- lowed. If, however, the source of the inflammation should be due to a rheumatic diathesis, the treatment advised for Rheumatic Iritis, page 99, should be adopted. No per- manent benefit, however, will be gained by the mere use of medicines, and soothing applications to the eye ; so long as the iris remains tied down to the lens capsule, and the communication between the anterior and posterior chambers is destroyed, recurrences of the inflammation are liable to occur. As soon therefore as the eye has be- come free from active irritation, an iridectom}- should be performed ; firstly, with the object of restoring the channel through the pupil between the anterior and posterior chambers ; and secondly, for the purpose of making an artificial pnpil, and exposing a portion of transparent lens and capsule, through which the patient may have better vision. There are several difficulties which beset the ope- ration of iridectomy in these cases. a. From the shallowness of the anterior chamber, owing to the iris being pressed forwards towards the cornea, it is often unsafe to use the triangular-shaped iridectomy CHOROIDO-IRITIS. 125 knife. In such cases Graefe's cataract knife should be used in the manner recommended in " the operation of iridectom}'," page 111. /5. In drawing out the portion of iris through the wound previous to excising it, the pupillary border which is ad- herent to the lens capsule often becomes detached and remains in situ. No attempt should be afterwards made to get it away, as it in no way interferes with the good eflfect of the operation. y. The iris may be so rotten, and have formed such broad adhesions between its posterior surface and the lens capsule, that there may be difficulty in drawing out a portion of it with the forceps ; or after the iridectomy has been completed, the sight may be in no way improved owing to the exposed lens capsule being covered with uvea. In such cases it is generally advisable to remove the lens at a future operation. When it is evident that broad and extensive adhesions exist between the posterior surface of the iris and the lens capsule, and that therefore, an iridectomy would fail to benefit the sight, the following operation, which has been frequently adopted by Mr. Bowman and Mr. Critchett, may be performed. The lids being separated with a spring speculum, an iridectomy knife is used to make an opening at the margin of the cornea, as in an ordinary operation for iridectomy ; but the point of it is carried beyond the pupil, and dipped downwards, so as to make a transverse cut in the iris just below the pupil. The blades of a pair of fine scissors are then introduced through the opening at the margin of the cornea, one blade in front of and the other behind the iris ; and a cut is made first on one side to join one ex- tremity of the transverse slit below the pupil, and the same proceeding is then repeated on the other side to make a similar cut to join the other end of the transverse 11* 126 DISEASES OF THE IRIS. incision. The somewhat oblong-shaped piece thus in- cluded in the section consists of iris, and a portion of the anterior capsule of the lens adherent to it. The piece is then lifted awa3^ by a pair of forceps, and the lens-matter behind removed by a curette or cataract-spoon. Fig The dotted lines in Fig. 7 represent the line of the incision at the margin of the cornea, and the piece of iris which is afterwards excised. SYMPATHETIC OPHTHALMIA Is a peculiar inflammation of one eye excited b}' some special irritation in the other. There are two forms of sympathetic ophthalmia. The first, from being the slighter of the tAvo, ma}' be called sympathetic irritation. The second is the severe disease now so well known by the name of sympathetic ophthalmia. Sympathetic Irritation consists of attacks of extreme irritability of the sound eye, Avhich ma}' come on when- ever the lost or injured one becomes inflamed. There is a slight indistinctness of vision, the objects seem to dance SYxMPATIIETIC OPHTHALMIA. 127 about, aucl reading tires the eye. Tlie patient may be able to read No. 1 of Jaeger, and to see distant figures rightl}", but he cannot do so for any length of time, the effort of accommodation soon fails, and the eye becomes fagged. During the attack the eye is slightly reddened, watery, and irritable: occasionally^ it is painful; the pa- tient has neuralgic shootings in it, and this may then be the sj'mptom which gives the greatest trouble. The at- tack generally lasts for some daj's, or it ma}' even con- tinue for one or two weeks, and then gradually' cease ; the recovery being frequently coincident with the cessation of the irritation in the injured eye. The points in which sympathetic irritation differs from sympathetic ophthalmia are : 1. Although the eye may be subjected to frequent re- currences of the attacks, yet no fibrinous effusions nor disorganizing changes of its different tissues take place. 2. The excision of the lost or injured eye at once arrests the disease. All S3^mpathetic irritation ceases when the cause which gave rise to it is removed. Sympathetic Ophthalmia is essentiall}' an adhesive or fibrinous inflammation. Its tendency is to rapid plastic effusions, which soon become organized and incapable of absorption — blending the different tissues together, im- pairing their textures, and destroying their functions. I have never known an e3'e affected with sj'mpathetic inflammation suppurate. The causes of sympathetic ophthalmia are^ 1. Wounds of the e3'e. 2. The lodgement of foreign bodies within the globe. 3. The irritation excited b}^ degenerative changes taking place in e^'cs already lost. Sj'mpathetic ophthalmia is seldom, if ever, excited by a suppurative inflammation of one e3'^e. This fact has been 128 DISEASES OF TUE IRIS. noticed by Von Graefe, and my own experience accords with it. If, however, a foreign body is within the globe, suppuration does not lessen the danger which its presence in the stump will keep up. The age of the patient has a remarkable injluence on this disease. — The young are much more prone to it than the old, and it runs its course more rapidly in the child or the young adult than it does in the middle-aged or the old. The period at ivhich s7/mpathetic ophthalmia may come on after an injury. — It is difficult to assign any date at which sympathetic ophthalmia may be expected, or after which the sound ej-e may be considered as safe. So long as the irritation primarily excited by the injury continues, the sound eye may sympathize. The risk cannot be said to have passed awa}^ until the injured e^^e has quite re- covered ; the sclerotic must have gained its normal white- ness, and all photophobia and lachrymatiou have ceased. Tension of the Eye. — The tension of a s^nnpathetically inflamed eye varies with the development of the disease. In the early stages it is usually increased, sometimes to the extent of T 2 or 3, so that the globe cannot be in- dented with the fingers. This state of increased tension may continue during many months, or even last bej'ond a year. It may accompany the acute or subacute symp- toms which precede atroph3^ If the disease runs on un- abated and unarrested, the increased tension subsides, and the eye gradually becomes softer than normal, and sinks to — T 2 or 3. The vitreous slowly atrophies, loses consistency and diminishes in bulk, and with these changes the eye softens. But, woi'st of all, as the atrophy of the vitreous proceeds, the retina is deprived of its nor- mal support, and falling forwards becomes parti}' or com- pletely detached. Symptoms At the commencement of the attack, the SYMPATHETIC OPHTHALMIA. 129 eye is irritable and abnormally sensitive to light; there is some lachrj'mation, the conjnnctiva is a little injected, and the pupil is decidedly sluggish in its action ; the power of focusing the eye for near objects is diminished ; and the patient is unable to maintain a prolonged accom- modative effort. Reading or any fine work quickly in- duces a fatigue which is followed first by the words be- coming confused and blurred, and, lastly, if the eyes are not rested, by a complete loss of their image. A few minutes' rest and the eye can resume its work, but the same symptoms shortly reappear and oblige it to desist. If the disease progresses, the globe from sclerotic in- jection assumes a pinkish appearance, with a distinct ciliary zone around the cornea, showing internal conges- tion. The pupil contracts adhesions to the anterior cap- sule of the lens, and becomes stationary ; or if atropine is dropped into the eye, it dilates only slightly, irregu- larl^', and partially. The aqueous becomes serous, and the striation of the iris, at first indistinct, is afterwards completely lost. At the onset of the disease there is generally no pain^ not even sufficient to draw proper attention to the eye ; but in the later stages the globe is tender to the touch, and there is frequently supra-orbital pain. Lymph is speedily effused in large quantities as an infiltration into the difterent tissues involved in the inflammation ; the pupillary area of the capsule of the lens is covered and the iris almost soaked Avith it. This exudation rapidly becomes organized, and contracts firm adhesions between the posterior surface of the iris and the lens capsule. Commencing generally in the iris, the disease extends itself back to the choroid, and a form of irido-choroiditis is established, very difficult to arrest. Earl}' in the disease, when the iris is saturated with 1} mph, it is soft and rotten ; but at a later date, when all 130 DISEASES OF THE IRIS. the acute symptoms have passed awaj', the iris has be- come completely changed in its character; it is exces- sively tough, has completely lost all its elasticity, and is converted into a dense fibrous membrane. Treatment. — In the treatment of s^-mpathetic inflam- mation of the eye, we must consider — firstl}', how to arrest the progress of the disease ; and, secondly, how to deal with an eye which remains damaged after the dis- ease has been arrested. 1. Hoio to arrest the progress of the disease. — If the sympathetic inflammation of one eye is dependent on in- jur}' to the other, and it is clear that the wounded eye is irreparably blind ; or if the exciting cause of the mischief is a previously lost eye becoming inflamed, then there cannot be a moment's hesitation about the propriety of at once extirpating the diseased or the injured eye. The importance of removing at an earl}^ period an eye which has been so injured as to be useless, and which is exciting irritation in the other, or the inflamed remnant of a lost ej'e which is acting in the same prejudicial man- ner, cannot be exaggerated ; for though in the very early stage of sjanpathetic ophthalmia the removal of the cause of irritation will and generally does cause its subsidence, 3'et when the disease has thoroughl}- taken hold of the sound ej^e, even the removal of the lost one ma}' fail to arrest its progress. General Treatment. — Absolute rest to the eyes is im- peratively demanded ; all reading, writing, or fine work of any kind, must be forbidden ; when at home, the room should be kept darkened, and, when out, dark neutral- tinted glass goggles should be worn. It is impossible to overrate the imi^ortance of keeping the patient for a long period in a very subdued light ; it affords the best hope of success, and places the eyes in a position to receive most favorably the influence of any other treatment which SYMPATHETIC OPHTHALMIA. 131 ma}^ be adopted. However well the patient ma^' progress, the order to rest the ej'es and abstain from work should not be rescinded for at least from six to eight months. The disease is very recurrent in its nature, and the too soon exposing the eyes to the stimulus of strong light will increase the chances of relapse. The patient should be well fed, as the disease is ver}' depressing, and tonics of quinine, iron, or bark, should be prescribed. I have occasionally found the mineral acids with tincture of nux vomica (F. 60) do good. From the use of iodide of potassium and perchloride of mer- cury, both of them favorite medicines in the treatment of irido-choroiditis, I have never known the slightest benefit. In some cases I have seen decided impi'ovement from a moderate inunction of mercury, but quinine in one- or two-grain doses must be given at the same time. Local Applications. — Belladonna in one form or another affords the most grateful application to the eyes. A solu- tion of atropine, of the strength of one grain to the ounce, should be dropped into the eyes three or four times a day. It is a direct and very excellent sedative to the eye, allays irritability and relieves pain, and sometimes it seems to exert almost a specific action on the disease. The fre- quent use of a belladonna lotion (F. 32) also gives great comfort. No operation should be performed either with the view of arresting the disease, or for the purpose of making an artificial pupil so long as the eye is inflamed. 2. How to deal ivith an eye which remains damaged after the disease has been arrested. — If the disease has been stayed before the deeper parts of the eye have been seriously implicated, and a fair perception of light re- mains, much may be done by operative treatment to re- store useful vision to the eye. The objects to be attained 132 DISEASES OF THE IRIS. are, the formation of a new pupil, and the extraction of the lens. There are very few e^'es which have suffered from sympathetic ophthalmia in which an artificial pupil can be satisfactorily made without at the same time re- moving the lens. The iris has become so changed in structure, and so adherent to the lens capsule, that it is difficult and often impossible to perform an iridectomy ; and even when this can be accomplished, it usually fails to benefit the sight, from the exposed capsule of the lens being coated with uvea. It is, therefore, generally ad- visable to endeavor to remove a portion of iris and to ex- tract the lens in the one operation. To eflfect this, one of two proceedings ma}^ be adopted. The operation recom- mended in the treatment of irido-choroiditis, page 125, may be performed ; or the one which has been recently practised b}^ Mr. Bowman, of first excising a triangular portion of iris and adherent lens capsule with a pair of scissors, and then extracting the lens. See Artificial Pupil by Excision of a triangular-shaped piece of Iris, page 116. The extraction of the lens seems to exert a beneficial influence on the eye, as after it has recovered from the effects of the operation, it is much less diposed than it was before to a recurrence of the inflammation. glaucoma. There are three forms of this disease : 1. The acute and subacute inflammatory. 2. The chronic or simple. 3. The consecutive or secondar3\ The characteristic sj^mptoms of all are, increased ten- sion of the globe, impairment of the field of vision, and fading sight. The progress of each diflfers, but if unin- GLAUCOMA. 133 terrupted by treatment, the end is the same — sooner or later irreparable blindness. To ascertain the tension of the globe. — See page 140. The impairment of the field of vision in glancoma is veiy great. It usually commences at the inner or nasal side, at which part it is sometimes completely wanting. In some cases the field is simply contracted, and this occasionally goes on to such an extent, that the patient will describe his limitation of vision " as if he were look- ing through a tube." In other cases portions of the field are completely obliterated, so that in certain directions the eye is blind. To determine and viop out the field of vision. — See article on this subject. Causes. — Glaucoma is a disease of advanced life, the large majority of the cases being in jjatients over forty- five years of age. There are, however, exceptional in- stances in which it has occurred at a much earlier date. Glaucoma may be idiopathic, that is, it may develop itself in an eye without any apparent cause ; or it may be de- pendent on an injur^^, or on some form of inflammation of the eye to which it is secondary. The advent of an attack of acute glaucoma seems to be sometimes due to a sudden mental shock occurring to a person already depressed and with eyes probably predis- posed to the disease. Thus I have on several occasions seen it come on after severe affliction caused by the death of near relations, or by great pecuniary loss. In one case which came under my notice, a sudden fright in a patient exhausted b}" night watching, apparently induced the dis- ease. The patient, a nurse, had from sheer fatigue fallen asleep by the bedside of the patient she was watching, when she was suddenly awoke in the night by the snap- ping of the sash cord, and the sudden falling of the win- dow. Within a few hours she had an attack of acute 12 134 DISEASES OF THE IRIS. glaucoma. Patients who have suffered from gout or from disorders of the digestive system have been supposed to be specially liable to glaucoma, but this has not been satisfactorily proved. Both ej'es ma}^ be simultaneously involved ; but it is more usual for one to be first affected, and for the disease to follow in the other after a varj'ing interval. When one eye has suffered from glaucoma, the other is specially liable to be attacked. The j^remonitory symptoms are, rapidly increasing presbyopia^ the patient finding it necessary to frequently change his convex glasses for stronger ones on account of his defect of sight increasing. Periodic obscurations, sudden dimness, varying in degree and lasting from a few minutes to several hours. Halos or rainbows around the candle or an}^ other light is a frequent sjmptom, and one which generally draws the patient's attention to his ej'e. Diminution of the field of vision and fading sight ; and lastly, a gradual increasing hardness of the globe. Such are the warning symptoms of glaucoma, but they may be all so slight, or may make their appearances so slowl}" that they may be unheeded, and this is especially the case if one eye onl}' is affected. AcLTE Inflammatory Glaucoma is generally sud- den in its attack, occurring usually in ejes which have had premonitory symptoms, though they may not have been appreciated by the patient ; or it may supervene on the simple form of the disease, the chronic glaucoma rapidly and suddenly assuming the acute inflammatorj- type. Symptoms. — The eye exhibits all the external manifes- tations of great internal congestion and acute inflamma- tory action. There is distension of the ciliary vessels, both of the veins which emerge through the sclerotic in front of the insertion of the recti, and of the zone of GLAUCOMA. 135 arteries around the cornea ; occasional!}' there is also chemosis of the conjunctiva. The anterior chamber is diminished in size, sometimes to such a degree as to bring the iris almost into contact with the cornea ; the pupil is dilated and either very sluggish or completely inactive. The patient sees rainbows or halos of bright-colored light around the candle or gaslights. The field of vision is diminished, or parts of it are obliterated. The sight is greatly impaired, and is rapidly getting worse ; in a few hours it may be so reduced as to be able only to distin- guish Xo. XX, or to count fingers. The tension of the globe is increased from T 1 to T 3, or stony hardness. The pain is usually most severe, oftentimes of an almost maddening character. There is a sense of aching and tightness of the globe, with pain extending around the orbit, along the side of the head, and down the nose, but the most acute agonj^ is often referred to the back of the head. This is usually accompanied with severe vomiting, so as to give to the symptoms an aspect of a severe bilious attack, for which indeed it is unfortunately too often mis- taken. Examined with the Ophthalmoscope the vitreous may be so turbid as to preverft the fundus from being seen ; but if the humors are still sufficiently clear, there will be found a cupping of the optic nerve, with pulsation of the retinal vessels, either spontaneous, or produced by the slightest pressure on the globe. Small blood-spots will" be often seen scattered at different parts of the retina. They are the result of capillary hemorrhages, which take place in most cases of the acute, and in many of the chronic glaucoma. Filmy blood-clots are also often found in the vitreous. The Characteristics of a Glaucomatous Cup. — Its mar- gin is abrupt, sharp, and sometimes excavated, and the vessels as they curl over its edge appear to be either in- 136 DISEASES OF THE IRIS. terrupted or distorted. If the excavation is deep^ the continuity of the vessels, as they ascend the side of tlie cup and mount over its edge, seems to be lost, and the vessels look as if the}^ were interrupted or broken in their course ; whilst if the cupping of the nerve is shallow, the vessels appear bent or distorted as they pass over its edge. The optic disc is encircled b}' a light-colored zone. This is caused by the edge of the sclerotic ring shining through a rim of atrophied choroid, and it is best seen in those cases where the excavation is deepest. The central portion of the papilla has often a peculiar bluish-gray tinge which increases in intensity towards the circum- ference of the nerve. So deceptive is the appearance of a deeply excavated uerxe that it resembles more the promi- nence of a sphere, than the hollow of a cup. This illusion is, however, at once corrected by the apparently discon- nected or distorted vessels. The glaucomatous excava- tion is perfectly distinct from what is termed the physio- logical cup). This latter is simplj- a shallow depression confined to the centre of the optic disc, in the site where the retinal vessels pass ; it looks white and glistening, and its sides are usually bevelled or sloping ; it varies greatly in size, but it is surrounded by healthy-looking nerve- structure ; it is congenital, and has no unfavorable omen. In addition to these two, there is a third form of excava- tion of the disc produced by atrophy of the optic nerve. See Atrophy of Optic Nerve. Two modifications of this acute form of glaucoma should be noticed. A subacute in which all the symptoms are diminished in intensity ; and a hemorrhagic form in which there is a peculiar tendenc}' to retinal hemorrhages, and in which, bleeding between the choroid and retina will sometimes occur immediately the tension of the globe is relieved by iridectomy. Results The vision maybe reduced to a mere percep- GLAUCOMA. 137 tiou of large objects in a few daj's, or, in very acute cases, as in the " Glaucoma fulminans " of Graefe,* in even a few hours. If the acute symptoms subside, and some of the lost sight is regained, the eye is still left in a ver}'^ un- healthy and unsatisfactory state. The sight remains im- paired, the tension of the globe will generally continue too great, and there is a probability, amounting almost to a certainty, that the eye will sooner or later be subjected to another attack which will still further damage the sight, if it does not altogether destroy it. After one or more of these acute attacks, the eye will drift into that state of hopeless blindness which has been described as glaucoma absolutum. It is, in fact, the last stage of the disease, when the eye is irremediably^ blind, and when all hope of benefit from treatment has passed. The globe is of stony hardness, the j)upil widely dilated, and often irregularly so ; the anterior chamber is so shallow that the iris is almost in contact with the cornea, which is anaesthetic and dull in appearance, having lost much of its normal lustre. The humors are turbid, so that the fundus can- not be seen ; and it may be that the lens is also catarac- tous. But, in addition, the eye is often subject to severe pain, which is either constant or so frequently' recurring as to destroy sleep and impair health. One source of the suffering is the repetition of the acute inflammatory at- tacks, which continue even though the eye is lost. But another cause of the pain which is so often continuous, is to be found in the irritation which is excited by the de- generative changes which are taking place in the tissues within the globe. Treatment. — For the acute inflammator}- glaucoma, there is but one plan of treatment which holds out the promise of regaining much of the lost sight, and at the * Archiv fur Ophthal. viii, 2. 12* 138 DISEASES OF THE IRIS. same time of relieving pain, and that is iridectomy. The results of this operation in acute glaucoma have been most brilliant; its curative effect is now an established fact, and cannot be controverted by ignorance or prejudice. To Yon Graefe is to be ascribed the honor of having originated the operation, and the thanks of all who are benefited b}' it are due to him. The effect of iridectomy is to relieve tension, and the symptoms which are de- pendent on it at once begin to subside. The operation should be performed as soon as possible after the acute sj^mptoms have set in, as every hour tends to diminish the chances of recovery. Chronic, or Simple Glaucoma. — The progress of this disease is usually unaccompanied by pain. It may in- volve one or both eyes ; but when both are affected, it is genex'ally more advanced in one eye than in the other. The vision gradually fades, and there are occasional ob- scurations in which the dimness is greatly increased — in some cases almost to darkness ; but after a varying time the sight is regained. The patient sees rainbows or halos of colored light around the caudles. The pupil is slug- gish and more dilated than normal. The anterior cham- ber becomes shallow, and the humors turbid. The ten- sion of the eye is increased ; and the field of vision is con- tracted, or in parts lost. These symptoms may steadily progress, with occasional remissions or exacerbations, until all sight is extinguished. Frequently, however, an acute attack supervenes, and all the sjmptoms which characterize the acute inflammator}' glaucoma are at once developed. Examined with the ophthalmoscope the same appear- ances are presented which were mentioned in the section on Acute Glaucoma, page 135 ; viz., cupping of the optic disc with pulsation of the retinal vessels, either spon- GLAUCOMA. 139 taneous or produced under the slightest pressure of the fingers on the globe ; turbidit}' of the vitreous, and occa- sionally small extravasations of blood on the retina. Treatment. — Iridectomy affords the best chance for the eye ; but the results of this operation in the chronic or simple glaucoma are not near so favorable as when per- formed for the acute form of this disease. It will gener- ally arrest the progress, and retain for the patient the vision he still has, but it will often fail to bring back the sight which has been lost. Still, so long as the e3'es pos- sess perception of light, it is worth performing iridectomy, as the results of the operation will often far exceed the expectations, and especiall}^ if the disease has been of short duration. In some cases which have been under my care, where the vision was so reduced that the pa- tients could onlj'^ count fingers, I have been gratified by such a restoration after the operation as has enabled them to read fair-sized tj^^e, such as, from No. 6 to Xo. 10 of Jaeger. The cases of chronic glaucoma which hold out the best promise of success are those in which the field of vision is still entire, and where the disease has not continued long enough to produce severe atrophic changes in the optic nerve and retina. Consecutive or Secondary Glaucoma may compli- cate many of the diseases and injuries of the eye. It may follow a perforating wound in which the lens has been injured ; or it may come on after a needle operation for cataract or for opaque capsule ; or after a dislocation of the lens into the anterior or vitreous chambers. It is then known as traumatic glaucoma (see page 179). Sec- ondary'' glaucoma is also occasionally met with in cases of iritis, and irido-choroiditis, in staphyloma, in sympa- thetic ophthalmia, and in some forms of deep ulceration 140 DISEASES OF THE IRIS. of the cornea. Whenever it occurs, it must always be regarded as a grave symptom. Treatment. — In those cases where the increased tension of the globe is dependent on removable causes, the source of the irritation should be taken away. Where a wounded or broken up lens is pressing upon the iris, and exciting glaucomatous symptoms, it should be either sucked out with a syringe or removed by linear extraction. When a dislocated lens is the cause of irritation, it should be extracted. In cases of increased tension after capsular operations, paracentesis of the cornea will generally afford relief. (See page 52.) The same operation ma}' be also tried when glaucomatous s^^mptoms are associated with deep ulceration of the cornea ; but should it fail to dimin- ish the tension, a portion of the iris should be excised by iridectomy. In iritis or irido-choroiditis with increased tension of the globe, iridectomy should be performed. To ASCERTAIN THE TENSION OF THE Globe, the patient should be told to gently close his eyes and look down- wards Avhilst the surgeon places his two forefingers on the upper part of the eye, and by an alternating pressure Muth first one finger and then the other, as if feeling for fluctuation, he determines the degree of tightness of the globe. The tension of eyes varies considerably in difler- ent patients even in health ; it is well, therefore, when de- ciding on the degree of tension of a diseased eye, to ex- amine also the sound one so as to compare the two, as their normal condition may be either slightl}^ above or below the usual standard of tightness. The following s^-mbols were suggested by Mr. Bowman, in the British Medical Journal, October 11, 18G2, for re- cording accurately the varying degrees of increase and diminution of tension : "T represents te)isio7i ('t' being commonly used for TREMULOUS IRIS. 141 'tangent,' the cnpital T is to be preferred); Tn, fcnsion normah The interrogative, ?, marks a doubt, which in snch matters we must often be content with. The nume- rals folloAving tlie letter T on the same line indicate the degree of incr-eased tension ; or, if the T be preceded l)y — , of diminhhed tension^ as further explained below. Thus : " T 3. Third degree, or extreme tension. The fingers cannot dimple the e3'e by firm pressure. "T 2. Second degree, or considerable tension. The fingers can slightly impress the coats. " T 1. First degree. Slight but positive increase of tension. " T 1 ? Doubtful if tension increased. " Tn. Tension normal. " ■ — T 1 ? Doubtful if tension be less than natural. " — T 1. First degree of reduced tension. Slight but positive reduction of tension. " — T 2\ Successive degrees of reduced tension, short " — T si of such considerable softness of the eye as allows the finger to sink in the coats. It is less easy to define these b}' words." Tremulous Iris — Iridodonesis — are terms applied to an iris which trembles and vibrates with each movement of the e^'c. It is most frequently caused b}' the loss of the lens, and is thus occasionally seen after the extrac- tion of cataract, or it may be produced by a partial or complete dislocation of that structure either into the ante- rior chamber or vitreous. The iris is also generall}^ trem- ulous in cases of hydrophthalmos, owing to the loss of the lens from an increase in the size of the posterior aqueous chamber, and a stretching of the suspensory lioament. 142 DISEASES OF THE IRIS. CoLOBOMA OF THE Iris is a congenital cleficienc}' of a portion of the iris, caused by an arrest of development in early foetal life. It usually occurs in the lower part of the iris, and is associated with a similar defect in the choroid. A case is reported by Mr. Hulke,* in which there was a coloboma of the iris, choroid, retina, and op- tic nerve-sheath. Coloboma of the iris most frequentlj'^ occurs in both eyes, but it is not uncommon to find only one eye affected. It is occasionally associated with mi- crophthalmos or congenitally stunted eyes. Mr. White Cooper has related the history of three children, out of a famil}^ of seven, each of whom were afflicted with microph- thalmos and coloboma of the iris in both eyes-f DISEASES OF THE VITREOUS HUMOR. ITyalitis, or inflammation of the vitreous, rarely occurs either as an idiopathic or a primary affection. It is usually associated either with disease of the iris, the choroid, or retina, to which it is secondary. It may be induced by an injury, and especially the lodgement of a foreign body in the vitreous or the adjoining ciliar}^ processes. The inflammation may be either simple or suppurative. In simjile hyalitis there is a diffused haziness of the vitreous, with here and there small filmy opacities. These may be caused by portions of the connective tissue be- coming opaque, or by small effusions of lymph into the vitreous from the neighboring ciliary processes. When the hyalitis is due to the presence of a foreign body within the e3^e, large masses of l^nnph will be frequently seen behind the edge of the lens projecting into the vitreous, whilst the rest of its structure is so turbid as to exclude the fundus of the e3'e from ophthalmoscopic view. If the * lloyal London Opbtlialniic Hospital Reports, vol. iii, p. 835. t Ibid. vol. i, p. 110. OPACITIES OF THE VITREOUS. 143 inflammation is long contiuiiecl, the vitreous loses its con- sistency, and becomes more or less fluid and reduced in bulk. With this diminution of volume detachment of the retina and shrinking of tiie globe are apt to occur. Suppurative hyalttis is met with in ophthalmitis and suppuration of the globe. The efiusion of pus may be often seen to commence in the ciliary region behind and to one side of the lens, but it soon diff'uses itself through- out the whole of the vitreous. Treatment. — As hyalitis is seldom a primary aflfection, the treatment for it will be found under the heading of the diseases to which it is secondary. MUSC^ YOLITANTES: OPACITIES OF THE YiTREOUS. Opacities of the vitreous, the result of disease, must be distinguished from the motes or muscse volitantes, which are perfectly compatible with healthy eyes, although they are the source of much anxiety and even of misery to the patient. Two varieties of muscse — the transparent and the opaque — are commonly met with, and they occur mostly amongst myopic patients and those who use their e^'es much for fine or close work. The transparent miiscee are best seen when looking up in the light, or against a white surface through a small aperture in a card, or with the lids partially closed. They consist of numerous small transparent bead-like bodies, some of them hanging together in rows or in clusters, whilst others are floating as isolated circles in myriads before the eye. They do not obscure vision, as every- thing is seen clearly through them, or by their side. If the eyes are suddenly turned upwards and then fixed, the}^ will be observed by the patient to float slowly down- wards, as if gravitating to the fundus of the glode. They are perfectly innocuous, and merely represent the corpus- cles of the vitreous and debris of cells, which in certain 144 DISEASES OF THE VITREOUS. lights become obvious to the eye in which they exist. The different shapes assumed by these transparent muscse are caused by aggregations of the corpuscles either into groups or strings. Opaque Muscee. — The second form of mote which is often complained of consists of one or more dark spots of different fantastic shapes, which are constantlj' floating before the field of vision, and shifting with the movements of the eye. Thej^ will appear suddenlv, and remain for 3-ears without increasing or diminishing, or without the eye becoming in any other way affected. They will also disappear occasionall}' for months or longer, and then turn up again in their old familiar form. This, perhaps, may be explained by supposing that the body of which the mote is composed floated out of, and was for a time accidentall}^ kept from, the field of vision, when, again be- coming free, it reappeared. The cause of these opaque muscae it is difficult to ascertain. They may be the de- bris of cells congregated together, or opaque detached filaments from the connective tissue of the vitreous, or a little of the pigment of the uvea which has been acci- dentally detached from the ciliary processes and worked its way into the vitreous. Donders, in speaking of miiscae volitantes, says, "I succeeded in finding, on microscopic examination, with Professor Jansen, some, and subse- quentl}' with Dr. Doncan, all forms in the vitreous hu- mor of the human eye." He detected " pale cells and debris of cells in a state of mucine-metamorphosis ; fibres furnished with granules, and groups of granules with ad- herent granular fibres." * Treatment. — Rest the eyes by abstaining from all close work, and avoid constantl}^ looking for the musc«. If in * Bonders on the Accommodation and Kefraction of the Eye, Sj'denham Society, p. 199. OPACITIES OF THE VITREOUS. 145 bright lights they become visible without the patient searching for them, he should be provided with neutral tint or dark cobalt-blue glasses. Tonics of quinine or iron frequently do good by improving the health and ren- dering the eye and the mind of the sufi'erer less impres- sionable to little defects. No local applications will be of any service for the getting rid of the true muscae voli- tantes. The patient should be assured that they are not portentous of coming blindness, and that they may con- tinue for years without causing an}- more than their pres- ent annoyance. Muaese must not be confounded with scotomata, which are fixed blind spots in the field of vision, dependent on a complete loss of sensibility of a portion of the retina. Opacities or the Yitreous are a frequent result of disease of the iris, choroid, and retina, and especially of those affections which have a syphilitic origin. They may be due to inflammatory changes in the cells or connective tissue of the vitreous, or to small effusions of lymph, or to extravasations of blood. They are frequently asso- ciated with a general turbidity of the vitreous, but they ma}^ also exist in large numbers when that structure is perfectl}^ transparent, so that with the aid of the ophthal- moscopic mirror these opaque bodies may be seen floating in a perfectly clear medium. The opacities may assume a variety of forms resembling either grains of soot, dark threads, or membranous expansions. When they are numerous, there is usually great impairment of vision ; but this is often as much due to the disease which has led to their formation as to the impediment they offer to the passage of light to the retina. Those which are placed deeply in the vitreous create the most confusion by throw- ing their shadows on to the retina. Treatment. — Opacities of the vitreous must be treated 13 146 DISEASES OF THE VITREOUS. by attacking the disease which has given rise to them. Those which have a syphilitic origin, and are dependent on small plastic effusions, are more amenable to remedies than any of the other forms. For the filni}^ opacities due to hemorrhage nothing can be done. In the course of time they will shrink considerably, and many of them will disappear from the field of vision. The dense mem- branous opacities, which greatly obstruct vision by float- ing in front of the object. Von Graefe has treated success- fully by dividing with a fine needle, as in a capsular ope- ration after cataract. Sparkling Synchysis. — Synchysis scintillans. — These euphonious titles have been given to the beautiful appear- ance which is presented by sparkling flakes of cholesterine floating in a fluid vitreous. They frequently abound in such quantities, that they may be seen to descend in a perfect shower after every movement of the eye. With the ophthalmoscope the crystals of cholesterine look like chips of gold leaf, and make the vitreous closely resemble the liqueur called gold-water. The cholesterine is prob- ably derived from blood which at some distant period had been efl"used into the vitreous. Fluidity of the Vitreous — Sy7ichysis — is the begin- ning of the end of many of the diseases of the eye which lead to blindness. It may be due to ophthalmitis, or to inflammation of the iris, choroid, or retina. It is one of the terminations of sympathetic ophthalmia, and is a fre- quent result of injuries of the eye accompanied with deep or posterior intraocidar hemorrhage. It also usually oc- curs in hydrophthalmos, and in most cases of general staphylomatous enlargement of the globe. In many dis- eases, fluidity of the vitreous with softening of the eye follows increased tension ; it is so in sympathetic ophthal- FOREIGN BODIES IN THE VITREOUS. 147 mia, and in iridoclioroiditis, and frequently also in glau- coma. It then indicates that the disease has done its worst, and atrophy of the tissues within the eye has com- menced. A fluid vitreous does not necessarily imply a soft eye ; the globe may in certain cases be of its normal tension, or it may be even glaucomatous and have its hardness increased. A soft eye, however, usually indi- cates a fluid vitreous, unless the diminution of tension has been caused by a recent escape of vitreous from an injury. Although a loss of consistence of the vitreous is commonl}' produced b}' some inflammatory disease, ^et it may occur in e3es which have never suffered from any in- flammatory affection and which still retain very fair sight. Such eyes, however, are prone to the early formation of cataract, and to detachment of the retina. This fluid state of the vitreous is frequently met with in extreme myopia associated with large posterior staphyloma, and in cases of cataract coming on in young people without any assignable cause, but probabl}' due to defective nutrition arising from some constitutional ailment. A loss of vitreous occasioned by some penetrating wound is rapidly replaced by aqueous. Fresh vitreous is never generated. If the amount lost be small, no ill effects may follow, as sufficient aqueous will be kept secreted to supply its place ; but if the escape of vitreous be large, the eye usually suffers. For a while the globe is plumped out by aqueous, but the supply after a time fails to meet the demand, and the eye first becomes soft, then shrinks, and ultimately all sight vanishes. Foreign Bodies in the Yitreous. — A foreign body may be lodged in the vitreous and remain there for a long period provided it does not exert anj^ injurious pressure on any of the other parts within the eye. The danger is, that with the motions of the globe its position may be 148 DISEASES OF THE VITREOUS. shifted, and falling to the fundus ma}' then excite a dangerous inflaniination, which may lead to destruction of the other eye from sympathetic ophthalmia. Treatment. — If the foreign body can be seen, an en- deaA'or should be made to remove it. Hemorrhage into the Vitreous may take place — 1. From rupture of some of the vessels of the ciliary pro- cesses ; 2. From choroidal hemorrhage ; the blood break- ing through the retina and becoming extravasated into the vitreous ; or, 3, it may ensue from the rupture of a retinal vessel, but this is rare. Blood effused into the vitreous is but slowly absorbed. If the clot be small, it gradually loses its coloring matter, and shrinks, and after a few weeks or months, it is seen with the ophthalmoscoi^e either as a small dark mass, or as floating filaments in the vitreous. If, however, there has been much hemorrhage, loss of the eye is certain to follow. To allow the blood to be extravasated, the h^-a- loid has to be ruptured, and wherever the blood forces its way, it breaks down the texture of the vitreous. From this mutilation of structure the vitreous does not recoA-er ; it atrophies, loses its consistence, and becomes fluid. The blood-clot softens and is gradually dissolved, and its coloring matter stains the whole of the fluid which occupies the vitreous space to a yellow or brownish-yellow tinge, which color may last for years. The mischief, howcA'er, does not end here ; for, as the vitreous becomes fluid, it diminishes in bulk ; and the retina, losing the support which it had received from the healthy vitreous, falls forward and becomes detached. CATARACT. 149 CHAPTER IV. DISEASES OF THE CRYSTALLINE LENS. Cataract is an opacity of the lens. In the great ma- jority of cases the opacity is confined to the lens sub- stance, the capsule remaining transparent. Cajjsidar Cataract is the term used when the opacity is apparently limited to the lens capsule. Capsulo-lenticular Cataract is when there is opacity of both the lens and its capsule. Causes op Cataract. — Whatever interferes with the due nutrition of the lens tends to produce cataract. a. It may occiir from old age ; it is then one of the re- sults of senile decay, and has been rightly called "senile cataract." /?. It may be dependent on a constitutional disease, in which the general nutrition of the body fails, as in dia- betes. This form is recognized as a " diabetic cataract." y. It may be due to disease of the deep structures of the eye, the choroid and retina, to which it is indeed secondary. This class is distinguished as " secondary cataract." S. It may be produced by injury, and it is then termed "traumatic cataract." e. Lastly, it may be congenital. Cataracts may be divided primarily into two great classes — soft and hard cataracts. I. SoET Cataracts may occur at any period between infancy and thirty or thirty-five years of age. They may 13* 150 DISEASES OF THE CRYSTALLINE LENS. be congenital, or the}^ may be dependent on one or other of the causes already' related ; the consistence of the cata- ract being mainly determined b}^ the age of the patient. Congenital or Infantile Cataract may come on in early infancy, or as its name implies, it maybe a congeni- tal defect. E^^es with this form of cataract are usually below the normal standard in size. They are also often associated with other congenital deficiencies, such as microphthalmos or small ill-developed eyes ; or with a stunted bodil}^ growth ; or occasionallj' with mental im- pairments, varying from slight imbecility to idiotcy. On the other hand, it is only right to say that I have seen congenital cataracts in well-grown and finely developed patients, with a mental activity to be admired, and with such an exaltation of one or other faculty as justly to entitle them to the rank of genius. Mr. Bowman has drawn attention to the fact, that there is probably some intimate connection between infantile convulsions and congenital cataract. I have myself questioned the parents of many children who have been aflflicted with cataract, and have been struck with the number of them who have also suffered from convulsions. There are two kinds of congenital cataract, each of which requires to be specially noticed — the "lamellar," and the "cortical." The Lamellar Cataract is where there is a central opacity of the lens with a more or less clear circumferen- tial margin. The density of the opacity is uniform, and seems to be due to a layer of opaque matter between the central nucleus and the transparent surface of the lens. The Cortical Cataract is where the opacity commences in the margin of the lens, and it is seen as opaque striae running from its circumference towards its centre. In the early stage ol this form of cataract the intermediate INVOLUNTARY OSCILLATIONS OF THE GLOBE. 151 spaces are clear, and through them the fundus of the eye can be exaniined with the ophthahiioscope ; but patches of cloudiness or opaque dots soon appear in different parts of the lens, and these gradually diffuse themselves and ultimately render the Avhole opaque. The defect of sight in congenital cataract is very vari- able ; it is of course dependent on the extent and density of the opacity. A slight and partial opacity may remain stationarj' for man}- 3'ears, but as a rule the whole lens will, sooner or later, become opaque. Involuntary Oscillations of the Globe — Nystag- mus — are frequently associated with congenital cataract. These movements are quite beyond the patient's control, and continue without his knowledge. They generally in- dicate a somewhat unsound state of the nervous sj-stem of the eye, and they may be either congenital, or brought on from defective vision produced by any cause during childhood. The division of the ocular muscles affords no relief to the constant oscillatory motions. In one patient, from whom I had occasion to remove a shrunken globe which oscillated in concert with its fellow, the muscles continued their alternating action, and jerked the conjunctiva to which their cut ends had become at- tached, in unison with the movements of the remaining 63^6. The onl}' treatment which is likel}^ to diminish the frequency of the oscillations is to improve, if possible, the sight, and this is one of the strongest reasons in favor of an early operation for congenital cataract in those cases where the opacity of the lens is sufficient to prevent the child discerning objects. When the cataract is thus com- plete, even though there ma}' be no oscillator}- movements, they may after a time be acquired, and the good effects of a future operation will be then diminished. Ti^eatment of Congenital Cataract. — In those cases in V 152 DISEASES OF THE CRYSTALLINE LENS. ■which the opacity is central, and the margin of the lens clear, and where there is reason to hope that the cataract is not progressive, Mr. Critchett has adopted his opera- tion of iridodesis. By drawing the pupil opposite to that portion of the lens which is transparent, good sight is often at once secured to the patient. The advantages which this operation offers are, that its object is attained quickly, and with even less risk than that which accom- panies the removal of the lens by solution ; and, secondl}', the patient seeing through the margin of his own lens, is able to use his ej'es without the aid of cataract glasses. The disadvantages of this operation are, however, great, as congenital cataract is very rarely stationary, but sooner or later the opacity extends, and a farther operation is then required. When this becomes necessary, the eye is in a much less favorable condition for any operative pro- cedure, and the results will not be so satisfactory. The operations which are suited for congenital or other forms of soft cataract are — 1. Solution and absorption of the lens. 2. Linear extraction. 3. The suction operation. Operation by Solltion — Keratonyxis — consists in breaking up with a flue needle the central portion of the capsule of the lens, so as to freely admit the aqueous, and allow it to exert its solvent influence on the lenticular matter. A description of this operation is given at page 153, under the heading of " the first stage of the operation of linear extraction," the only diflerence being that the lens substance should not be quite so freely comminuted. The precautions which are there given, both prior to and after the operation, with reference to the dilatation of the pupil, must be rigidly followed. Occasionally one needle operation will suffice, but generally it has to be repeated EXTRACTION OF CATARACT. 153 two or three times before the whole of the lens is absorbed. The intervals between each operation mnst be regulated by the progress of the case ; from three to six months is the time which is nsnally required. If after one of the needle operations the swollen lens should press injuri- ously on the iris, and produce symptoms of irritation, the second stage of linear or suction extraction, page 155, should be at once performed, and the lens, or what remains of it, be removed. This method of dealing Avith a congenital or soft cata- ract is undoubtedly the safest of all the operations, and I believe the results on the whole are the most satisfac- tory. It presents, however, these difficulties : the process of the absorption of the opaque lens occupies a long period, and it is essential for the safety of the eye that the patient should continue during that time under the supervision of the surgeon. Linear Extraction of Cataract The operation known as Gibson's, from the late Mr, Gibson, of Man- chester, having first suggested and performed it, is now recognized and practised with some slight modifications, under the name of linear extraction. It is well adapted to a large majority' of the cases of soft cataract, but it is an operation which requires great care, and great delicacy of manipulation. Prior to performing the operation, the pupil should be fully dilated with atropine, so that the whole of the lens may be under the observation of the operator, and the iris ma}' be drawn away as far as possible from the chance of injury. The operation ma}' be divided into two stages. The first stage of the operation is to break up with a fine needle (Fig. 8) two-thirds of the anterior capsule of the lens ; and by carefully moving the needle through the soft 154 DISEASES OF THE CRYSTALLINE LENS. lenticular matter, so as to comminute it, that every portion of it may be brought into contact with the aqueous. Fig. 8. Great care must be taken not to injure the pos- terior la3^er of the capsule of the lens, as by so doing the h^'aloid membrane would be ruptured, and the vitreous mixing with the particles of the lens would materially interfere with the due action of the aqueous humor on them, and also render more difficult the second part of the operation. After the operation, the patient should be kept in a darkened room, but not in bed, and a solu- tion of atropine of the strength of gr. 2 ad aquse ^ 1, should be dropped into the eye twice a day. The second stage of linear extraction consists in remov- ing the broken-down lens through a small linear opening in the cornea. Before it is attempted, if nothing has happened since the first operation to necessitate its im- mediate performance, sufficient time should be allowed to elapse for all the transparent portions of the lens to become opaque, and somewhat macerated b}' the aqueous. From three to six daj-s will be about the time required for the desired changes to take place, but much depends on the condition of the cataract at the time of the Fig. 9. operation, and upon the extent to which the cap- I sule has been torn, and the lenticular matter broken up. The pupil being widely dilated with atropine, an opening is to be made in the cornea with a broad needle (Fig. 9) at a point just external to where the pupillary margin of the iris is seen. Instead of inserting the needle through the cornea directly from before backwards, it should, as Mr. Bowman has suggested, be made to pass obliquely- inwards through the lamellae of the cornea. The aperture thus made will be valve-shaped, the object being, that the OPERATIONS FOR CATARACT. 155 curette in and after its introduction shall not press at all upon the iris. A sufficient opening having been made, the curette, Fig. 10, is next to be introduced, and this should be done with a gentle lateral motion. The eye being still held by the surgeon with a pair of forceps in the most convenient position, the curette is moved Yiq. 10. gently from side to side, pressing slightly on the mouth of the wound to permit the aqueous with the softened lens to flow down its groove. When the largest portion of the lenticular matter has escaped, small opaque pieces will occasionally be seen which have not flowed away in the stream ; these may be followed by the curette, and on the point of it being dipped beneath them, thej^ will also escape along its groove. All the move- ments of the curette must be conducted with the greatest caution, as it is essential that the posterior capsule should not be broken. When this accident happens, the opaque fragments of lens become entangled in the vitreous, and no further attempt should be made to remove them. The lens having been removed, or as much of it as will readily flow away, the patient is to be sent to bed in a darkened room, and the pupil is to be kept under the in- fluence of atropine. Extraction of Soft Cataract by Suction. — This method of removing a soft cataract was reintroduced by Mr. T. Pridgin Teale, Jr., of Leeds, who suggested the operation, and performed it with success in December, 1863, on a j^oung man who had a traumatic cataract. The extraction of the lens by suction may be completed in one operation, but my own feeling is that it is better. 156 DISEASES OF THE CRYSTALLINE LENS. as a vule, to divide it into two stages. The fimt Mage is tlie same as the preliminary needle operation for linear extraction described at page 153. Two, three, or four days having elapsed, the second stage or suction part of the operation ma}- be performed, and the whole lens, now opaque and diffluent, will be readily drawn through the tubular curette of the instrument. The second stage ^ or the suction part of the operation^ ma}' be performed as follows : The pupil having been pre- viously^ fiiily dilated with atropine, an opening is made in the cornea with a broad needle, immediately^ within the pupillar}' margin of the dilated pupil, sufficient in size to allow of the easy entrance of the tubular curette. A delicate manipulation of the instrument is required to move it from point to point, so as to place the open month of the curette in the most favorable positions for sucking in the lens matter, without in any waj^ injuring the iris. The suction power must be carefully regulated b}^ the operator, who is able to arrest it instantl}' if neces- sary. The best suction instrument is that made b}' Messrs. AYeiss of the Strand. The suction power is obtained through a delicate metal sj^ringe placed at one extremity of a glass tube, which is furnished at the other end with a tubular curette, the aperture of which is countersunk. The syringe is so contrived, that with one hand the piston can be worked, and the movements of the curette within the eye guided, whilst the other hand is left free to fix the globe with a pair of forceps. II. Hard Cataracts are characterized b}' a firm nu- cleus, and ma}' occur at any period of life after 35 or 40 years of age. There are ditterent forms of hard cataract, which are distinguished from each other: 1, by the part CATARACT. 157 of the lens in which the opacit}' begins ; 2, by its general appearance; and 3, by the age of the patient. Nuclear- Cataracts are those in which the opacity com- mences in the nucleus, the marginal portion of the lens remaining for a time transparent. Striated Catai-acts. — The opacit}^ first shows itself in opaque lines in the cortical substance of either the ante- rior or posterior surface of the lens, or in some cases in both simultaneously. These strife radiate from the cir- cumference towards the centre of the lens. Black Cataracts. — There are two classes of cataract to which the name black has been given. 1st. To the hard opaque senile lenses, in which the nucleus has acquired an exceptionally dark reddish-brown color. 2d. To those rare cases in which a lens with commencing cataract has become darkl^"^ stained with haematine from some prior extravasation of blood into the aqueous chamber. Dis- solved in the aqueous, the haematine has permeated the lens capsule and been deposited in the lens substance. Senile Cataracts usually occur from 50 to 55 years of age. They may be either nuclear or striated. They vary greatly in consistence, but are always distinguished by the presence of a distinct firm nucleus. In some cases the nucleus is small and hard, with a good deal of soft cortical matter surrounding it ; in other patients the nu- cleus is large, hard, and amber-colored, and with scarcely a trace of cortical substance. Lastly there is a third class of senile cataracts, in which there is a small or medium- sized nucleus, surrounded by an opaque but fluid cortex. The P7'ogress of Hard Cataracts is ver}' variable. In one patient its formation will be ver}^ rapid, whilst in another it will take man}' years before the whole lens be- comes opaque. Again, it may be slow in its early stages, but develop itself quickty in the last. Treatment of Hard Cataracts As a rule it is wise to 14 158 DISEASES OF THE CRYSTALLINE LENS. postpone an operation for the extraction of a bard cata- ract until the whole lens is opaque. This may be always couvenientl}' done when one eye only is affected ; but it often happens that the cataract is slowly advancing in both e3'es, and the sight has become so far dimmed as to prevent the patient following the business on which his daily bread depends. In such a case the patient cannot afford to wait, and one of two courses may be pursued. 1. The lens ma}' be extracted from one eye b}' a "modi- fied linear extraction operation." If some soft cortical matter remains behind, the pupil must be kept dilated with atropine after the section has united. 2. Before attempting any operation the surgeon may prick the lens with a fine needle, simpl}^ puncturing its capsule at two or three points, so as to admit sufficient aqueous to render opaque the transparent portions of the lens. The patient should then be placed for a few da3's in a darkened room, and the pupil kept under the influ- ence of atropine, so as to ward off" any of the inflamma- tory eff'ects which pricking a hard lens will sometimes produce. When all irritation has subsided, the opaque lens may be extracted by the operation the surgeon may select. When both eyes are affected with cataract, the two operations should never be performed at the same time. The risk is too great. Some accidental cause, which, on a future occasion, miglit be averted, may influence the patient unfavorabh', and both e3'es ma}'^ be lost. No operation should be done on the second eye until the re- sult of the first has been decided. For the extraction of a hard cataract, one of the follow- ing operations may be selected. Flap Extraction Operation for Cataract The principle of this operation is to make a section of the OPERATIONS FOR CATARACT. 159 Fig. 11. cornea of such a size as will admit of the easy exit of the lens. The incision should be confined throughout its extent to the true corneal tissue. The patient should lie on a couch with his head slightl}^ raised, and the operator should stand behind. If he is ambidextrous, the knife should be held in his right hand for the right eye, and in his left for the left 63*6 ; but if he is unable to work with his left hand, he must stand in front of the patient and make the corneal incision in the left eye with his right hand. Ojicration — First step. — The upper lid is to be raised by the index finger of the operator, and maintained in this position by its tarsal margin being pressed slighth^ against the edge of the orbit, whilst his middle finger is placed against the sclerotic on the inner side of the globe, to prevent its roll- ing inwards before the point of the knife has transfixed the cornea. The lower lid is to be drawn down by one finger of the assistant, with which he presses it against the malar bone, so as to avoid making any pressure on the eye. The point of a Beer's or Sichel's knife (Fig. 11), with its edge upwards, is now made to enter the cornea, just within the corneal margin, and at about the level of the centre of the pupil. The blade is then urged steadily onwards across the anterior chamber in front of the iris, until its point transfixes the cornea at a spot correspond- ing to that at which it entered. The section is to be com- pleted slowly in the withdrawal of the knife, the edge of which is to be directed slightly forwards as it cuts its waj'' out. A too rapid completion of the incision is apt to be followed by a spasmodic contraction of the muscles of the e3'e with an escape of the lens, an'd very probably' of a part of the vitreous also. 160 DISEASES OF THE CRYSTALLINE LENS. When there is much spasm of the ocular muscles or straining on the part of the patient, it is often wise to draw out the knife before quite finishing the section, and thus leave a small bridge of cornea to be cut through with a small secondarj^ knife (Fig. 12j, after the capsule has been opened. The second step of the operation is to tear through the anterior capsule of the lens. The patient is told to look downwards at his hands or his feet, so as to expose fuU^' the corneal wound, thi'ough which the ordinary pricker, or Graefe's c3-stotome (Figs. 13, 14), is then introduced sidewa3-s, and the capsule freely opened. Fig. 12. Fig. 13. Fig. 14. Tl\e third stej:) is the evacuation of the lens through the corneal section. The patient is again directed to look towards his feet, when the operator jDlaces the point of his finger on the upper eyelid, and presses gently' on the globe, whilst he applies the side of the curette (Fig. 10) along the lower lid, through which he exerts a steady pressure on the eye, which, if necessary, is so regulated as to alternate with that being made by the finger above. As the lens begins to escape through the wound, the OPERATIONS FOR CATARACT. 161 pressure on the globe must be relaxed ; and in many cases just before its expulsion is completed, it must be entirely removed, as the too rapid exit of the lens is often accom- panied by an escape of vitreous. Accidents which may happen in the course of the Operation.— a. The aqueous may escape too soon, so that the iris may fall in front of the knife. When this happens, the operator should press the cornea gently against the blade with one of his fingers, whilst at the same time he continues the section with the edge of the knife turned slightlj^ forwards. By this manoeuvre the iris will often be made to recede, and the section be com- pleted without cutting it. /3. The section may be too small. When this' is the case, the incision should be enlarged with a secondary knife. y. The vitreous may escape before the lens. This may be caused by the incision being cai'ried into the sclerotic, or from the straining and struggling of the patient. When this casualt3^ occurs, all pressure on the eye should be at once released, and the lens should be withdrawn from the eye, if possible, in its capsule by one of the spoons (Figs. 15, 23) used in the traction operation for cataract. 8. Deep intraocular hemorrhage may occur. This is the most fatal accident which can happen ; the eye is always irrecoverably lost. It most frequently happens in eyes which are glaucomatous, or otherwise previously dis- eased. The bleeding usually takes place from between the choroid and sclerotic. See article Hemorrhage be- tween Choroid and Sclerotic Remarks on Flap Extraction' of Cataract. — The cases which seem to me most fitted for the flap operation 14* 162 DISEASES OF THE CRYSTALLINE LENS. are senile cataracts in thin wiry patients, who have rather deep-set eyes, and possess good control over their emo- tions. The operation is usually attended with a little difficulty if the eyes are much sunken, but the results I have generally found good. When patients cannot or will not take chloroform, the flap extraction should be selected, if not contraindicated by some special cause, as it is not only the least painful of all the operations for cataract, but it is also the most expeditious. Lastly, the flap operation is quite inadmissible in patients who have cough, or who are liable to sudden and repeated sneez- ings. The Traction Operation was first suggested by Yon Graefe for those forms of traumatic cataract where the niicleus was too dense to be easily removed by linear ex- traction. His assistant. Dr. Schuffc (now Waldau), ex- tended the application of this operation to cases of ordi- nary cataract, and designed a series of scoops for the drawing out of the opaque lens from the eye. His de- scription of the operation is published in the Royal Lon- don Ophthalmic Hospital Reports, vol. iii, page 159. The object of the operation is to draw the opaque lens out of the e3'e through a slit-like opening, in preference to the large incision with a corneal flap. A portion of the iris is removed at an early stage of the operation, so as to avoid contusion or laceration of its structure, from the in- troduction of instruments within the eye for the with- drawal of the lens. Tlie first stage of the operation is to make a sufficient opening in the margin of the cornea for the extraction of the lens, and to remove a portion of the iris. The ope- rator stands at the head of his patient, and with his left hand fixes the eye with a pair of forcejjs, just below the centre of the lower margin of the cornea, at the spot di- OPERATIONS FOR CATARACT. 168 rectly opposite to that where he wishes to introduce the point of his triangular knife. AVitli the right hand he malces the incision into the upper border of the cornea with a lance-shaped iridectomy knife (Fig. 3, p. Ill), causing it to enter that structure at the corneo-sclerotic junction. The opening should always be made sufficiently large to allow of the easy introduction of the scoop, and the ready escape of the lens. If the aperture is found on the with- drawal of the knife not to be ample enough, it should be enlarged laterally by a pair of scissors. He next proceeds to excise a i:)ortion of the iris. This he does by introducino- a pair of iris forceps (Fig. 4, p. 112) through the wound, and seizing the iris near its pupillary border, draws out a portion of it, and cuts off as much as he desires with a pair of fine scissors. If the iris has al- ready prolapsed through the corneo-sclerotic incision, he has only to take hold of it with the iris forceps, whilst he removes a piece of it with the scissors. The second stage of the opei^ation is to tear through the capsule of the lens. This is to be done with an ordinary pricker (Fig. 13), or with Yon Graefe's fleam-cj'stotome (Fig. 14), which should be gentl}' introduced sideways through the section, so as to avoid tearing the iris or scratching the inner surface of the cornea. The third stage of the operation is the withdrawal of the lens from the e^'e. This is accomplished by gently intro- ducing the traction instrument through the wound, using scarcely any perceptible force, but urging it onwards by one or two slight lateral movements, directing it at the same time first a little backwards, so as to insinuate its extremity between the posterior surface of the lens and its capsule, and then downwards and slighth' forwards, allow- ing it almost b}' its own weight to follow the posterior curvature of the lens. Having secured the lens within its grasp, the instrument is to be gradually Avithdrawn, 164 DISEASES OF THE CRYSTALLINE LENS. slightly depressing its handle during this inoA-ement, so as to draw the lens with it out of the eye. If the whole lens, as occasionally happens, is brought out with the first withdrawal of the instrument, the operation is completed. Generall}^, however, some soft lenticular matter is left behind, and sometimes some fragments of the nucleus which have become detached. A cataract spoon must now be reintroduced to bring awa}' the lens matter which remains. For the withdrawal of the lens from the eye several diiferent shaped spoons have been devised. Fig. 15 is a front view of one used b}^ Mr. Critchett. Figs. 16, 17 Pig. 15. Fig. 16. Fig. 17. Fig. 18. represent a front and side view of a spoon designed by Mr. Bowman. For the removal of any soft lenticular matter which maj* remain after the nucleus of the lens has been taken awa}', one of Schuft's (now Waldau's) spoons (Fig. 18) will be fonnd verj^ useful. Graefe's Modified Linear Extraction is the opei*a- tion which now gives the most general satisfaction for the OPERATIONS FOR CATARACT. 165 removal of senile cataracts. It is the one which requires the least selection of cases, and fields the most favorable results. He has divided the operation into five stages : 1. The Incixion. — The lids should be separated by a stop-speculum, and the globe steadied by a pair of forceps in the left hand of the ojjerator, with which he takes hold of the conjunctiva ^^^- ^^^ and deep fascia at a point just below the centre of the cornea. The point of a fine knife (Fig. 19) is then inserted at A, Fig. 20, about Y" fi'om the margin of the cor- nea ; it is first to be directed towards c, so as to extend slightly the inner wound, and when it has fairly entered the anterior chamber, it is to be turned upwards to b, where the counterpunc- ture is made. The blade is now pushed ou a little way in the scleral plane, and then being turned steeply forwards, it should cut its way out. The section should be completed in the withdrawal of the knife. The length of the incision must be proportioned to the size and density of the lens. A small flap of conjunctiva is generally made with the sclerotic section. 2. The Iridectomy. — The forceps are now to be handed to the assistant, who steadies the eye, and, if necessary, slightly rotates it downwards, whilst the operator seizes hold of the iris with the iris forceps, and cuts off" the pro- truding portion, taking care that no ends of it are left in the edges of the wound. 3. Dilaceration of the Capside. — This is to be accom- plished by drawing the point of the cj'stotome over the lens capsule from the lower edge of the pupil to the upper 166 DISEASES OF THE CRYSTALLINE LENS. equator of the lens, first along its nasal, then along its temporal margin. 4. Evacuation of the Lens. — This is usually easily effected by gently pressing and at the same time sliding upwards the curve of the curette against the lower por- tion of the cornea, whilst the fixing forceps are made to pull on the eye slightly downwards. Another mode of proceeding is to press the curve of the curette against the sclerotic edge of the section, so as to cause the wound to gape a little, at the same time Fig. 21. Fig. 22. Fig. 23. that downward traction is made rC\ on the globe with the stead}^- Y i^g forceps. If after cautiously trying these means, the edge of the lens does not present itself at the section, or if an}' vitre- ous should escape, a blunt hook or a cataract spoon must be em- ployed to complete the extrac- tion. The blunt hook used by Graefe is of the form repre- sented in Fig. 22, with its stem bent as in Fig. 21, to enable it be readily pushed under the nucleus. I prefer mj-self either Critchett's or Bowman's spoon. Figs. 15, 16, 17, p. 164, or the traction instrument (Fig. 23) designed by Mr. Taylor of Nottingham. 5. Clearing the Pupil and Coaptation of the Wound. — If any soft cortical substance remains in the pupil, a little gentle friction and pressure with the finger over the closed lids will generall}' be sufficient to cause its evacuti- tion — it is onl}' in very exceptional cases that a scoop should be introduced for its extraction. The wound should now be cleared with the iris forceps of all coagula, OPERATIONS FOR CATARACT. 167 and the conjunctival flap, if there is one, be restored to its proper position. From my own experience I can speak most highly of this operation ; and prefer it to all others when the patient is both able and willing to take chloroform. But if, from any cause, chloroform is inadmissible, I think that the ordinary flap extraction is safer. The details of Graefe's operation require to be so delicately executed, and the time of their performance is comparatively so long, that the patient will often lose self-control, and by his unre- strained movements greatly jeopardize the eye. The incision which I make in this operation differs slightly from that recommended by Graefe. I commence it lower down, so that the point of the knife enters the margin of the cornea on a level with the upper edge of the pupil, and I carefully confine the section to the corneo-sclerotic junction, preferring rather to invade the cornea than to trespass on the sclerotic. There are other operations for cataract to which I need only refer. They have each been strongly advocated by their originators, and have met in their hands with a cer- tain amount of success. Mooren's Operation for the Extraction of Cata- ract consists in making an iridectomy, and after waiting from a foi'tnight to six weeks to allow the eye to recover from all the irritation consequent on the operation, he performs an ordinary flap extraction. The preliminary iridectomy should be upwards, and the corneal section should be afterwards made in the same direction. Jacobson's Operation for the Extraction of Cata- ract combines an iridectomy with the ordinary flap ex- traction. The corneal section is made downwards in the corneo-sclerotic junction. After the lens has been re- 168 DISEASES OF THE CRYSTALLINE LENS. moved, he draws out with a pair of iris forceps the cor- responding segment of the iris, and excises it with a pair of scissors. There are two great objections to this oper- ation : 1st. The unseemh^ appearance of an eye in which an iridectomy has been made downwards. 2d. The difficulty which must always ensue from ex- cising a portion of the iris after the lens has been re- moved. It would be better to perform the iridectomy before the extraction of the lens. Pagenstecher's Operation for the Extraction of Cataract differs from all the others in that he removes the lens in its capsule entire". He makes a flap incision, nsually downwards, and entirely through the sclerotic, leaving a small bridge of conjunctiva at the apex of the flap. He next excises a large segment of the iris, and then completes his section by dividing the conjunctival bridge. B^^ gentle pressure on the e3'e he now endeavors to urge the lens in its capsnle through the sclerotic wound, but should he fail in doing so, or if an}^ vitreous should escape, he at once introduces a scoop behind the lens, and draws it out of the eye in its capsule. Pagenstecher states that on several occasions he has succeeded in thus extracting the lens without the loss of anj" vitreous, not- withstanding that in some of the cases it was accom- plished by the aid of the scoop. He also refers to the re- markable absence of iritis after this operation, Macnamara's Operation for Cataract. — The follow- ing is Mr. Macnamara's account of his own operation : " The pupil having been fully dilated with atropine, the patient laid on his back, and placed under the influence of chloroform, the operator adjusts a stop-speculum. Sup- posing the right e^'e is to be operated upon, the surgeon OPERATIONS FOR CATARACT. 169 standing behind liis patient with a pair of toothed forceps, seizes the internal rectus, so as to steady the eyeball, and in the other hand takes a short and broad-bladed trian- gular knife, and thrusts its point through the circumfer- ence of the cornea a little within its margin. The blade of the knife is to be passed steadily onwards nearly up to its heel, so that an opening is made through the cornea nearly half an inch in extent. As the blade of the knife is being withdrawn from the eye, its point may be run into the lens so as to rupture the capsule. The knife being laid on one side, but the speculum and hold of the internal rectus retained, the scoop is to be inserted so far into the anterior chamber as to enable us to reach the margin of the pupil. The handle of the instrument being raised, and its rounded extremity depressed, the latter evidently rests on the capsule of the lens, immediately within the margin of the pupil. The scoop is now to be slightl}^ withdrawn, still keeping its extremity on the lens, but so as to draw open the pupil far enough to enable us to press on the edge of the lens with the rounded ex- tremity of the scoop. The instant this is done, the lens tilts over on its axis, and the scoop being thrust onwards, the lens comes to lie in its concavity, and ma}^ be removed from the eye. An}' particles of lenticular matter remain- ing in the anterior chamber must be removed with the scoop or by a suction instrument."* Treatment of the Eye after an Extraction of the Cataract. — After the operation is completed, both ej^e- lids should be gently closed, and a Liebreich's bandage (F. 1) applied ; and the patient should be then placed in bed in a darkened room with the head slightly raised. If the case progresses favorably the patient may be allowed * Macnamara on Diseases of the Eye, p. 475. 15 170 DISEASES OF THE CRYSTALLINE LENS. to get up after thirty-six hours, aud lie on a sofa, or if in a hospital, rest on the outside of his bed. After a flap extraction the lids should not be opened to look at the e^'e until the seventh da}' ; but after a modified linear, or a traction operation, the eye may be examined with safety on the third or fourth day. The bandage should be changed night and morning as the flow of tears renders the linen wet and uncomfortable. If the lids become gummed together, a piece of linen wet with tepid water should be drawn a few times across their tarsal borders, and then gently pulling down the lower lid with one finger, the}" may be sufflcienth' parted to allow any pent-up tears to escape. If the patient should complain that the cotton- wool pad makes the eye hot, it may be removed, but the fold of linen over the ej-es, and the bandage, should be continued. After about eight or ten days the bandage may be given up, aud a broad shade be worn over both ej-es. Three or four times during the da}^ the lids should be bathed with tepid water, or if there is any irritation, with the belladonna lotion (F. 32). When there is rest- lessness after the opei'ation, an opiate should be given at bedtime ; and if the patient complains of severe pain in the e^^e, suflficient to prevent sleep, two or three leeches should be applied to the temple. If these fail to give re- lief, the bandage should be removed, and a fold of linen wet with cold or iced water should be laid over the closed lids. A mild purgative must be ordered if necessary, so as to insure the regular daily action of the bowels with- out straining. The patient should be allowed his regular diet, with the exception of the day of the operation, when I generally advise only beef-tea and farinaceous food. The Caslalties which may occur after an Extrac- tion OF A Hard Cataract are : 1. Prolapse of the iris. This is peculiar to the flap ex- OPERATIONS FOR CATARACT. 171 traction, and to those operations in w^hich no portion of the iris is removed. 2. Iritis. 3. Suppuration of the cornea. 4. Acute ophthahnitis and suppuration of the globe. 5. Imperfect union of the corneal wound, and conse- quent fistula. 6. Cystoid cicatrix. 1. Prolapse of the iris may come on from the first to the fifth day after a flap extraction, and sometimes even later. It is the most frequent cause of failure of this ope- ration, and in many cases seems to be due to the irrita- tion excited b}^ some cortical lens matter left in the pupil at the time of the operation. It is, however, often pro- duced b^^ some spasmodic action on the part of the patient, such as coughing or sneezing, or by some violent emotion. Treatment. — At first apply a compress bandage (F. 2), and leave the prolapse alone. If after a fortnight or three weeks the prolapse continues large and shows no tendency to subside, it may be pricked at two or three points with a fine needle, and the compress be reapplied. This prick- ing operation may be repeated two or three times at in- tervals of three or four days. 2. Ii'itis^ after extraction, is usually' chronic and serous. It commences as a rule from one to three weeks after the operation. It is always accompanied with photophobia and lachrj^mation, and frequently with the edges of the lids puffy, thickened, and excoriated. For a further ac- count of this form of Iritis, see Traumatic Iritis, p. 102. Treatment. — Belladonna to the eye in one form or an- other to relieve pain and keep the pupil dilated. Tonics of quinine or iron, or both (F. 64, 65, 66) should be given. Counter-irritation in the form of small blisters the size of a shilling to the temple or behind the ear occasionally do 172 DISEASES OF THE CRYSTALLINE LENS. good; and if the case is very obstinate, benefit is some- times derived from a moderate mercurial inunction. Tlie acute iritis is comparatively rare. It usuallv fol- lows one or two days after the operation, and unless soon arrested it may lead to the destruction of the e^^e. Occa- sionally it will partially subside, and then become chronic. Treatment. — Leeches to the temple and cold a^jplica- tions to the eye. A fold of linen should be laid over the closed lids, and be moistened with iced water as often as it becomes hot or dry. If the cold ceases to be grateful to the patient, hot fomentations of poppy -heads or bella- donna (F. 8, 9) ma}^ be substituted. Diffusible stimuli and tonics (F. 54, 63, 64) should be ordered, with a liberal diet, and opiates be given if necessar}' to relieve pain and produce sleep. Mercury in any form is seldom of use in these cases ; it usuallv depresses the patient and so does absolute harm. In the acute traumatic iritis which fol- lows the extraction of cataract, there is a strong tendency for the inflammation to spread to the neighboring tissues, and thus to drift into ophthalmitis or general inflamma- tion of the ej'e. 3. Suppuration of the cornea ma}' be either partial or complete. It may commence in the line of tl\e incision and involve more or less of the corneal flap, to which it ma}' be limited ; or it ma}- be diff'use, and include the en- tire cornea. Symptoms. — Increasing pain in the eye and around the orbit ; cedematous swelling and redness of the lids ; che- mosis of the conjunctiva and a muco-purulent discharge. If the suppuration is ^ja7'/ia7 and circumscribed., the line of the incision will look opaque and yellow, and there will be some purulent infiltration extending into the flap of the cornea, whilst the lower part of the cornea, although perhaps slightly tnrbid, will still retain some of its trans- parency and polish. This condition of the eye is suf- OPERATIONS FOR CATARACT. 173 ficient to create great anxiety ; but if the suppuration can be confined to the margin of the wound, it is not hopeless. The dangers are, firstty, that the suppuration will become dittuse ; secondly, that it will extend itself to the deeper structures and induce a suppurative inflammation of the globe ; thirdly, that although the suppuration of the cornea may be subdued, a secondary iritis or irido-cyclitis may follow, which will in the end produce softening and atro- ph}^ of the globe. When the suppuration of the cornea is diffuse or com- plete, the symptoms are the same but intensified. The suppuration, instead of being confined to the margin of the flap, invades the whole structure of the cornea. The eye must be then considered as irreparably lost. In old and feeble patients suppuration of the cornea will occasionally occur without the usual inflammatory sjanptoms of pain with redness and swelling of the lids being manifested. This once happened to a poor old woman, who had long been an inmate of a workhouse, on whom I operated for cataract. With only a sense of grittiness in the eye, and with the slightest trace of swell- ing of the upper lid, partial suppuration of the cornea followed on the fifth or sixth day after the operation. Treatment. — An attempt may be made to ward off the earh^ sj^mptoms b}^ the application of two or three leeches to the temple, and iced water to the e^'e ; but as soon as it is ascertained that suppuration of the cornea has com- menced, a different treatment should be adopted. Warm fomentations of poppy-heads or belladonna give the most relief, and may be used every two or three hours, and in the intervals a fold of lint should be laid over the eye and kept moist with warm water or the belladonna lotion. Pain should be relieved by repeated doses of opium, which may be combined with ammonia, quinine, or liq. cin- chonie»(F. 62). The patient should be fed up with such 15* 174 DISEASES OF THE CRYSTALLINE LENS. food as he can be prevailed on to take, and a moderate allowance of wine be ordered for him. A compress band- age (F. 2) applied to the eye on the first indication of corneal suppuration is often of service, and maj^ be used jointh' with the warm applications, the bandage being re- moved three or four times daily to allow of the fomenta- tions. If the pressure be painful, it should not be per- severed in. 4. Acute OjMhalniitis aiid Suppuration of the Globe. — When this happens, the eye is lost, and the only course to be pursued is to hasten the suppuration by warm and soothing applications ; to give free vent to the pus b}' in- cision through the cornea if necessary ; to relieve pain by opiates ; and to support the patient by tonics, stimulants, and a good diet. ' 5. Imperfect Union of the Corneal Wound and conse- quent Fistula. — From some cause, often difficult if not impossible to explain, the wound of the cornea after the extraction of cataract fails to unite completel}^, and a small fistula remains through which the aqueous slowly dribbles. Treatment. — A compress bandage (F. 2) should be placed over the closed lids, and twice a day a few drops of a solution of atropine gr. 1 ad aqua; ^ 1 be dropped into the eye. This tre'atment generalh' succeeds in closing the fistula, but if after a fair trial it produces no efiect, the opening in the cornea may be touched with a fine camers-hair brush charged with nitrate of silver, as rec- ommended at SLie 66. For the symptoms and further treatment of corneal fis- tula, see Fistula of the Cornea, page 65. 6. Cystoid Cicatrix. — This can only occur when the incision has been made in the sclerotic. It is due to the edges of the wound not coming into close contact, and to their consequent union through the intervention of cica- CATARACT. 175 tricial tissue, which gradually 3'iekls before the outward pressure of the parts within the e^e, and becomes thinned and bulging. This condition of the cicatrix in the scle- rotic will be occasionally met with after iridectomy for glaucoma. It is most liable to happen in eyes in which there is an increased intraocular tension. Treatment. — If the cj'stoid cicatrix is small or gives no inconvenience, it is best to leave it alone. When large or troublesome, it may be punctured with a broad needle. If the bulging of the cicatrix is on the increase, and the tension of the e3'e is glaucomatous, an iridectomy should be performed. Capsular Cataract is a misnomer. There cannot be an opaque capsule and a transparent lens. There may be an opaque and chalky capsule containing the shrunken remains of a lens, or there may be an opaque capsule fill- ing the pupil after the lens from some cause has gone, but neither of these can be considered as examples of capsular cataract. The class of cases to which the term can be most correctly applied are those in which there are spots or patches of opacity on the capsule with a perfectly transparent lens. These local opacities may exist under two circum- stances : 1st. Patches of opacity on the lens capsule may be formed from inflammatory exudations during iritis or other inflammations of the eye. They are usually central and correspond to the pupil, but occasionally ih.Qy are de- posited as a white zone around the margin of the lens, and can be only detected when the pupil is dilated. 2d. In 3'oung children one or more white spots are occasionally seen on the lens capsule, the lens itself being clear. On examining the cornea of such ej'es a small nebula will be frequently found to correspond with the 176 DISEASES OF THE CRYSTALLINE LENS. siaeck on the lens capsule; and on inquiry it will be found that these patients have had purulent ophthalmia. The inference is that during the attack the swollen cornea and the most prominent part of the lens came together, and that the capsule at the point of contact then became opaque. It should be remembered that in newl3'-born children the space between the centre of the lens and the cornea is so small as hardly to deserve the name of an anterior chamber. When the centra] capsular opacity is single and prominent, it has been called j^y^^amidal cata- ract. Capsulo-lenticular Cataract. — ^In this form of cata- ract the capsule partakes of the opacity. It may not be absolutely opaque, but its transparenc}' is so atfected that it would materially interfere with vision after the opaque lens has been removed. This opacity is generally con- fined to the anterior layer of the lens capsule. Tr^eatment. — In these cases the plan practised by Mr. Bowman should be adoptecL After the section of the cornea has been completed and the piece of iris excised, if an iridectomy has to be performed, instead of tearing through the lens capsule with the ordinary pricker, a pair of fine iris forceps is introduced through the corneal wouhd, and seizing hold of the anterior layer of the cap- sule it is withdrawn from the eye, and the operation of extraction of the lens is then completed in the usual wa}^ Diabetic Cataract. — The only peculiarity in this variety of cataract is its origin. The opaque lens pre- sents no characteristic to distinguish it from cataract arising from other diseases or from senile decay. As diabetes frequently attacks young people, this disease may be considered as one of the causes of cataract in early life. The cataract is usually soft, but this is due to CATARACT. 177 the age of the patient, who is generally below the period of life at which cataract is common. In diabetic cataract the opacit}^ is prol)abl3' dependent on impaired nutrition. Treatment. — The same as for ordinary cataract. The l^resence of diabetes has been urged as a reason for not operating ; but if the patient is apparently in fair health and not much emaciated, an operation is certainly not contraindicated. I have on several occasions operated myself for diabetic cataract, and have fi-equently seen my colleagues do so at the Ophthalmic Hospital, and in no case have any unfavorable symptoms followed. Fluid Cataract usually occurs in joung patients and is sometimes congenital. It has a uniform grayish-white milk-and-water color without any visible strire or spots. The fluidity does not always include the whole lens ; it occasionally happens that within a fluid and diffluent cor- tex there is a small firm nucleus. There is, however, a form of fluid cataract which is met with in elderly people, which seems to be an advanced stage of degeneration of the lens. The lenticular matter is converted into a semi- transparent 3-ellowish fluid, which contains oil globules and sometimes plates of cholesterine. In some excep- tional cases the fluid is of a dark chocolate or sepia color. Mr. Ilaynes Walton relates the case of a lady, ffit. 77, on whom he operated, in which the "capsule did not contain a particle of lens, but was filled with material like coffee grounds."* Treatment. — The same as for other forms of cataract. If after the section has been made in the cornea and the lens capsule opened with the pricker, the lenticular matter is found to be fluid, it may be either sucked out with a syringe or allowed to escape along the groove of a curette. * Surgical Diseases of the Eye, 2d edition, p. 512. 178 DISEASES OF THE CRYSTALLINE LENS. Traumatic Cataract, or cataract the result of an in- jury to the eye, may occur either with or without a rup- ture of the external coats of the eye. 1. Traumatic Cataract with Rupture of the External Coats of the Eye. — One of the most frequent complica- tions of a wound of the cornea is an injury to the lens. Wounds of the lens terminate almost invariably in cata- ract. The point of injury is within twenty-four hours in- dicated by an opaque patch, and this opacitA" gradually increases until the whole lens becomes opaque. The rapidity of the formation of the cataract will depend partly on the extent of the injur}^ inflicted on the lens and its capsule, and parti}' also on the age of the patient. If the rent in the capsule is large, and the lenticular matter has also been broken into, the aqueous humor will be rapidly brought into contact with the lens substance, and its transparency will be quickly destroj-ed. In the young, the lens is soft, and becomes more rapidly cata- ractous from an injury than in the aged, where it is more dense and has a firm nucleus. A wound of the lens is ver}' commonh' associated with a prolapse or laceration of the iris, or with both: indeed it is more usual for it to be accompanied with some lesion of the iris, than for the injury to be confined to the lens. The immediate effect of a wound of the lens is the admission of the aqueous within its capsule. This is imbibed hy the lens tissue, each part of which becomes opaque, and rapidly swells as it is brought under the influence of the aqueous ; so that the swelling of the lens increases with the opacity until the whole is opaque. The lens thus swelling frequently presses on the posterior surface of the iris, and excites great irritation : hence it is of the utmost importance that the pupil should be kept fnlly dilated with atropine, in order to aftbrd space for the swelling lens, and to prevent as far as possible its encroaching on the iris. CATARACT. 179 The irritation which is tlius excited by a cataractous lens is greater and more apt to occur in the adult and aged person than it is in the child. The most serious S3'mptom which the pressure of a swollen lens on the back of the iris is apt to produce is a glaucomatous hardness of the globe — a condition known as '•''traumatic glaucoma^ It is ushered in with increased pain and irritation ; the anterior chamber is diminished in size from the lens having pushed the iris forwards towards the cornea; the e.je, has a pinkish tinge from a general fulness of the sclerotic vessels, but especially of those which form the ciliary zone, and the tension of the globe is increased. This state of eye is fraught with danger, and alwa3^s de- mands immediate treatment. 2. Traumatic Cataract ivithout Rupture of the External Goats of the Eye. — Sudden violence against the ej^e, or to the bony parts which surround it, may cause, without any rupture of the external coats of the eye, a rent in the capsule of the lens sufficient to allow the aqueous to per- meate its structure and to render it cataractous. Yon Graefe has noticed that in" such cases the rent is generally at the periphery of the lens, or within the area of the thin posterior capsule, but never in the middle of the anterior capsule. Again, a blow on the eye ma}', without any apparent injury of the lens capsule, so disarrange the internal structure of- the lens that its nutrition will become im- paired, and as a result its transparency will be destroyed. This accident is more rare than the preceding, in which the lens capsule is torn. The form of cataract which is usually produced is a diffused opacit}'; a portion of the lens first becomes nebulous, and this nebulosity increases until the whole lens is opaque. Treatment of Traumatic Cataract. — 1. If the cataract is uncomplicated with injury to the iris, and has been 180 DISEASES OF THE CRYSTALLINE LENS. caused by some fine shai'p-pointed instrument penetrat- ing the cornea, there is good reason to hope for a favor- able result. A solution of atroi:)ine, gr. 1 ad aquae ^ 1 should be dropped twice or three times a day into the eye to dilate the pupil fully, and thus to keep the iris out of the way of the swelling lens. A compress and bandage should be fastened over the closed lids, or, if it is more comfortable, a fold of linen wet with cold water, or the belladonna lotion (F. 32) may be laid over the eye. If there is pain in the eye or around the orbit, two leeches should be at once applied to the temple. The patient should be kept in a darkened room. If after all the irri- tation occasioned by the injury has subsided, a gradual absorption of the lens matter is found to be going on, it is wise not to meddle with the cataract, but to keep a careful watch over the e}' e, and be prepared to treat symp- toms as the}^ arise, being guided b}^ them in the future management of the case. 2. If the wound in the lens is complicated with injury to, or jjrolapse of the iris, attention must first be directed to the iris, which, if prolapsed, will require to be dealt with in one of the wa3's suggested under the heading Prolapse of the Iris. The general treatment recom- mended in the preceding section must be also adopted here, and if no untoward symptoms arise, the cataractous lens must be left untreated until the eye has quite recov- ered from the primary shock of the injury. - Whenever a traumatic cataract excites great irritation or induces s3^mptoms of traumatic glaucoma, the lens should be at once removed. The operation to be selected will depend on the density of the lens, the general con- dition of the eye, and the age of the patient. As a rule, when the lens is soft, a linear extraction or a suction operation should be performed. Either of these opera- CAPSULAR OPACITIES. 181 tions may be combined with an iridectom}- if circnm- stances render it advisable. If, howeA^er, the patient is advanced in years, and the lens consequently more or less hard, the best operation will be either the modified linear extraction or the trac- tion operation. Secondary Cataract is when the opacity of the lens is dependent on, and secondary to, disease of the vitre- ous, choroid, or retina. In these cases the lens not only grows opaque, but frequently undergoes a further degen- eration, and earthy salts, the carbonate and phosphate of lime, are deposited both in it and in its capsule. The appearance of such a lens is ver}^ characteristic. It is usually somewhat shrunken and flattened, with a peculiar o^Daque chalky look, and either strikingly white or tinged slightly with j^ellow. It is often associated with other degenerative changes within the eye, and occurs con- jointly with bony formations on the choroid and second- ary detachments of the retina. Treatment Secondary cataracts, as a rule, are best left alone. In the majority of cases, the eye, when the cataract is complete, is blind, and the extraction of the lens would give no improvement of sight. Even in the most favorable instances, where there is some perception of light, and a moderately active pupil, the fundus of the eye is usually so unsound that it is always doubtful whether the slight chance of benefit is sufficient to justify the risk of an operation. Certainly, wnen the patient has one eye good, no operation for the extraction of the opaque and chalky lens should be performed. capsular opacities. Capsular Opacities following the Loss of the Lens — After the lens has been removed, either by ab- le 182 DISEASES OF THE CRYSTALLINE LENS. sorption or extraction, some densit}^ of the capsule wliicli has been left is very apt to occur, and to greatly mar the excellence of vision which the patient would otherwise possess. The degree of opacity varies very much, and is dependent on different circumstances. The simplest form of opacity of the capsule is that which often occurs after an operation for the removal of the lens, especially after linear or suction extraction. Its formation is unaccompanied with any inflammatory ac- tion. Examined with the ophthalmoscope, a film of cap- sule will be found occupying the pupillary space, not actuall}^ opaque, but with its transparency sufficiently dulled to interfere with the due passage of the light to the fundus of the eye. Mr. Bowman has shown that the capsule may cause a serious imperfection of sight without becoming opaque, by assuming a wrinkled and folded state, so as to produce an unequal refraction of light in its passage through it, and a consequent confusion of the image on the retina. The second form of opacity of the capsule is where the membrane itself is semi-opaque ; but its opacity is con- siderably increased by bits of soft lenticular matter having become inclosed between parts of the anterior and posterior layers of the capsule. If the pupil be dilated with atropine, the opacity of the capsule will be seen to vary in density in different points of its area, according to the quantity of lens matter which has been inclosed between its laj^ers. This form of opacity js not necessarily accompanied with any inflammatory action. Dr. Schweigger, of Berlin, has shown that the opacit}^ of the lens capsule may also be increased by an imperfect growth of those intracapsular cells, which from some cause have escaped the action of the aqueous on them. The third form of ojmcity of the capsule is always asso- ciated with iritis. Lymph is eflused on the surface of CAPSULAR OPACITIES. 183 the capsule, and adhesions more or less extensive between it and the iris close the pupil. The capsule itself becomes opaque, and blending with the l^mph upon its surface grows tough, and almost fibrous in its structure, losing all its natural elasticit}^ This state of the capsule is very frequently combined with some soft opaque lens sub- stance shut in between its layers ; indeed in many cases it is due to the irritation which has been excited from some lenticular matter having been left behind at the time of the operation for the extraction of the lens. It is this form of membranous opacity which frequently undergoes after a lapse of time a degeneration of struc- ture : in some cases losing the toughness it at first ac- quired, it becomes brittle and friable, allowing a needle or a pair of iris forceps to pass through it like tinder ; or it may in after years become the seat of earthy deposits. The second form of capsular opacity I alluded to, where a portion of lenticular matter is inclosed between the lay- ers of the capsule, is also liable to degenerative changes, and to have earthy salts deposited in the vestiges of the lens between its folds. Treatment of Capsular Opacities. — In treating opacities of the capsule after the lens has been removed, it may be taken as a rule which should never, if possible, be departed from, that no operation should be performed so long as the eye is red or irritable. Needle Operation for Opaque Capsule. — A single nee- dle is usually sufficient to tear an opening through the semi-opaque or wrinkled capsule which is often found after an ordinary operation for cataract, but two needles should be in readiness in case a second is required. Before commencing the operation the pupil should be fully dilated with atropine. The needle should penetrate the cornea obliquely about one or one and a half lines 184 DISEASES OF THE CRYSTALLINE LENS. from its circumference, and passing across the pupil to the opposite side, it should puncture the capsule close to the iris, and. by then slightl}' depressing tlie hand, the needle is made to dip a little into the vitreous, and to cut its way through the capsule. In some eyes one or two dips of the needle will suffice to make a clear opening in the capsule, whilst in other cases they have to be re- peated mau}^ times. Occasionally it happens, that after the needle has made an opening through the capsule, an adherent film remains stretching across the pupil, which a single needle fails to divide. A second needle should then be used, after the manner first recommended by Mr. Bowman. It should be introduced by the other hand thi'ough the cornea at a point nearly opposite to the first ; and passing its point behind the band, whilst that of the first needle remains in front of it, so that their points cross, the one needle is made to revolve a few turns over the other, until the band of capsule is torn; or if this does not readily follow, the two needles nia^^ be then slightly but slowly sepa- rated; a proceeding which will seldom fail in breaking it through. In cases where there is some lens matter inclosed be- tween the anterior and posterior layers of the capsule, a needle operation such as has been alread}^ described will generally be sufficient. The breaking up of the capsule will expose the particles of lens matter to the action of the aqueous, and they will usually be quickly absorbed. When there has been iritis, and the pupil is closed with a dense membrane, a new pupil may be formed and the capsule torn through with two needles ; but this will not alwaj'S suffice, as iritis will often follow the operation and the pxipil will again become closed. It is generally necessary, after the capsule has been torn through, to re- move a portion of the iris and make a false pupil. CAPSULAR OPACITIES. 185 To use two Needles^ to tear through the Opaque Capsule and open out the closed Pupil — One needle is to be in- troduced through one side of the cornea, and be passed into the centre of the capsule upon which the pupil is contracted and adherent. The second needle is to pene- trate the opposite side of the cornea,' and to be inserted also into the capsule close to the first. The points of the two needles are now to be dipped downwards a little into the vitreous, and to be drawn slowly in opposite direc- tions, so as to tear through the capsule, and at the same time to pull open the pupil. Having done this, the needles are to be withdrawn, and according to the size of the pupil which has been formed must depend the ne- cessitj- of making an artificial pupil by removing a piece of the iris. If the new pupil does not open out sufli- cientlj', it will be well at once to make an opening in the cornea with a broad needle, and with a Tyrrell's hook (Fig. 6, p. 114) to draw out a piece of the iris and cut it off. The most difficult cases, however, of all to treat are those in ivhich there is a piece of tough milky-xchite-look- ing lens capsule occupying the pupillary area, and to which the iris is adherent at points. The normal elas- ticity of such a portion of capsule has been lost, and oftentimes some of the earthy salts are found to be in- coq^orated with it, or with the remains of the little len- ticular matter which has been inclosed between its layers. A needle operation here would do no good. There are two modes of dealing with such cases : 1. Having fully dilated the pupil with atropine, detach the opaque capsule from its adhesions to the iris by a fine needle introduced through the cornea. This being done, the fine needle is to be withdrawn, and the opening it has made is to be enlarged with a broad needle to allow of the introduction within the anterior chamber of the canu- 16* 186 DISEASES OF THE CRYSTALLINE LENS. FfG. 24. lar forceps (Fig. 24), with which tlio piece of capsule is to be seized and drawn out of the eye. If, on drawing out the oi)aque capsule through the aperture in the cornea, a point of it is found still adherent to the iris, that which has b^en withdrawn should be snipped off with a pair of scissors, but no attempt should be made to detach it by force. This opera- tion is a very hazardous one^ though the re- sult when success follows is very brilliant. The great danger consists in the dragging upon the iris and the ciliary' processes. I have occasionally seen suppuration of the globe follow this operation. 2. The second plan which may be adopted, and in many cases it is a very safe and efll- cient one, is first to make an iridectomy of a moderate size, selecting that part of the iris which is either free, or has the least ad- hesions to the capsule in the pu pillar}' space. A piece of opaque capsule will be then seen occupying the greater part of the area of the new pupil. Through the wound in the cornea the blades of a pair of fine iris scis- sors may be introduced, and passing one blade in front of the opaque capsule, and the other behind it, with three clips a triangular piece may be cut out, which may be lifted away by a pair of forceps. A clear space may thus be made for the free passage of light into the eye with far less danger than by forcibly removing the opaque capsule entire. After all operations for capsular opacities, the eje should be kept for at least three or four days with the pupil full}' dilated with atropine. DISLOCATIONS OF THE LENS. 187 dislocations of the lens. Dislocation of the Lens into the Anterior Cham- ber may be either congenital, or the result of an injury, such as a blow on the eye^ or on the head in the vicinity of the eye. Occasionally it is caused by excessive retch- ing or coughing, but in such cases it will generally be found on inquiry that the eyes were unsound, and pre- disjoosed to this accident. Symptoms. — A transparent lens Ijang in its capsule in the anterior chamber presents a iDeculiar and charac- teristic appearance. It looks like a large drop of oil lying at the back of the cornea, the margin of the lens exhib- iting a brilliant yellow reflex. The iris is pushed back- wards, and the anterior chamber is thus greatly deepened. The pupil is always more or less dilated in proportion to the amount of pressure the lens exerts upon the iris. The lens in this abnormal position acts as a foreign body. It is productive of great irritation, and of severe pain. The inflammation which so frequently follows this accident may be partially due to other parts of the eye having suffered from the primary injury; but much must also be attributed to the pressure of the lens on the iris. The pain which accompanies this displacement of the lens is usually severe and neuralgic in character, often- times more intense than the state of the eye would lead us to anticipate ; but the pressure on the iris, and conse- quently on the ciliary nerves, is sufficient to account for its severity. Treatment of Dislocation of the Lens into the Anterior Chamber. — If the lens is giving rise to irritation, it should undoubtedly be removed, and as soon as possible : the ir- ritation will probably continue and increase if it is allowed to remain in its abnormal position. But if the lens, al- though lying in the anterior chamber, is not acting as an 188 DISEASES OF THE CRYSTALLINE LENS. irritant, and the eye, when seen by the surgeon, is per- fectl}' quiet and free from undue vascularity, what course should be pursued ? To answer this question, it is nec- essary first to consider what are the present, and what are likel}^ to be tlie ultimate effects of such an accident. There are two results which generally follow the long- continued presence of the lens in the anterior chamber, viz., paralysis and atrophy of the iris : both of tliese are due to the one cause, pressure of the lens on the iris. They are not the immediate results of a dislocated lens, but they are the sequences of the prolonged pressure Avhich is kept up by the lens against the iris, when it has been allowed to remain for many months or years in con- tact with it. Now although the eye when first seen may be quiet and free from all vascular excitement, yet it is impossible to say how long this quiescent state may last. An outbreak of acute inflammation may occur at any time without any special assignable cause beyond the abnormal pressure of the lens on the iris. Again, the presence of the lens in the anterior chamber is very apt to give rise to a glaucomatous state, under which the tension of the globe becomes suddenly increased, and the pain very severe. This condition is alwaj's one of peculiar danger to the eye, and calls at once for active treatment. Considering then the many casualties which may hap- pen to an eye with a dislocated lens lying in its anterior cliamber, I believe it is advisable in all cases to remove it. In children a suction operation or a linear extraction maybe performed. It is generally judicious in such cases to complete the extraction of the lens in one sitting, rather than to divide it into two stages, with an interval of some days between them, as in the ordinary mode of perform- ing suction and linear operations. If the patient is an adult, or a person advanced in years, the dislocated lens should be removed by a traction ope- DISLOCATIONS OF THE LENS. 189 ration, or hy Graefe's linear extraction. Having made the section in the corneo-sclerotic junction, either witli a large keratome or with Graefe's cataract knife, and if possible excised a portion of the iris, the lens should be taken away in its capsule, with the aid of one of the trac- tion instruments, page 164, or with the skeleton spoon, Fig. 23, or with a sharp hook, which may be made to seize hold of it, and draw it from the eye. During the opera- tion an escape of vitreous will probably occur, as the sus- pensory ligament must have been torn to allow of the lens being dislocated, and this could hardly have been ac- complished without at the same time some rupture of the hyaloid membrane. Dislocation of the Lens into the Vitreous. — This accident may occur either with or without rupture of the external coats of the eye. The lens is usually dislocated inclosed in its capsule, which may be either entire or partially lacerated. If the capsule has been torn, the lens will soon become cata- ractous ; but even if it is entire, the lens generally after some months becomes opaque, on account of its due nu- trition being interfered with. If the dislocation has been complete^ the iris, having lost the support of the lens, will fall slightly backwards towards the vitreous, and thus increase the depth of the anterior chamber. The iris will also generally be found tremulous, its whole surface vibrating with the move- ments of the QyQ. If, however, the dislocation has not been quite complete, but, as is usually the case, some shreds of the suspensory ligament still connect the lens in its capsule with the upper region of the globe, then the lower surface of the iris against which the lens presses will be bulged towards the cornea, whilst the plane of the upper part will be un- 190 DISEASES OF THE CRYSTALLINE LENS. altered. When the lens is thus suspendedy it may be sometimes seen by the unaided e3'e, but always b}' focal illumination, hanging by film}' shreds from the upper sur- face of the globe, and swaying to and fro with the motions of the e3'e. State of the Pupil. — There is always more or less dila- tation of the pupil. This is probabl}' chiefly due in most cases to the injur}- which the ciliary nerves have sustained in the accident, although it may also be partly accounted for by the pressure which the displaced lens often exerts on the lower segment of the iris. The general symptoms are those of great irritation. There is increased vascularity, with dread of light, lach- rymation, and pain. The eye, from the first effects of the injury, becomes actively inflamed, but this state, under treatment, may gradually subside. It is, however, gen- erally succeeded by a low form of choroido-iritis or cho- roido-retinitis, which is kept up by the irritation caused by the abnormal position of the lens. In this stage a glaucomatous state frequently supervenes, and the ten- sion of the eye becomes greatly increased. With fhe in- crease of tension, all the symptoms become aggravated ; and unless the lens, the source of the irritation, is re- moved, the loss of the eye is certain. This glaucomatous condition is liable to occur in all the dislocations of the lens icithin the eye, but it is more prone to follow those in which the lens is either partially or completely dis- placed behind the iris than when it is thrown in front of that structure. Treatment of Dislocation of the Lens into the Vitreous. — If the dislocation is complete, and the eye is free from irritation, it should be left alone, but the patient should be kept under careful supervision. If, however, the dis- placed lens is exciting inflammation, it should be re- moved. This is best done by a traction operation. (See DISLOCATIONS OF THE LENS. 191 page 162.) An opening having been made in the corneo- sclerotic junction, the lens should be extracted with a medium-sized spoon. There is, however, one difficulty which besets this operation when performed for the ex- traction of a dislocated lens from the vitreous. It is often impossible to seize hold of the iris to draw it out of the wound preparatory to excising a portion of it ; for, hav- ing lost the support of the lens, it will sometimes fall backwards, and get so behind the cut edge of the sclerotic that the forceps cannot be made to grasp it. This diffi- culty is increased by an escape of vitreous, which almost invariably takes place immediately on the withdrawal of the knife from the eye, and is dependent on a rupture of the h^^aloid at the time of the accident, which has allowed the vitreous to fall forwards. If, therefore, the attempt to seize and draw out a piece of iris is unsuccessful, it is better at once to abandon it, afid to go on with the oper- ation, as the repeated introduction of the forceps within the eye will cause a large and unnecessary amount of vitreous to be lost. Dislocation of the Lens beneath the Conjunctiva can only occur in cases where the sclerotic has been rup- tured, but the conjunctiva over the rent has remained entire. The lens, separated by the violence of the injury from its ciliary attachment, is forced out of the eye through the wound, and, as the conjunctiva has not been lacerated, it will be seen lying beneath it. The disloca- tion is almost invariably upwards, or upwards and in- wards, as it is in the upper region of the eye, between the insertion of the recti muscles and the margin of the cornea, that the split of the sclerotic coat most frequently occurs. Symptoms. — The lens will be seen lying beneath the conjunctiva, forming a small, roundish, semi-transparent 192 DISEASES OF THE CRYSTALLINE LENS. swelling. If the anterior chamber is clear, the altered shape of the pupil, probably also the tremulous state of the iris, and "the presence of a subconjunctival tumor, will be sufficient evidence of the nature of the accident. The lens is nearly always dislocated inclosed in its cap- sule ; but owing to the rough manner in which it is squeezed through the aperture in the sclerotic, the cap- sule is often lacerated, and the lenticular matter fre- quently somewhat comminuted. Treatment. — When the lens is seen lying beneath the conjunctiva, it should be removed; and this may be done by making a small incision through the conjunctiva either with a cataract knife or with a pair of fine scissors, and then, if the lens is entire in its capsule, by at once lifting it out; or if its capsule has been broken and its substance comminuted, carefully taking it away piecemeal with a small scoop, paying special regard that fragments of it are not left between the lips of the wound of the sclerotic to interfere with its primary union. The lids should be then closed, and a cotton-wool compress with a light bandage be applied to the e3^e. It will be well, as a precautionary measure, to apply two or three leeches to the temple, and for a few days to keep the patient on a slightl}^ antiphlogistic regimen. Partial Dislocations of the Lens may occur from blows on the eya or the side of the head, when a portion only of the suspensory ligament is detached, and conse- quently a limited or only partial displacement of the lens ensues. 1. The lens may be dislocated either partially upwards or partially downwards, and in either position it may con- tinue permanently fixed. Occasionally the lens is found to be slightly tilted without an}' absolute displacement ; DISLOCATIONS OF THE LENS. 193 one margin is pressed forwards against the iris, whilst the other is forced back into the vitreons. 2. The suspensory ligament may have been torn or partially detached at one part of its cii'cumference ; and although no immediate displacement of the lens may have followed, yet, owing to this loosening or partial detach- ment of its ligament, it may have become what is called a movable or swinging lens, swaying backwards and for- wards with the movements of the head or the eye. In certain postures of the head, as in looking downwards or in stooping forwards, a partial dislocation of the lens through the pupil may take place ; whilst with the head erect, as in looking directly forwards or upwards, the lens may sink back behind the pupil to apparently its normal position. Independentlj^ of the intraocular symp- toms which such a swinging lens is liable to excite, a serious defect in vision will be produced by the frequent changes in the position of the lens, such as to render the e3'e not only comparatively useless, but a source of very considerable annoyance and even of danger to the patient by causing him to misjudge and confuse objects with which he may come in contact in his daily work. General Symptoms. — Partial displacements of the lens are generally accompanied by grave symptoms. The blow required to produce such an injury must be one of con- siderable force, and the mere laceration of the suspensory ligament, irrespective of the irritation which the malposi- tion of the lens may give rise to, is sufficient to place the eye for a time in some danger. But when all the first symptoms which may be attributed to the blow have passed awaj', there often remain severe neuralgic pains in the eye. and around the orbit, wiiich in some instances are persistent, though var}- ing in intensit}^, whilst in other cases they are recurrent, with intervals of perfect ease. The sight is always materially affected, as in proportion 17 194 DISEASES OF THE CRYSTALLINE LENS. to the tilting forwards of the lens the patient becomes myopic. The lens ma}^ continue transparent for a long time after the injury, but the general rule is for it sooner or later to become cataractous. The most alarming condition which a partially dis- placed lens is likely to produce is a state of glaucoma, which may come on at any period after the accident. In such cases the glaucomatous symptoms are generally more or less recurrent ; for the increased tension of the eye, being dependent on pressure on the back of the iris, is produced whenever the lens falls forwards against that structure, and gradually subsides when this pressure is removed by a change of the position of the lens. A fre- quent repetition of this glaucomatous condition will, how- ever, speedily induce such changes, that unless means are adopted to arrest it, total loss of sight must in the end be the result. Treatment of partial Displacements of the Lens. — If the lens is partially dislocated and fixed, and the eye is quiet, it may be satisfactorily treated by Wecker's* plan of performing an iridodesis, so as to draw the iris over the edge of the displaced lens, and thus making the new pupil correspond to the space in which the lens is want- ing. The patient afterwards will, of course, require cata- ract glasses for near and distant vision. If the lens from partial detachment of its suspensory ligament is a swinging or movable one, and is causing personal inconvenience from frequently dropping par- . tially through the pupil, and thus producing a confusion of the patient's vision, even though there is no pain, its extraction should be advised. If glaucomatous symptoms come on, the removal of the lens becomes an absolute necessity for the safety of * "W^ccker, Muladies dos Yeux, 2d edition, p. 477. HYPERiEMIA OF THE RETINA. 195 the eye, and an operation for its extraction should be performed with as little delay as possible. The choice of the operation for the removal of the lens in these cases lies betweeen the ordinar}^ extraction with a large corneal flap, the modified linear extraction, and the traction operation. In either operation a certain amount of vitreous must be lost, as, with the rupture of the suspensory ligament, the hyaloid is certain to have been broken, and a portion of the vitreous will neces- saril}'^ escape either immediately before or else directly following the exit of the lens from the eye. In all cases in which a glaucomatous state has followed a displace- ment of the lens, the traction operation should be per- formed, as the excision of a portion of the iris will help to restore the eye to its normal tension. But, in addition to this, the lens will be removed through a comparatively small opening, and the risk of posterior hemorrhage, which is always great when the ordinary flap extraction is performed on glaucomatous eyes, will be thus prevented. CHAPTER V. DISEASES OP THE RETINA, CHOROID, AND OPTIC NERVE. Hyperemia of the Retina. — In estimating the de- gree of vascularity of the retina, the fundus of the dis- eased eye should be compared with that of the sound one, as fulness of the vessels, if equally present in both ej'cs, would clearly not account for a special defect in one of them. Hyperoemia may be caused by overworking the eyes, and especially if they are hypermetropic, or myopic; or it may come on from the repeated exposure to bright 196 DISEASES OF THE RETINA. lights ; or it may be associated with inflammation of any part of the eye. The fundus looks too red, and the optic nerve has a decidedly pinkish aspect. The patient com- plains of occasional flashes of light, and an inability to continue his accustomed work for an}- length of time, from a sense of fatigue and heat in the ej^es. I have seen this condition of the eyes in seamstresses, bootbinders, engra- vers, and amongst the Spitalfields weavers, who are often engaged for many hours at close work with an inefficient light. It is occasionally associated with hypersesthesia, or undue sensibility of the retina. The 63^6 is thus ren- dered intolerant of bright light, and frequently during the day the lids are spasmodically closed from sudden gushes of hot tears acccompanied with a sense of gritti- ness and increased photoph(;bia. These paroxysms usu- ally last only two or three minutes, when the eyes return to the condition they were in before. A more serious form of hyperfemia is a passive venous congestion due to some impediment in the return flow of blood. It is seen in impairments of sight due to the presence of tumors within the orbit or the skull, or to some local congestion of the brain. It occurs in cases of acute amaurosis dependent on suppressed menstrua- tion, and it will be also found in all glaucomatous affec- tions. Treatment. — For the first-mentioned form of hyperemia of the retina, rest of the eyes is imperative. The patient should abstain from all work which requires close appli- cation of the eyes or a stooping position of the head, and he should wear blue glasses when exposed to any glare or artificial light. One or two leeches applied to the temple, and repeated at intervals of two or three days, are often of service ; and mild counter-irritation behind the ears, or to the temple, by the repeated application of small blisters or a stimulating liniment, will occasionally RETINITIS. 197 do good. As the congestion is often due to some impair- ment of the sympathetic nerve, which from some canse fails to exert its proper influence in maintaining a due tonicity of the vessels, preparations of iron, the mineral acids, and bark, are frequently of the greatest benefit. As a local application, the cold douche is the best. It' should be applied to the eyes with the lids closed. For the second form of hyperemia, the treatment must necessarily' be very unsatisfactory. When there is rea- sonable evidence to suppose that it is caused by a tumor within the skull, medicine can do little if any good. The iodide or bromide of potassium, singl}^ or combined, may be tried ; but my own experience is that they are seldom of any benefit. Retinitis or Inflammation of the Retina, gener- ally arises from some constitutional cause, as syphilis, or disease of the kidneys ; but it may also be produced by over-use of the eyes before strong lights. It may occur as a secondary affection from obstruction to the I'etinal circulation, from orbital tumors, or from embolism, or from an extension of an inflammation of the neighboring structures. So intimately associated are the retina and choroid in health, that it is difficult for one to be affected b}' disease without the other also participating. In speak- ing, therefore, of the diseases of the retina, it must not be inferred that the retina only is affected, but that it is the structure primarily involved, and the seat of the prin- cipal morbid changes. As in iritis, 1 will flrst describe the general symptoms of retinitis, and then briefly refer to the special peculiarities which mark the various forms of this disease. General Symptoms. — The patient complains that he sees surrounding objects darkl}', as though he were look- ing through a mist. He has to examine closely whatever 17* 198 DISEASES OF TUB RETINA. he wishes to see correctly, and to use a strong light ; in fact, from the dulled sensibility of the retina a deep im- pression is required. As the disease progresses, the field of vision becomes contracted, or portions of it are lost ; and the darkness steadily increases until ultimately the eye is blind. The defect of sight is influenced by the part of the retina which is chiefly affected ; when the peripheral portions are first attacked, the field of vision is contracted, but the impairment of sight is much less than when the region of the yellow spot is invaded by the disease. The external appearance of the eye is un- changed, there is nothing about it to strike the ordinary observer ; it is onl}^ b}^ the ophthalmoscope that the sj-mp- toms complained of by the patient can be explained. Examined with the opJithahnoscojye, there is seen a change in the transparency of the retina, which is slightly turbid or milk}^, from a delicate film of exudation on its surface. There is usually some swelling of the optic disc, its outline is indistinct, and looks blended with the sur- rounding parts. The veins are generall}' more or less distended and sometimes tortuous, and parts of them are here and there rendered less distinct, on account of the film Avhich covers them. There ma}^ be extravasations of blood, or inflammatory exudation into the retinal tissue, wdiich will appear as grayish-white spots. llie lorognoais of retinitis, except when it proceeds from syphilis, is generally unfavorable. The prospect of recovery is diminished in proportion to the extent of the hemorrhages, and the amount of the inflammatory exu- dations. Nerve structure once destroyed is never re- placed. It is only, therefore, when the exudations have been chiefly confined to the connective tissue of the retina that a favorable result will follow. When there has been neither hemorrhage nor isolated graj' spots of exudation, the eye may recover with fair sight. Retinitis may ter- RETINITIS. 199 minate in blindness from atrophy of the retina, or by its detachment from the choroid. Treatment. — For that form of retinitis whicli is ap- parently unconnected either with syphilis or disease of the kidney, small alterative doses of the hydrarg. per- chlorid. (F. 80) may be given two or three times a day; or the iodide or bromide of potassium (F. 74, 79), may be prescribed, and at the same time slight counter-irritation may be kept up by rubbing into the temple every night a little of the unguent, hydrarg. biniodid. (F. 105). The eyes should be allowed absolute rest, and this can be ob- tained b}^ the patient abstaining from all close work, and b}^ wearing spectacles with glasses of a rather dark cobalt blue. If the retinitis can be traced to overwork, or has come on after fever or any seA'ere illness, tonics of quinine, iron, or cinchona with the mineral acids should be ordered, with rest to the e3^es, and, if possible, change of air. Retinitis Albuminurica — Nephritic Retinitis. — This form of retinitis has received the name of " albuminurica," from being frequently associated with renal disease, when the urine is charged with albumen. It usually occurs in patients who have Bright's disease of the kidney, and, consequent on it, an hypertrophy of the left ventricle of the heart. Symptoms. — There are two forms in which this nephritic retinitis may occur. 1. It may gradually develop itself with the advance of the kidney disease. For a long time the patient may have complained of a general mistiness, everything appearing as if through a veil ; or the impair- ment of vision may have been confined to one portion of the field, when suddenly the sight is discovered to be markedl}' worse. The whole field may be thus affected, so that the eye is almost dark ; or the blindness may be partial. This sudden loss of sight is probably due to 200 DISEASES OF THE KETINA. retinal hemorrhage, and is in proportion to the number, size, and locality of the blood-clots. 2. The second form of nephritic retinitis is dependent on uraemia, and occurs in the later stages of kidney dis- ease, associated with suppression of urine, delirium, and convulsions. The loss of sight is very rapid and some- times permanent. If no organic changes have taken place in the retina from hemorrhage during the attack of urtemic poisoning, the patient may gradually regain much of his sight after the kidneys have resumed their functions ; but the prognosis is always unfavorable. Ophthalmoseojnc aj)pearance.s. — The optic nerve is slightly swollen and cedematous, with its margin indis- tinct and blurred into the surrounding cloudy retina. Around the disc the retina looks of a grayish white, and the vessels as the3' pass to and from the optic nerve are in parts obscured by the exudation. At various points of the retina butt-colored patches are seen, and in the neigh- borhood of the yellow spot, small whitish glistening bodies appear sprinkled. The retinal veins are distended and tortuous, and there are numerous small eff'usions of blood scattered over the retina. The hemorrhage is always from the capillaries, and this no doubt is due to the mor- bid state of the coats of the A^essels in advanced Bright's disease, and to the increased force by which an hj'per- trophied heart sends the blood through them. Mr. Hulke has had two opportunities of dissecting eyes aflected with chronic renal retinitis, an account of which he published in the " Ophthalmic Hospital Reports. " * He found there was : " 1. (Edematous swelling of the optic nerve and retina. " 2. Large granular corpuscles, more or less abundant, mostly in the intergrauule layer. * Koyal London Uiilitliahnic Hospital Keports, vol. v, p. IG. RETINITIS. 201 " 3. Botryoidal masses of colloid, also in this laj'er. " 4. Xests of sclerosed and enlarged ganglionic cells, or raoniliformly swollen and sclerosed nerve-fibres in the ganglionic and opticus layers, " 5. Hemorrhages : the shape of the patches of the extraA'asated blood being determined b}' the arrangement of the tissues into which the blood escapes." It has been said that bj^ the presence of retinitis albu- minurica, the surgeon may at once diagnose with the ophthalmoscope Bright's disease ; but it should be remem- bered that the affection of the eyes is secoudar}- to that of the kidnej's ; and that it is only in advanced cases of the disease that the sj^mptoms are sufficiently marked to do more than point to the kidneys as the probable source of the mischief. Treatment As the state of the eyes is secondary to, and dependent on, the disease of the kidneys, the treat- ment must be constitutional, and those remedies should be selected which are suitable for the renal affection from which the patient is suffering. The bowels should be made to act onge daily, the pulv, jalapse comp., or some hydragogue cathartic being given early in the morning when necessary. The preparations of iron usuall}' do good, and of these the tinct, ferri perchlorid, is perhaps the most useful. The object to be attained is to relieve the kidneys by promoting the action of the skin and the bowels. Mercury in any form, in nephritic retinitis, should be strictly avoided. If the eye is painful, a leech applied to the temple will often give ease, and it ma}^ be repeated from time to time. The patient should strictly rest the eyes, and protect them from all exposure to glare or artificial light, and for this purpose he should wear spectacles with curved cobalt-blue glasses. He should also avoid stooping, as it favors the flow of blood to the 202 DISEASES OF THE RETINA. eyes, aiul thus renders them more liable to retinal hemor- rhages. Retinitis Syphilitica There is one form of retinitis which is undoubted!}' due to syphilis. The history of the case and certain ophthalmoscopic appearances mark its specific origin. It nsually occurs during the tertiary period of S3philis, when nodes form on the bones, and the patient has pains in his limbs and joints; when in fact the constitution has been thoroughly imbued with the poison. Mr. Hutchinson* has shown that choroido-reti- nitis may arise also from inherited syphilis. Symptoms. — A gradual fading of the sight extending over the whole field of vision. The pupil is sluggish and inclined to be dilated. There are no external manifesta- tions to account for the great loss of sight. A past his- tory ma}^ reveal syphilis, or there may be local evidences of the disease which will render a searching interrogation unnecessar}^ Examined tvitJi the Ophthalmoscope. — There is usually turbidity of the vitreous, and a diflTused gra^'ish haze of tlie retina extending from around the optic disc; whilst here and there are seen buff-colored patches of exuda- tion. The absence of an}' hemorrhagic spots are also to some extent characteristic of syphilitic retinitis. Pure and uncomplicated sj-philitic retinitis is a rare disease ; it is usually combined with exudative choroid- itis, and to the joint affection of the retina and choroid, the term " syphilitic choroido-retinitis " has been well applied. See Exudative Choroiditis, p. 217. The prognosis of retinitis syphilitica is more favorable than that of any of the other forms of retinitis. When seen sufficiently early, the disease will generally j'ield to * Syphilitic Diseases of the Eye and Ear, p. 130. RETINITIS SYPHILITICA. 203 appropriate treatment, and a great amelioration of the symptoms will usually folloAv, and in some cases a com- plete restoration of sight. Treatment. — The iodide of potassium and the prepara- tions of mercury are the drugs to be relied on for the re- lief of this disease. I have found the mist, potassii iodidi cum hydrarg. perchlorid. (F. 78) extremely beneficial, and have had patients recover under its influence in a most marked way. This mixture, however, is very apt to dis- agree with the stomach, and to produce a feeling of dis- comfort, and, in many instances, to bring out an attack of mercurial erythema, which induces the most intolerable irritation when the patient is warm in bed, and obliges him to desist from the medicine. It is most easily toler- ated if it is taken about one or two hours after a meal. When the progress of S3'philitic retinitis is very rapid, it is desirable to get the patient quickly under the influence of mercur^^, and this may be readily accomplished by rubbing half a drachm of the unguent, hjxlrarg. into the axilla or inner side of the thighs night and morning until the gums are slightly affected, when its eflTects may be continued, without being increased, by diminishing the frequency of the inunction. If the patient is feeble, qui- nine may be given during the exhibition of the mercury; but if not, small doses of the iodide of potassium two or three times a day will be the most useful. In some cases I have seen very good results follow the use of Mr. Henry Lee's mercurial vapor bath (F. 3). The patient should commence his fumigations with gr. 10 of calomel, and continue them every night, the surgeon keeping a careful watch that he does not become too much affected by them. The baths should be discontinued or intermitted if the gums become spongy. During the day the patient may take the iodide of potassium (F. 74) ; or, if his strength is failing him, he may be prescribed quinine or cinchona 204 DISEASES OF THE RETINA. with nitric acid. The mercurial baths are most efficient during the summer months, when the skin acts freel}', and when there is the least liability of the patient getting chilled after taking them. I should not order the baths during the cold months unless the patient was able to have them in his own bedroom, and provide himself against all risks of exposure either during or after their administration. Retinal Apoplexy — Hetimfis apoplectica. — Retinal hemorrhage ma}' occur from disease within the eye, as in retinitis or glaucoma; but it may also come on from some extrinsic cause, and it is this form of intraocular hemor- rhage we have now to consider. Sudden hemorrhage from the rupture of a retinal or choroidal vessel ma}' arise from a diseased state of the heart, or an atheromatous condition of the coats of the vessels, or from embolism, or from suppressed menstrua- tion. It may happen also in young patients, who, with- out any evidence of disease, have a morbid tendency to bleed, and exhibit this predisposition by frequent attacks of epistaxis. In such cases the liability to retinal hemor- rhage is favored if the daily employment necessitates a stooping position of the head. A well-marked example of this form of retinal hemorrhage, apparently due only to a peculiar hemorrhagic tendency, came under my care at the hospital in a young fellow, aet. 19, who was by occu- pation a currier. He was accustomed to work for many hours with his body bent, and his head stooping forwards. About eight weeks previously to my seeing him he was at his usual employment, and after his day's work went to bed feeling quite well ; but on getting up in the morn- ing he was so blind that he could scarcely find his way to the work-yard; and in about two hours he was obliged to return home, as he had only sufficient sight to guide Rl<:TrNAL APOPLEXY. 205 himself about. The boy had suftered from repeated at- tacks of epistaxis, and only a week before he had lost a large quantity of blood from the nose. Examined with the ophthalmoscope, there was seen extensive retinal hemorrhage in each eye. There were dark clots in the vitreous of both eyes, and in the left a ruptured retinal vessel could be distinctly made out. Symptoms. — Occasionally there are the premonitory warnings of a disturbed circulation ; the patient has at- tacks of giddiness and dimness of vision which may last from a few seconds to a few minutes ; he complains of pain in his head, or has bleeding from the nose ; but in many cases the retinal hemorrhage occurs suddenly with- out an}' previous indication of existing disease. The sud- denness of the loss of sight is one of the most character- istic symptoms. The patient may awake in the morning and find himself nearly blind with one or both eyes ; or whilst engaged at his usual occupation a dark cloud, or, as some haA^e described it, a red ball may seem to appear before the affected eye, and to gradually increase in size until the vision is either partially or complete^ lost. The impairment of sight produced by the hemorrhage de- pends on the extent of the effusion and the locality in which it has taken place. One large retinal vessel may haA^e given way, and a single clot have formed on the sur- face of the retina ; or there may be several small ecchj^- moses from ruptured retinal or choroidal capillaries. When it is from a large retinal vessel, the bleeding is often extensive, and the blood breaking through the hya- loid membrane will be extravasated into the vitreous, or it may force its way backwards through the layers of the retina, and form a clot between that structure and the choroid. The blindness ma}^ be complete, or it ma}^ be central, so that the patient can only see on either side of the object he looks at ; or it may be confined to a portion 18 206 DISEASES OF THE RETINA. of his field of vision, according to the part of the retina pressed on by the clot. Ophthalmoscopic appearances. — If there has been much hemorrhage, and the blood has been extravasated into the vitreous, the fundus may be so masked that it will be impossible to make out any details. The historj- of the case, combined with the detection of blood in the vitreous, will, however, at once explain the cause of the loss of sight. When the hemorrhage has been of less extent, a retinal vessel vixa.y be often seen terminating in a lai-ge clot. If there have been many small capillary ecchj-moses, these will be clearly made out with the oph- thalmoscope. Frequently the remains of old blood-clots may be also seen, there having been previous hemor- rhage ; or markings on the retina maj^ indicate the site which some former clots occupied. The prognosis is alwa3's unfavorable, for, although some improvement may be gained b}^ the absorption of the clots, yet, as the exciting cause remains, the hemor- rhage is ver}' likely to recur. When the blood has been extravasated, either into the vitreous, or formed a clot be- tween the retina and the choroid, the prospect of regain- ing any sight is very slight. In such cases, as the blood is slowly absorbed, the vitreous becomes fluid, the retina detached, and the globe soft. The prognosis is most fa- vorable when there is only one clot, even though it be a large one, provided the surrounding retina be healthy, and there has been no extravasation into the vitreous. Treatment. — Inquiry must first be made as to the cause of the retinal hemorrhage, and when this can be ascer- tained, the endeaA-or should be to remove it. If the hem- orrhage is due to suppressed menstruation, means should be taken to restore the uterine function. The mist, po- tassi iodidi (F. 14), or the mist. boraci*(F. 58) is often of service ; or, if there is much anaemia, the mist, ferri RETINITIS PIGMENTOSA. 207 comp., or some other preparation of iron, should be pre- scribed. The regular action of the bowels should be maintained by the pil. aloes et myrrhae, or the pil. aloes Barbadensis. When the hemorrhage apparently arises from heart disease, or a morbid condition of the coats of the vessels, the medical man in attendance must be guided by the symptoms which are present, and prescribe accordingly. In all cases of retinal apoplexy, it is well to keep up a slightly increased action of the bowels, and, for this pur- pose, the bitter waters of Friedrichshall, Pullna, or Kis- singen, are very useful. No local application will benefit the eye ; if it is hot or painful, a fold of lint wet with cold water ma}^ be laid over it, or one or two leeches may be applied to the temple, and repeated if they atford re- lief. Retinitis pigmentosa has derived its name from the peculiar deposition of the pigment in the retina which characterizes this disease. It may occur in persons of all ages. Generally the commencement of this affection may be traced back to early childhood, but, occasionally, " the first symptoms have appeared as late as the age of fift}^"* I believe that in most cases it is congenital, and in some hereditary. Both eyes are usuallly affected, and to a similar extent, although to this there are exceptions. Wells mentions a case in which only one eye suffered. Liebreich has shown that retinitis pigmentosa is frequent amongst deaf-mutes, and also amongst the offspring of marriages between blood relatives. These observations have been confirmed b}' Mooren in an excellent paper on this subject.f * Bador on the Natural and Morbid Conditions of the Human Eye, p. 470. f Ophthahnic Review, No. 1, p. 4. Translated from Zehendcr's 208 DISEASES OF THE RETINA. Symptoms. — The characteristic signs of this disease are, torpidit}^ or diminished sensibility of the retina ; a gradually increasing contraction of the field of vision, and a peculiar deposit of pigment in the retina. The first symptom which generally attracts attention, is the ina- bility to walk about in a dim light. The patient suffers more or less from hemeralopia or night-blindness ; by da}' his direct vision is good, but after dusk it is consid- erably impaired. The contraction of the field of vision increases almost imperceptibly year by year, but the di- rect central sight maj' remain for a long period unchanged. If, however, the disease continues to progress, the acute- ness of the central vision becomes first dimmed, and then gradually' darker, until ultimatel}' the patient is blind. The diminution of the field is concentric and equal in the two eyes. In man}' of the ( ases recorded by Mooreu, commencing cataract in the posterior pole of the lens was observed in the later stages of the disease. Examined icith the ophthalmoscope, the retina presents a ver}' striking appearance. Sprinkled in an apparently irregular manner, are large deposits of pigment ; some of the spots are stellated, or of a spider shaj^e with man}- small offshoots ; others look like mere granules, either congregated together in groups, or scattered about indif- ferently. This deposit usuall}'' commences at the peri- phery and gradually extends towards the centre. When more carefully examined, the deposition of pig- ment seems in places to foUow the course of the retinal vessels, parts of which they will overlay. In manj- cases the choroid is also affected, when, from the wasting of its epithelium and atrophy of its stroma, patches of it are rendered so transparent as to allow the white sclerotic to " Klinische Monatsbliitter fiir Augenbeilkuiidc," i, p. 93, by Zacba- riiih Laurence. DETACHMENT OF THE RETINA. 209 shine through and render more conspicuous the black patches in the retina. The retinal vessels appear small, but this diminution is said by Schweigger to be due to a thickening of their coats and a consequent lessening of the calibre, which restricts the flow of blood through them, and to this state of anemia he attributes the defective sensibility of the retina. The optic nerve has a pale aniemic appearance, and when the disease has advanced it exhibits the peculiar dull white of confirmed atrophy. Treatment. — Little if an}' benefit is to be derived from medicine. The aim must be to retain the sight the pa- tient has, rather than to endeavor to recover that which has been lost. The use of the ej'cs must be restricted ; he should avoid reading, writing, and all work which re- quires an effort of the accommodation. Small doses of the iodide or bromide of potassium, or of the perchloride of mercury, have been recommended, and may be tried, but they should be given up if they interfere with the general health. Spectacles with curved cobalt-blue glasses should be worn when in the open air or bright sunlight, as the}' afford rest to the eyes, and protection from the irritating effects of wind. Detachment of the Retina ma}- be caused — 1. By the extreme elongation of the coats of the eye which occurs in severe cases of myopia, when the retina being less extensile than the choroid is in parts separated from it, and the intervening space is occupied by a serous fluid. 2. By a diminution of the btdk of the vitreous, so that the retina, losing its due amount of anterior support, gradually becomes loosened from the choroid, and falling forward is at first partially, and ultimately completely de- tached. This change may be induced by disease, but most frequently it is the result of a penetrating wound of 18* 210 DISEASES OF THE RETINA. the eye, which has been either accompanied with a loss of vitreous, or with liemorrhage into its substance. 3. By hemorrhage between the choroid and retina. — This may occur in retinitis or glaucoma ; or it may be caused by blows on the eye. In most cases the blood-clot is ultimately absorbed, but the retina remains detached. 4. By serous effusion between the choroid and retina. — This may occur in a normally shaped eye without any stretching of the posterior coats as in myopia, or without any previous separation having been etfected by hemor- rhage. In some instances it may possibly be due to dis- ease of the vitreous resulting in a change of its structure and a lessening of its bulk ; but in many cases no satis- factory cause for the detachment can be detected, and it is, therefore, ascribed by some to inflammator}^ action of which there is little or no evidence. 5. By the presence of tumors of the choroid. As the growth advances the retina is carried in front of it, and the detachment increases with the progress of the disease. Detachment of the retina ma}' be partial or complete. It generally commences in the lower region of the fundus, and gradually mounts up towards the optic nerve. It usually occurs in one eye only, but both may sufter if the separation has been produced by causes which equally af- fect the two ej'es, as in cases of extreme myopia. The tension of the globe is as a rule slightly diminished when there is a simple detachment with subretinal effusion ; but if the displacement is due to a choroidal tumor, the tension is usually increased. Syynptoms. — It is often very diflicult to ascertain from a patient the early symptoms of a displaced retina ; they have either passed unnoticed, or in the lapse of time have been forgotten. Some indications of retinal irritation are, however, the general precursors of the detachment ; the patient is frequently troubled for some weeks pre- DETACHMENT OF THE RETINA. 211 viously with the occasional and sndden appearance of bright flashes or scintillations, or of circles of fire, &c., or with floating mnscae and dimness of vision. The S3mp- toms which may be said to characterize a detachment of the retina are : Loss of vision in one direction, so that a portion of the field may be completely wanting ; the pa- tient, with the aflfected eye, may be only able to see a portion of the object he looks at, a half or a quarter of it being quite dark; or if the loss is central, the point on which he directs his eye is blank, whilst he can see on each side of it. He complains also of a waving up and down with the movements of the head. This is caused by the floating to and fro of the detached portion, and is recognized by the part of the retina still in situ. Another symptom often mentioned is that objects appear bent, twisted, or in some other way distorted, and is no doubt due to some disarrangement of the layers of a portion of the retina which is loosened, though not yet separated from the choroid. Examined with the Ophthalmoscope The detachment is best seen by direct examination, when, if the case is one of partial separation of the retina from the choroid, the detached portion will appear as a bluish-gray film, bounded by a sharp line, on one side of which is the bright expanse of the choroid, shining through the trans- parent retina in situ, and on the other this semi-opaque gray web, which is bulged slightly forwards towards the vitreous. Tracing the course of the retinal vessels from the optic nerve, they seem to be suddenly bent when they arrive at the line of the detachment. A partial, or an entire displacement of the retina, if the separation from the choroid is complete, is easily recognized. It is when a portion of the retina is rather loosened or wrinkled than absolutely detached that the diagnosis becomes exceed- ingly difficult. This condition is recognized by a slight 212 DISEASES OF THE RETINA. opacity of the retina at one spot, and b}' noting the ap- pearance of the vessels, which appear to stand out at one point and to be lost in the shade at another, as they rise or fall in their passage over the foldings of the loosened retina. The prognosis is ver^- unfavorable. The tendency is for the disease to extend, and more retina to become de- tached until at last the e3'e is blind. The most favor- able cases are those in which there is a limited detach- ment, the result of an injur}', probabl}' a small effusion of blood between the choroid and retina. A blind spot in the field of vision will alwajs remain, but the rest of the retina raa,y retain its functions unimpaired. Cases have been recorded where the sub-retinal fluid has disap- peared, and the retina, having again fallen back to its place, has still retained some power of sight, but they are exceptional. Treatment. — Detachment of the retina is very intract- able, and generall}^ uninfluenced by medicines given for the purpose of procuring absorption of the sub-retinal fluid. A spontaneous cure or arrest of the disease has occasionally occurred from the accidental laceration of the retina, and the escape of the fluid into the vitreous. The knowledge of this fact induced Graefe and Bowman to endeavor to establish artificially a permanent rent in the detached portion of the retina, through which the fluid could extravasate into the viti-eous. This they did by tearing through the displaced retina with either one or two needles introduced through the sclerotic. Yon Graefe employs a long cutting needle, " furnished with two very sharp edges, and the neck of which fills the wound, so as to leave no space for the escape externally of the fluid."* Mr. Bowman uses two rather long needles, * Graefe on Perforation of Detached Retina. Translated by George Henry Rogers, R. L O. H. Reports, vol. iv, p. 222. EMBOLISM OF CENTRAL ARTERY OF RETINA. 213 which he introduces through the sclerotic, at from a quarter to half an inch from the cornea, and in the space between the recti tendons. The eye should be first ex- amined with the ophthalmoscope to determine the exact position of the detachment. The operation may be thus performed : The patient should be on a couch, and the lids being parted with a spring speculum, one needle should be in- troduced through the sclerotic at a point where it will perforate the detached portion of the retina at a promi- nent part. The second needle is then to be inserted at a short distance from the first, and so directed that its point shall penetrate the retina at or close to the same sj^ot. To avoid the risk of wounding the lens in the pas- sage of the needles, they should be thrust through the sclerotic nearly verticall^y. A rent is now to be torn in the retina by separating the points of the two needles. There is generally an escape of the sub-retinal fluid by the side of the needles during the operation, and fre- quently in a sufficient quantity to infiltrate a consider- able extent of the subconjunctival tissue. The fluid is generall}^ of a jellowish color, and when tested jdelds a large quantity of albumen. ^ Embolism of the Central Artery of the Retina is a cause of blindness and subsequent atrophy of the optic nerve. The loss of sight is usually sudden and unaccom- panied by pain. With the ophthalmoscope the optic disc appears blanched, the arteries reduced to the size of threads, and the veins also much diminished. In some of the cases which have been recorded, there was a loss of transparency of the retina around the optic nerve, and in the region of the jcllow spot, probably due to a slight serous effusion. In the case of a young woman under my care, the sight 214 DISEASES OF THE RETINA. was lost siuldeiil}- and -without any premoniton- symp- toms a fortnight aftei* her confinement. She had no pain, but she experienced a sudden sense of darkness over her left e^e, which caused her to cover the right with her hand, when she immediateh^ discoA'ered her blindness. When I first saw her, about six weeks afterwards, the optic nerve was of a milk}^ whiteness, and the retinal arteries were dwindled to mere lines, two or three of which were evidently oul}- empty tubes. The prognosis is unfavorable. Xo treatment is of any avail. The only consolation to be offered the patient is, that there is no reason to suspect that the other e^'e will suffer. TUMORS OF THE RETINA. Glioma of the Retina. — The terrible disease which ^ has received this name was former^ recognized as me- dullary cancer. There are two varieties, the soft or me- dullary, and the hard or fibrous glioma. According to Yirchow, these growths spring from the interstitial tissue of the retina, and are composed of lenticular, roundish, spindle-shaped, or branched cells, and of an intercellular substance which is finely fibrillated or granular in chromic acid preparations. There is another form of this disease which he calls glio-sarcoma , from its presenting, under the microscope, the mixed characters of both glioma and sarcoma. Glioma generally attacks young children, affecting first one eye, and frequently, after a short interval, the other also. I had a little patient in whom the disease com- menced at the age of three months, and was then visible to the mother. When nine months old she first came under my care, and then I excised the eye. The child recovered without a bad symptom. Symptoms. — A rapidly increasing loss of sight in the TUMORS OF THE RETINA. 215 eye^ with more or less dilatation of the pupil. If the patient is a child, the mother's attention is often first drawn to its e^^e, by noticing accidentally a bright yel- low reflection from the bottom of the globe, when the light falls upon the eye in a particular direction. Ex- amined with the ophthalmoscope, the tumor will be seen occupying a limited portion of the retina, and with blood- vessels on its surface, which clearly belong to the new growth, and indicate its great vascularity. In the imme- diate locality of the tumor the retina is detached, and this separation increases with the advance of the disease. Steadil}' progressing, the glioma gradually fills the globe, displacing the vitreous and pressing the iris and lens for- wards. The cornea first ulcerates, then gives way, and the tumor bursting through the perforation grows with an unrestrained activity. It quickly attains great dimen- sions, its surface fungates and bleeds; and ultimately the patient dies, either from being worn out with pain and repeated loss of blood, or from meningitis caused by an extension of the disease to the brain. In some cases the tumor will make an exit for itself from the globe by breaking through the sclerotic in the posterior region of the eye, but more frequently it selects the cornea. In the early stages of the disease there is generally no pain ; the tumor is as yet small, it has room within the globe to grow, and it presses upon none of the ciliary nerves. When, however, all these conditions are reversed, and the tumor has filled the globe, and by its increasing size distends to bursting the coats of the eye, pressing tightly upon all the nervous structures within them, the suflferings of the patient are extreme. The prognosis of glioma is most unfavorable. The dis- ease is very apt to recur in the orbit after the eye has been removed, and to appear in the other eye if it has not been already affected. The tumor spreads by infection, which 216 DISEASES OF THE RETINA. travels along the optic nerve, and, after death, a similar growth is frequently found in the brain in direct com- munication with the optic tracts. Treatment. — The onl}- chance for the patient is an early excision of the globe ; and should the two eyes be affected I would excise both, provided the sight has been already destro3^ed, and the tumor has not burst through the ex- ternal coats. Such an operation would afford the onl^^ hope for recovery, whilst at the same time it would save the patient much ultimate suflering. On two occasions I have been induced to remove the second e3'e, for the sole purpose of procuring some temporary' relief from the ex- cessive pain induced by the over-distended globe, and at a time when there was not the slightest prospect of arrest- ing the disease. In each case the operation gave so much ease, that under similar circumstances I should not hesi- tate to repeat it. Cysts of the Retina are occasionally found In eyes which have been long lost, and appear to be due to degene- rative changes. In a paper by M. Iwanoff, on " The dif- ferent Forms of Inflammation of the Retina," read before tiie Ophthalmological Congress at Heidelberg, in Septem- ber, 18G4, he alludes to three specimens, containing re- spectively one, five, and seven cysts. The first example of this disease noticed in this country was in an e3'e which I removed from a patient at the Ophthalmic Hospital. The man had received a j)enetrating wound of the eye fifteen j-ears previously ; after the accident he only re- tained perception of light, and in the next eighteen months the ej-e became totally blind. He came under mv care in November, 186T. The lost eye was ver^' painful, its ten- sion was increased, and it was affecting prejudicially the sound one. Under these circumstances I removed the eye. On making a section of it, the retina was found EXUDATIVE CHOROIDITIS. 217 slightly detached from the choroid, and its outer aspect was studded with cysts of various sizes, the largest about that of a small pea. They were eleven in number, and each appeared to bulge out from the choroidal aspect of the retina, and to be formed by the separated layers of that structure. The specimen was exhibited at the Patho- logical Society, and in the Transactions, vol. xix, p 362, will be found a full account of the case, with two excellent woodcuts, which give good representations of the two sec- tions of the eye. A report of the examination of the C3'sts, made by Mr. Vernon, the curator at the hospital, is ap- pended to the case. It is as follows : " The cysts appear to have been formed at the expense of the outer layers of the retina. Their walls consisted of a very fine tissue of delicate fibres, which contained many nuclei of their own, and which were closely interlaced with small nucleated cells, intermingled with round highly refracting bodies, the remnants of the granular layers of the retina. To the outer walls of the cysts which were examined, some of the choroidal epithelium was adherent, while their inner sur- faces were lined with squamous epithelium. Many of the cells in the cj^st-walls contained fatty granules. With acetic acid the fibres forming the C3'st-walls appeared to consist of connective tissue without any elastic element." DISEASES OF THE CHOROID. Disseminated or Exudative Choroiditis is most fre- quently the result of syphilis, bpt it may also occur in pa- tients who are free from all specific taint, and from causes too indefinite or remote to be accuratel}^ traced. It is characterized by disseminated buff-colored exudations on the surface and into the tissue of the choroid. These ef- fusions are generally circumscribed, and between them portions of unclouded choroid are seen through the retina. 19 218 DISEASES OF THE CHOROID. As the disease progresses the diffused 13-mph is absorbed, but the portion of the choroid corresponding to many of the patches becomes atropliied, and frequently to such an extent as to allow the white sclerotic to shine through its attenuated remains. Around these white patches the cho- roidal epithelium filled with pigment collects and encircles them with a black rim. Frequently the retina becomes secondarily affected, and choroido-retinitis is established. Without, howcA'er, being involved in the inflammatory action, portions of the retina may be so pressed on by the exuded Ij'mph as to cause a tem^Dorar}' suspension of its functions, and, if long continued, atrophy of its structure. A general tui'bidit}^ of the vitreous with filmy opacities are frequently associated with this form of choroiditis, and especially if it has a syphilitic origin. General Symptoms. — A gradual failure of sight; sur- rounding objects appear dark and confused; occasionally the field of vision is contracted, or parts of it are de- stroyed, so that in certain directions the patient sees only a portion of the object he looks at. The pupil is slightl}^ dilated and sluggish. These symptoms, how- ever, are common to other deep-seated affections of the ej'e, and it is onl}^ by the aid of the ophthalmoscope that the exact localit\^ of the disease can be determined. When thus examined, the patches of exudation will be seen scattei'ed over the fundus of the ej'c; those that are re- cent will be recognized as opaque j-ellowish spots, whilst the site of old effusions will be here and there indicated by the glistening white of the sclerotic shining through the atrophied portions of choroid, which ai*e mapped out by an aggi'egation of pigment cells. AVhen the inflamma- tory action is confined to the choroid, the retinal vessels may be clearly traced throughout their course, and in places mounting over the effusion which is beneath them ; the retina itself is transparent, and allows the portions of EXUDATIVE CHOROIDITIS. 210 bright choroid unobsciired by lymph to shine through the spaces between the exudations ; and there are none of the hemorrhages which are so characteristic of most of the forms of retinitis. If the retina is aifected, as very fre- quently happens when this disease is due to syphilis, a diffused haziness of a part or whole of the fundus, with interruptions in the course of the retinal vessels from in- flammatory effusion, will mask manj^ of the ophthalmo- scopic signs already mentioned. When in addition to the retinitis there is also a turbidity of the vitreous, it is often impossible to make out the details of the changes which may have taken place, but sufficient information will probably be gained to form a diagnosis of the case. There are two forms of disseminated choroiditis, the syphilitic and the simple. In the syphilitic the exudation is very circumscribed, and often in nodules closely resembling those which are so frequentl}^ seen in the specific iritis, and there is no tendency for the effusions to run together. This exuda- tive choroiditis sometimes occurs as an extension of the iritis, and it is then associated with, or follows closely upon the secondar}^ eruption of the skin. It is also met with during the tertiary symptoms of syphilis, but it is then usually complicated with retinitis. In the simple form of disseminated choroiditis there is no history of syphilis, the disease rather resembles the simple iritis, in. which the effusion of lymph is small in quantit}^ and evenly diffused. The patches on the choroid are less circumscribed, and they have a tendency to co- alesce. The disease is more chronic and less amenable to active treatment. Treatment. — If the disease is due to syphilis, the treat- ment which was recommended for retinitis syphilitica, page 203, should be adopted, but with certain restrictions. When the disseminated choroiditis follows or is associated 220 DISEASES OF THE CHOROID. with the secondary skin eruption, the iodide of potassium (F. 74), with the mercurial bath (F. 2) every night, or with piL riummer, gr. 5, every other night, may he ordered ; or, if the patient has not yet been under the influence of mercury, the unguent, hydrarg. may be rubbed into the axilla or inner side of the thigh, every night, until the gums are slightly affected. If, however, the disease does not occur until the tertiary period of syphilis, the prepar- ations of the hj'drarg. perchlorid. with bark (F. 80) ; or the mist, potassii iodidi cum h^'drarg. perchlorid. (F. 78) will be the most useful. In the simple disseminated choroiditis, small doses of iodide and bromide of potassium (F. 77), or of the liq. hydrarg. perchlorid. should be prescribed and continued for some weeks, and at the same time a slight mercurial counter-irritation may be kept up by rubbing a little of the unguent, hydrarg. biniodid (F. 105) into the temple every night. If, however, the patient is very feeble and anaemic, the mercurial medicines should not be given in- ternally, but full doses of quinine, or quinine and iron, should be ordered, and the unguent, hydrarg. c. bella- donna (F. 99) rubbed into the brow and temple every night. ScLEBOTico-CHOROiDiTis POSTERIOR — Posterior StajiJiy- loma — is a prolongation of the posterior half of the e3-e, accompanied with atrophy of the choroid, caused bj^ the stretching to which it is subjected by the staphyloma. It is usually found in all cases of severe myopia. When the disease is stationary^ the mj^opia remains unchanged, and the patient suflfers no inconvenience. If, however, it is progressive, the myopia increases, and the acuteness of vision frequently diminishes. The patient also often complains of black muscte, sometimes like falling soot, and of occasional flashes of light, with other symptoms SUPPUllATIVE CHOROIDITIS. 221 of retinal irritation. If the eye be now examined with the ophthahnoscope, there will probably be found changes in the choroid, indicative of progressive atrophy. The white crescent on the apparent inner side of the optic nerve will have grown larger, and its outline irregular ; and scattered here and there will be white atrophic patches. Occasionally one or more of these spots will coalesce with the myopic arc, so as to greatly enlarge its area. Such ej^es are liable to become glaucomatous ; they are also occasionally subject to detachments of the retina, and to small hemorrhages from the choroidal capillaries. A further account of sclerotico-choroiditis posterior will be found in the article Myopia. Treatment. — Absolute rest to the eyes, and the direc- tions for myopic patients given in the article Myopia, should be strictly carried out. If there are rapidly pro- gressing changes in the choroid, small doses of the liq. hydrarg. perchlorid. (F. 80) may be prescribed. Suppurative Choroiditis — Ophthahnitis — Panoph- thalviitis — is an acute suppurative inflammation involv- ing all the tissues of the eye. It is most frequently in- duced by an injury, such as a penetrating wound, or the lodgement within the globe of a foreign body, or an abra- sion or burn of the cornea. It may also follow cataract or other severe operations on the eye, and occasionally it will come on in patients exhausted by fever or by long- continued bad living. Sympjtoms. — Great vascularit}'^ of the e3'e, with chemo- sis of the conjunctiva, and edematous swelling and red- ness of the lids. The aqueous first becomes serous, then turbid from cor- puscular lymph and pus ; and these sinking to the bot- tom of the anterior chamber, constitute the state known as hypopion. 19* 222 DISEASES OF THE CHOROID. The iris loses its striatiou and brilliancj' from inflam- matory exudation on its surface and into its substance, and the pujiil becomes blocked up with the like materials. The cornea becomes dull and steamy, and pus may be infiltrated between its laminae, a condition recognized as onyx or corneal abscess, or an irregular sloughing ulcer may appear on its surface. Such are the visible changes which are rapidly induced by an attack of ophthalmitis ; but similar mischief is also going on in the deeper parts of the eye. The ciliary processes become infiltrated with lymph and pus, and matted to each other. The vitreous humor grows turbid, and hmph and pus are efl'used within it. The same exudations also take place on the sui'face of the retina, and in some cases be- tween the retina and choroid, and between the choroid and sclerotic, all of which tissues may be covered with morbid deposits, and even separated the one from an- other by them. The pain of ophthalmitis is alwaj's very severe. It is supra-orbital, extending up the side of the head. It is around the orbit and down the side of the nose, and iu the eye itself At first neuralgic in character, sometimes acute, at others dull and aching, but, as the disease ad- vances, hot and throbbing, the pain is usuall}' sutficient to destroy sleep and to produce severe constitutional sj^mptoms. The prognosis of ophthalmitis is very unfavorable. Occasionally, under judicious treatment, combined with other favorable circumstances, the inflammation may sub- side, and a useful, although a somewhat damaged, eye be preserved. Generallj^, however, the activitj^ of the disease continues unabated, and does not expend itself until all the tissues of the eye are involved in one general suppuration. The cornea then gives way, or the pus SUPPURATIVE CHOROIDITIS. 223 makes an exit foi* itself througla the sclerotic between the insertions of two of the recti tendons. Treatment. — The eye shonld be frequently fomented with the fotus belladonnte (F. 8), or with the decoction of poppy-heads. A solution of atropine, gr. 1 ad aquae ^1, should be dropped into the eye twice or three times a day ; but it should be discontinued, as useless, when suppuration has actually set in. The patient should be kept in a darkened room, and all use of the eyes should be prohibited. The bowels should be acted on at the commencement of the attack, and if the patient is rest- less, sleep should be produced, and the pain relieved by opium. In these cases opium is usually of the greatest service. It assuages the pain, tranquillizes the patient, and places him in a more favorable condition for re- covery. Whilst there is hot skin and thirst, salines and diaphoretics should be prescribed ; but these must soon give place to quinine or bark, with the mineral acids. The strength of the patient should be maintained by a liberal strong beef-tea diet, with a moderate allowance of wine or brandy. But if the inflammation goes on, and the cornea becomes ulcerated, or infiltrated with pus; or if there is hypopion, w-ith the eye painfnl and the auterior chamber deepened by the increased secretion of the aque- ous, tapping the anterior chamber with a broad needle, will sometimes afford A^ery considerable relief, and mate- rially benefit the eye. The activity of the disease is fre- quently sensibly diminished after one such operation. It is not, however, a proceeding which should be undertaken rashl}'^, as, when it fails to do good, it often seems to irri- tate the eye and increase the urgency of the symptoms. In some bad cases of ophthalmitis w'hich have been under my observation, I am satisfied that the ultimate destruc- tion of the e3'e has been hastened by an injudicious para- centesis of the cornea. When the operation gives ease. 224 DISEASES OF THE CHOROID. it may be repeated at interA'als of twentj'-four or thirty- six lioiirs, if the i)aiii and acute s^^mptoms recur; but, if after once tapjjing the anterior chamber, the pain in the eye is increased, it should not again be attempted. If all treatment has failed to arrest the progress of the disease, and suj^puration of the globe has actually set in, I would advise the eye to be excised. The patient will thus be quickl}^ restored to health, and be spared much suffering. In my own practice I have never had any unfavorable s^'mptoms follow the excision of a suppurat- ing eye. Deposits of Bone on the Choroid are frequently found in eyes which have been long lost. The bony matter is on the anterior surface of the choroid, between it and the retina, which is always detached, and usually coarcted. In some cases a mere ossific film is found lying on the choroid, whilst in others there is a thick bony cup, sufficient in size to occupy nearly the entire stump. It seems very probable that the formation of these bony plates is due to an inflammatory exudation of l3'mph on the surface of the choroid, which after a lapse of time be- comes organized and converted into fibrous tissue. This afterwards undergoes a further change ; osseous granules are deposited within it, and it becomes bone, having all the characters, both anatomical and chemical, which dis- tinguish this tissue in other parts of the body. The cup of bone is usually perforated near its centre bj' a small canal, through which passes a band of the atrophied retina back to the optic nerve. Whilst bone is thus being developed in the fundus of the eye, earthy salts, such as the phosphate or carbonate of lime, are frequentl}- at the same time being deposited in the lens, if there is one, and between the laminae of HEMORRHAGE FROM THE CHOROID. 225 the cornea, or, if that has been destroj'ed, in the cica- tricial tissue which has replaced it. In a report of a specimen of ''bone from the inner sur- face of the choroid," by Mr. Hulke, in the Pathological Transactions, vol. viii, page 320, he has given the draw- ings of the microscopical appearances of the sections he examined. He found in them all the elements of true bone — a complete system of vascular canals, with lacunae and canaliculi. In the mere scales of bone which he has since examined, he has told me that he has been unable to detect any vascular canals, but in all he has seen the lacuna? and canaliculi. This is probably simply due to the fact that such delicate films of bone were too thin to admit of vascular canals. Tubercles in the Choroid may be frequently found in patients who are suffering from acute tuberculosis. In the cases which have been recorded they produced no defect of sight. With the ophthalmoscope they may be recognized as " small circular circumscribed spots of a pale rose-color, or grayish-white tint, and vary in size from ^ to 2.5 mm. The}' are chiefly situated in the vicin- ity of the optic disc, but may extend occasionally to a considerable distance from it." * Hemorrhage from the Choroid may occur from in- jury (see next section. Injuries of the Choroid), or it may be occasioned by disease, as in glaucoma, sclerotico- choroiditis posterior, or retinal apoplexy. See the arti- cles on these subjects. It may also be produced by prolonged and excessive strain of the eyes at close work, and especially if during its continuance the head has to be maintained in a stooping position. * Soelberg Wells's Treatise on the Eye, p. 440. 226 DISEASES OF THE CnOROID. The Treotment must depend on the exciting cause of the hemorrhage : see articles Glaucoma, Sclerotico- Choroiditis Posterior, and Retinal Apoplexy. INJURIES OF THE CHOROID. Injuries or the Choroid are usually- followed by im- mediate hemorrhage which always seriously affects, and often completel}^ destroj'S sight. A blow on the e^-e ma}^ cause a rent in the choroid, either with, or without rupture of the external coats ; or the choroid may be lacerated by a penetrating wound through the sclerotic. Hemorrhage at once takes place from the torn choroidal vessels, and ac- cording to the site and severity of the injurA^ the blood may be extravasated : 1. Between the choroid and retina. 2. Between the choroid and sclerotic. 3. Into the vitreous humor. 1. Hemori'hage between the choroid and retina is gene- rally caused by blows on the ej^e, and may occur either with or vnthout rupture of the external coats. The blood is poured out from the anterior surface of the choroid, and a clot is formed between that structure and the retina. When the clot is small, it may be absorbed, and the e3'e ma}^ regain useful vision, but there will alwavs remain a blind spot corresponding with the portion of retina which had been detached. If the hemorrhage is severe, there will be necessarily an extensive separation of the retina, and the ej^e for all useful purposes will be destroyed. 2. Hemorrhage between the choroid and sclerotic^ un- complicated with hemorrhage in any other part of the eye, is most commonl}^ produced by an escape of the lens and a sudden loss of vitreous through a wound in an unhealthy eye ; thus withdrawing unexpectedly the support which the choroid and retina had derived from these structures, HEMORRHAGE FROM THE CHOROID. 227 when, in their entirety, they occupied their normal posi- tion within the globe. In a healthy eye, the lens and a large amount of vitreous humor may be lost through a wound of its external coats, without exerting any very unfavorable influence on the retina or the choroidal vessels ; but in an unsound eye, a similar loss would probably produce hemorrhage between the choroid and sclerotic. From chronic disease, and the repeated increased vascularity of the eye consequent on it, the tonicity of the choroidal vessels is diminished, and their walls, either weakened by recurrent distension or from some deprivation of the nervous influence of the S3'mpathetic filaments which preside over them, become easily, and on the slightest irritation, undulj" dilated. In such e3'es, the loss of the lens, or of a portion of the vitreous, by diminishing the pressure on the choroidal vessels counter to the force of the impulse of the blood within them, will induce a sudden distension and yielding of their coats, which frequently lead to rupture, and hem- orrhage between the choroid and sclerotic. It is this form of hemorrhage which occasionally occurs after an opera- tion for the removal of a cataractous lens from an unsound eye. Indeed it is almost certain to happen if there be an increased or glaucomatous tension of the eye at the time of operating. In such cases, the hemorrhage takes place from the posterior surface of the choroid, detaching some- times partially, but generally completely, the choroid from the sclerotic, and forming a large blood-clot, it pushes in front of it the choroid and retina, aud extrudes more or less of the vitreous from the eye. When hemorrhage between the choroid and sclerotic is occasioned by blows on the eye, the bleeding is seldom confined to the space between the choroid aud retina, but takes place also in other parts of the eye, and blood is 228 DISEASES OF THE CHOROID. often found also on the retina, between it and the choroid, and in the vitreous. 3. Hemorrhage into the vitreous raaj occur from an in- jury of the choroid. If the hemorrhage is severe, the blood frequentl)' bursts through the retina and hyaloid membrane, and extravasates itself into the vitreous body. For a further account of hemorrhage into the vitreous, see the article in the chapter on the Diseases of the YiTREOUS, page 148. The prognosis of choroidal hemorrhage is always un- favorable. It is only when the bleeding has been slight and limited to a small surface, that even a hope can be held out that a certain amount of useful sight will be re- tained. If in such a case the patient progi'esses favor- abh', he will probably recover with some valuable sight, but he will not regain that which was destroyed by the blood-clot : one blind spot in his field of vision will indi- cate the extent of retina which has been detached, and the loss the eye has sustained. When there is extensive cho- roidal hemorrhage, the eye for all visual purposes is lost ; no matter whether the blood is effused into the vitreous, or between the retina and choroid, or the choroid and sclerotic. If the eye does not suppurate (and as a rule it does not do so if the external coats are entire), it grad- ually under treatment subsides into a quiet state, becomes soft, and somewhat smaller than the other. Treatment. — Immediately after the injury a leech or two raa}^ be applied to the temple with the hope of pre- A'enting au}^ undue inflammator}- action ; and a fold of lint or linen, dipped in cold or iced-water, should be placed over the eye, and wetted as often as it becomes dr^^ and hot. Two or three drops of a solution of the sulphate of atropia, gr. 1 ad aqua? 5 1, should be dropped into the eye twice a day. It will exert a sedative influ- ence, and also act beneficially on the pupil if any active TUMORS OF THE CHOROID. 229 inflammation comes on. Complete rest should be given to the sound eye by abstaining from all work, and the exclusion of strong light from the room. There are no special applications or medicines which can be given with the view of favoring absorption of the blood which has been effused. TUMORS OF THE CHOROID. Tumors of the Choroid are of two kinds, the sarcom- atous and the cancerous. In their first appearance, sub- sequent growth, and symptoms, they closely resemble each other ; it is only by a microscopic examination that their true natures can be correctlj^ determined. A small nodide first appears on the choroid, which detaches the portion of retina with which it is in contact, and loosens also that which surrounds it. As it grows it pushes for- wards the retina, displaces the vitreous, and presses the lens and iris towards the cornea. Frequently the globe loses its normal shape, and dark bulgings will be seen in the ciliary region. The cornea grows dull, then ulcerates, and through the opening the tumor crops out ; or else it makes an exit for itself posteriorly, and bursting though the sclerotic it extends itself into the orbit. Having es- caped from within the globe, it seems as if it had acquired new vitality, and grows with an increased vigor. After a time its surface ulcerates and bleeds, and it assumes an appearance which has given to it the name of " fungus hijematodes." The attacks of hemorrhage increase in frequency with the advance of the disease, until the pa- tient at length sinks, worn out with pain and loss of blood. Such is the history of a case which has been allowed to proceed to its termination unchecked by surgical treat- ment, but fortunately these examples are now rare. It should be remembered, that, during the progress of 20 230 DISEASES OF THE CHOROID. growth of an intraocular tumor, an increased tension of the globe frequentl^^ occurs, and that from overlooking the cause of these glaucomatous symptoms, mistakes have occasionally been made b}' treating such cases with iridectomy. Tlie sarcoma of the choroid is a recurrent growth, and in this respect resembles cancer, but it seldom produces secondary deposits in other organs. It grows from the connective tissue of the choroid, and as it fills the globe it does not infiltrate and become incorporated with the other structures of the eye as in true cancer. Examined with the microscope, it has a soft fibrillated matrix, in which are imbedded oval, spindle-shaped, and caudate cells, each containing a nucleus and nucleolus. When the sarcoma is more or less colored with pigment, it is termed melanotic sarcoma. In most cases there is some pigment disposed irregularly throughout the tumor. The Aledullary Cancer — encejyhaloid — medullary sar- coma — are the names which are commonly applied to this disease ; it is also known as the soft and the acute cancer. It is characterized bj'^ its rapid growth and its tendency to fungate as soon as it has burst from its confinement within the globe. It affects the neighboring h'mphatics and produces deposits in the brain, the lungs, the liver, and other viscera. It is very vascular, soft, and pulpy, like brain-matter, and on section it often exhibits many small hemorrhagic spots from divided vessels, which make its resemblance to cerebral substance more striking. Under the microscope, it is found to consist of a stroma of delicate fibres inclosing between its alveoli large nu- cleated corpuscles of various shapes — mostl}' roundish and fusiform. Melanotic cancer is the same disease as the medullary, the only difference being the addition of the black pig- ment which is scattered in varying quantities throughout OPTIC NEURITIS. 231 its structure. I have, ou two or three occasions, seen the identity of the two affections well illustrated by the changes which have occurred in the growth of the tumor. Whilst confined within the globe, the growth in each case was deeply colored with pigment, so as to be in parts ab- solutely black ; but having burst through the sclerotic posteriorly, it grew with an increased rapidity, and the extraocular portion was white. The tumor external to the globe was the same growth and continuance with that which was within the eye ; both were medullarj'^, but the addition of pigment made that within the globe me- lanotic. The prognosis of choroidal tumors is generally unfa- vorable. The best chance is afforded the jjatient when the disease is detected early, and the eye removed before the tumor has attained a large size. It is of the greatest importance that the eye should be excised before the tu- mor has burst through the external coats, as, when the disease has reached this stage, there is the probability that the neighboring tissues have become infected by it. For the detection of choroidal tumors the ophthalmoscope is invaluable, as with it the existence of a morbid growth ma^^ be determined, when the only sj-mptom is a loss of sight in a portion of the field of vision. Treatment. — Excision of the eye. If the tumor has made its wa}^ through the sclerotic, the chloride of zinc paste (F. 7) should be applied to the tissues in the orbit, in the manner recommended in the section Treatment OF Orbital Tumors. DISEASES OP THE OPTIC NERVE. Optic Neuritis — Neuro-retinitis There are two forms of neuritis : In the first, the inflammation is confined to the optic 232 DISEASES OF THE OPTIC NERVE. nerve. It is then the result of disease be3'ond the eye, and may be caused by tumors in the brain or in the orbit, or by an intracranial syphilitic node, or by meningitis, hydrocephalus, or any other affection within the skull which produces pressure on the nerve, or impedes the re- turn of blood through the opthalmic vein to the cavernous sinus. To this form of neuritis the term descending has been applied, because the symptoms descend along the trunk of the optic nerve to the papilla within the eye. In the second form of neuritis the inflammation is not limited to the optic nerve, but it includes also the retina, and may, therefore, be rightly termed neuro-retinitis. It may be induced by syphilis, by derangements of the functions of the uterus, or by fever, or any other ex- hausting disease. 1. Symptoms of descending Optic Neuritis. — During the acute or early stage, there is an increased redness of the optic disc, but this gradually subsides, and it as- sumes a grayish-white color, with a peculiar " woolly " look, " much as if cotton-wool had been carded until all its fibrils radiated outwards from a centre."* The state of the optic papilla presents a characteristic appearance which has been termed the engorged papiUa. It is swollen and prominent, sometimes bulging forward to such an extent as to be easily recognized by direct examination with the ophthalmoscope. The outline of the disc is ir- regular, confused, or lost ; the arteries are small and thready ; the veins large, dark-colored, and often tor- tuous, and portions of the vessels in their course oa' er the papilla are obscured by exudation. Occasionally there arc small hemorrhagic spots on the disc and in the adjacent retina, which is often of a dull and whitish color from * Hutc'hinson on Intliimniation of the Optic Nerve. Koyal London Ophthalmic llospital lieports, vol. v, p. 'J8. OPTIC NEURITIS. 233 inllanimatoiy eftusions, whilst the rest of the retina re- mains perfectly transparent. There is a steady diminu- tion of the acuity of vision, often accompanied with a contraction or partial loss of the visual field. The pupil is rather dilated and sluggish. The patient has no pain in the eye, nor are there any external manifestations to account for the increasing loss of sight. Both e3'es are generally affected, and the disease usually symmetrical ; but one eye may be attacked a little in advance of the other, or the impairment of sight may be greater in one eye than in the other. After a variable time all the l^rominent ophthalmoscopic symptoms of neuritis sub- side ; the morbid etfusions are absorbed, the disc be- comes flattened and of a creamy white, and the arteries are reduced to mere threads, but for a long time the veins continue large and tortuous. With all these changes there is a steady dimiuution of sight, until ultimately it is completely lost or reduced to a mere perception of large objects. A very interesting paper on " Defects of Sight in Diseases of the Nervous System," has been published by Dr. J. Hughlings Jack- son, in the Royal London Ophthalmic Hospital Reports, vol. iv, p. 389, in which he shows the frequency of optic neuritis in diseases of the brain, and to which I would refer the reader. The constitutional symptoms all point to disease within the head, and to an interference with the healthy cere- bral circulation. There is frequently severe headache and giddiness, both of which may be either constant or intermittent, or there may be loss of smell or defect of hearing, or occasional epileptic convulsions, or palsy of one or more of the ocular nerves, or a loss of the proper co-ordinating power over the muscles of the extremities. 2. Symptoms of Neuro-retinitis The optic disc is clouded, its outline is indistinct or lost, and the vessels, 20* 234 DISEASES OF THE OPTIC NERVE. as they pass over its surface, are more or less obscured ; but there is not the venous distension or the engorgemeut of the papilla which characterize the pure neuritis descen- dens. The great point of distinction, however, between neuritis and neuro-retinitis is, that in the one the retina is extensively involved, whilst in the other it is either not at all affected, or only for a short distance immediately surrounding the disc. In neuro-retinitis the whole surface of the retina seems obscured by a diffused haze, which renders all the minute A^essels indistinct, and gives a peculiar and characteristic washed-out appearance to the fundus. There is also an absence of the head symptoms, which were noticed as being generall}^ present in neuritis. In neuro-retinitis the disease is often confined to the one e3'e, whereas, in neuritis descendens, both e^^es are generaUy affected. The i^rognosis of neuritis dependent on cerebral causes is very unfavorable. The disease generally resists all treatment, and ends in atroph}' of the optic nerve and blindness. The prognosis of neuro-retinitis, although uufavoi-able, is yet more hopeful than that of neuritis, and especially if some blood-poisoning, such as syphilis, can be traced as the probable cause of the disease. Treatment. — For neuritia desce)idenst\xe treatment must be guided by the existing s3'mptoms, which generally point to mischief within the head. No special remedies, how- ever, can be advised for their relief, as the causes which produce them are both too numerous and obscure. Large doses of the bromide of potassium will sometimes do good ; or, if there is any syphilitic taint, the iodide of potassium ma}^ be also tried. In neuro-retinitis, care must be taken to ascertain the source of the disease, as it may be due to many causes. When it can be ascribed to syphilis, the mist, potass, iodid. (F. 74) may be given during the day, and pil. Plummer NEURO-RETINITIS. 235 gr. 5 every other night ; or the mist, potassii iodidi cum hydrarg. perchlorid. (F. 78) iLnay be prescribed. If the l)atient is feeble, the unguent, hydrarg. cum belladonna (F. 99) may be rubbed into the temple night and morn- ing, and the mist. quinjE (F. 64) be taken during the day. When the disease is apparently due to suppressed men- struation, every endeavor should be used to restore the uterine functions. In some cases I have had excellent ^sults from the iodide of potassium given in 10 gr. doses twice a day in water. It has then acted as a powerful emmenagogue. I must, however, confess that this medi- cine has occasionally failed to do good, or its administra- tion has been attended with only a partial success. No- tice should be taken whether the ameuorrha^a is due to antemia or congestion. If the former, tonics of quinine and iron, or the mist, ferri perchlorid. cum tinct. ergotoe (F. 12) may be ordered, but at the same time some aloetic pill should be prescribed to insure the regular daily action of the bowels. If the suppression is due to congestion, the bowels should be freely acted on by a brisk purgative. In some cases small doses of podophyllin given every other or third night, do good. During the day, the iodide and bromide of potassium, in a bitter infusion, or the mist, boracis (F. 58) may be given. When the sight is rapidly failing, and there is much pain in the head, I have known the inunction of the unguent, hydrarg., night and morn- ing, so as to get the patient quickly under its influence, productive of great good. As soon as the gums are spongy, the frequency of the rubbing in must be dimin- ished, but a slight mercurial action should be kept up for two or three weeks. In cases of neuro-retinitis dependent on or associated with great debility, such as after fever, or diphtheria, or from over-lactation, the mineral acids, with cinchona, or some of the preparations of iron, are most likely to do 236 DISEASES OF THE OPTIC NERVE. good. A slight mercurial counter-irritation may be also kei^t up on the temple of the affected eye, b}' rubbing in every night, a little of the unguent, hj-drarg. biniodid. (F. 105); or by applying small blisters about the size of a shilling, from time to time, and afterwards dressing the vesicated surfaces with the unguent, h^'drarg. Atrophy of the Optic Xerve — white atrophy — may be caused by disease of the brain or medulla oblongata or it ma}' be the unfortunate termination of some deep- seated inflammation of the eye. Atrophy of the optic nerve may therefore be considered under two headings : 1. That which proceeds from disease beyond the eye. 2. That which arises from disease icifhin the e3-e. 1. Atrophy of the Optic Nerve from Disease beyond the Eye. — This form is mostly occasioned b}^ cerebral or cere- bro-spinal disease, or by tumors within the orbit. Neu- ritis of both eyes ma}' be thus induced, and atrophj^ of the optic nerves may follow as a consequence. Atrophy ma}', however, come on without neuritis, dependent, no doubt, upon cerebral causes, but which are often too ob- scure to be diagnosed. It is to atrophy of the nerve, arising from disease beyond the eye, that the term "white atrophy" is properly applied. In the other forms of atrophy the papilla is also grayish-white or white, and especially in their most adAanced stages ; but the charac- teristic signs of white atrophy of the optic nerve are best found in cases arising from cerebral disease. See article Amaurosis, page 238. Ophthalmoscopic Apjpearances. — When the disease is fully advanced, the optic disc looks large, flat, and of a bluish or pearly whiteness. The retinal vessels are gen- erally small ; the arteries often appear as mere threads. 1% ATROPHY OF THE OPTIC NERVE. 237 but in some cases, and especially in those which proceed from neuritis, the veins are large and distended. The small bloodvessels, which are usualh' seen on the disc, have shrunken from view, and the surface of the nerve is blanched and bloodless. There is frequently an excava- tion of the optic nerve, not from any increased tension of the eye, but from a shrinking from atroph}^ of the ner- vous elements, and a falling in of the central portion of the papilla. The peculiarities of this '■''atrophic cup^^ are, that it is a shallow excavation, shelving from the margin towards the centre of the nerve, quite different from the abrupt edges of the glaucomatous cup. The disc presents the peculiar bluish or milk}' whiteness of atrophy, its ves- sels are small, and there is little or no displacement of them as they pass from the margin of the papilla on to the retina. For a description of the glaucomatous and the physiological excavations of the optic nerve, see arti- cle Glaucoma, page 132. 2. Atrophy of the Optic Nerve from Disease icithin the Eye ma}' be caiised by chronic affections of the choroid or retina, by glaucoma, by acute inflammation of the eye, or by an injury producing extensive intraocular hemor- rhage. As the original disease si bsides, the cloudiness of the inflamed structures may partially and sometimes completel}^ disappear, but the retina and optic nerve, in- stead of regaining their functions, undergo a slow process of atrophy, and ultimatel}' all sight is extinguished. The ophthalmoscopic appearances are variable, and depend very much on the nature of the affection which has caused the atrophy. The optic papilla is ansiemic, and of a cloudy or grayish-white, but it has not generall}' the brilliant tendinous whiteness of white atrophy; its outline is often indistinct or irregular, and its vessels are small and shrunken. In some cases the optic disc looks absolutely smaller than normal, and this is especially so if the eye 238 DISEASES OF THE OPTIC NERVE. Of is soft and somewhat shrunken. A cloudy film often pervades the whole fundus, and blurs the appearance of the structures behind it. Associated with this con- dition of the eye, there are frequently to be seen patches of atro})hied choroid with irregular deposits of pigment, and occasionally also a partial detachment of the retina. The Prognosis and Treatment. — The prognosis of at- rophy of the optic nerve is very unfavorable. The only hope is, that if there is any sight remaining, it may be still retained. Our first eftbrt must be to ascertain the cause of the atrophy, and then, by appropriate remedies, to arrest the progress of the disease. The treatment of the various att'ections which may cause atrophy of the ret- ina and optic nerve will be found under their respective headings. Atrophy of the Optic Nerve from Tobacco. — The theory that tobacco, in excess, will produce a peculiar form of white atroi)hy of the optic nerve, has received the sanction of the late Dr. Mackenzie, and of Messrs. Critchett, Wordsworth, Hutchinson, and others. My own experience at the Ophthalmic Hospital, however, leads me to dissent from this doctrine, as I do not remem- ber ever ha^ang seen a case in which the loss of sight could be fairly attributed to tobacco only. There was always, in addition to the immoderate smoking, some other excess, such as intemperance, dissipation, or an undue mental strain with loss of rest. AMAUROSIS AND AMBLYOPIA. Amaurosis. — It is best to restrict this term to those cases of impaired vision and blindness which are due to cerebral or cerebro-spinal causes. Before the discoverj^ of the ophthalmoscope, amaurosis was the generic name AMAUROSIS. 289 of a group of obscure diseases originating either witliin or beyond the eye, and characterized by a gradual failure of sight usually terminating in blindness. With increased facility for diagnosis, most of these affections have now been traced to their right source, and have received their own proper name and place in the list of ophthalmic dis- eases. There still, however, remain a large number of cases, marked by a progressive diminution of sight, de- pendent on changes in the brain or spinal cord, the exact nature of which we are unable to estimate during life, and which from a want of a more precise knowledge may be conveniently classed under the heading of amaurosis. Although the cause of the blindness is at a distance from the eye, yet secondarj^ changes soon take place in the optic papilla which enable the disease to be recognized by the oj^hthalmoscope, and its probable progress foretold. For many useful suggestions in the diagnosis and prog- nosis of amaurotic affections, I am indebted to the valu- able paper on "Amblyopia and Amaurosis," by Yon Graefe.* In the examination of patients suspected to be suffer- ing from amaurosis, we should ascertain, 1. The histor}' of the case. 2. The state of the field, and the acuteness of vision. 3. The condition of the optic papilla, 1. The history of the case always affords important in- formation both as to the diagnosis and prognosis of the disease. By it we determine whether the loss of sight was sudden or gradual; whether it was preceded by head symptoms, or by functional disturbances of other organs, as the kidneys, the liver, or the uterus ; or whether there * TransUited by Mr. J. Zachariah Laurence, from Zehender's Klin. Monatsbl. fiir Aiigenheilkunde, 1865, p. 129. Ophtlialmic Keview, No. 7, p. 232. 240 DISEASES OF THE OPTIC NERVE. had been any previous constitutional disease, such as gout, rheumatism, or syphilis. The duration of the impairment of sight is also an im- portant element in forming a prognosis ; thus, if the de- fective vision has been for some months stationary, and all evidences of the disease to which it was apparently due have passed away, a favoralile opinion would be given ; whereas, if the loss of sight is recent, and there are per- sistent head symptoms, we should conclude that the amaurosis is progressive, and will probably terminate in blindness. 2. The State of the Field and the Acuteness of Vision. — The condition of the visual field should be carefully tested by one of the methods described at page 252, so that any imperfection either as regards its periphery or its con- tinuity of surface raa,y be accurately noted, as, according to Von Graefe, the state of the field forms a good basis on which to ground a prognosis. In all cases of amau- rosis, the acuteness of central sight should be ascertained and compared witli the defects and extent of the field of vision. The following variations may be noticed. a. With diminished acuity of central vision, the field may be entire in its periphery and continuous throughout its area, whilst the visual power is reduced in all direc- tions. Such cases are usually stationarj^, and so far a hopeful prognosis may be given. /5. With diminished acuity of central vision, the field may be contracted in one or more directions, or broken b}^ blind patches (scotomata), whilst the visual power throughout the rest of its extent is greatly lowered. With these sj'mptoms the disease maj' be considered progres- sive, and the prognosis is blindness. y. There ma}' be complete loss of central vision, but with ^ varying coniiition of the rest of the field. If in such cases the periphery and continuit^^ of the field are AMAUROSIS. 241 good, there is reason to hope that the disease ma}^ be statioiiaiy, although there is but a slight prospect of re- covering the central vision which has been lost. The prognosis is therefore favorable, as the probability is that the patient will not go blind. If, however, in addition to the central scotoma, there are other blind patches in the field, or the periphery is much contracted, so that the eccentric vision is greatly reduced, then the prognosis is most unfavorable, and blindness may be predicated. It must, however, be remembered that the prognosis of this form of central amaurosis does not appl^' to a similar state of blindness which may be produced by retinal hemor- rhage, or some other disease within the eye, the seat of which can be accurately determined by the ophthalmo- scope. 8. There may be hemiopia or complete loss of half the field of vision, in many cases distinctly marked as if by a vertical line, on one side of which all is clear, whilst on the other all is dark. There are tico forms of hemiopia to be noticed, the fwst called equilateral^ from the corre- sponding halves of the two retinae being aflTected: thus the outer half in one ej'e, and the inner half in the other, may be jointly paralyzed, or the reverse. In the second form, which is extremely rare, the inner halves of the retinae of the two eyes are blind, but the hemiopia is more diffuse, and the limitation is seldom abruptly' marked as in the former. To understand the distinction between these two classes of hemiopia, it is necessary to refer briefly to the anatomy of the optic tract, commissure, and nerve. The central fibres of each optic tract decussate in the commis- sure, and are connected with the optic nerve of the oppo- site side, and supplj- the inner halves of the retinae; whilst the outer fibres of each tract go to the optic nerve of the same side, and supply the outer halves of the retinte. Each e3^e thus receives nerve-fibres from both optic tracts, 21 242 DISEASES OF THE OPTIC NERVE. the o?//t'r luilf of the retina being i:)rovi(lcd with lihunents from its own tract, whilst the inner half is furnished from the one of the opposite side. Hence it is, that a clot of blood, or a tumor pressing on the optic tract only of one side, say the right, will produce hemiopia of the outer half of the right eye, and the inner half of the left. If, howcA'er, the commissure is the part affected, there will be hemiopia of the inner halves of both e3'es. In testing the field of vision, the student must not forget that the right half of the field corresponds to the left half of the retina, and vice ve7'm. The prognosis of hemiopia must depend very much on the cause which has produced it. If the half blindness originated from the pressure of some syphilitic effusion on the optic tract, the sight may be regained ; or if it be from the presence of a blood-clot, there is reason to hope that even if the vision should not be restored, the defect may remain stationary ; but if a cerebral tumor be sus- pected, the prognosis is most unfavorable. 3. The condition of the ojDtic pa2:iilla in cases of ad- vanced amaurosis is that of white atrophy, as described at page 236. The symptoms which are associated with amaurosis are very variable. In one class of cases there is no pain in the eye or head, and no constitutional disturbance, the only symptom being a gradual fading awa}' of sight. In another class, the blindness is preceded by acute head symptoms, which may last for several days or longer, and then either cease altogether, or greatly diminish. With the cessation or diminution of the pain in the head, the first indications of failing sight are noticed. The patient may regain his health and the full enjoyment of all his mental and physical powers, but his sight steadily fades until he is in absolute darkness. The loss of vision in these cases is no doubt due to some or<>anic chanaes in AMAUROSIS. 243 the brain, produced during the acute inflammatory attack, when the pain in the head was severe. The cause was transitory, but its effects are permanent. In a third class, the pain in the head is continuous, the patient is never free from suffering. Intense headache is the first symptom of the disease, and it precedes the loss of sight. Although at times its severitj'- is lessened, it is never absent. I have had such patients tell me that they would not mind being blind, if they could onlj^ be free from pain. These are the most distressing of the amaurotic cases; we can do nothing for the absolute blind- ness, and but little for the constant pain, as the prepara- tions of ojjium are seldom tolerated. Amaurosis maybe associated with epileps}^, hemiplegia, and locomotor ataxy. It nia}^ also occur with paraplegia: Dr. Hughlings Jackson says, " Dr. Brown-Sequard has frequently drawn my attention to cases of paraplegia in which amaurosis has also existed, without any other symptoms to suggest disease within the cranium." . . . " The blindness he believes is the result of eccentric ii'ri- tation. Dr. Wilks also has observed several such cases."* State of the Pupil. — In the early sj-mptoms of amau- rosis dependent on brain disease, the pupil is rather di- lated and sluggish; but in the later stages it is widely expanded and fixed, giving to the eyes the peculiar vacant stare which is so characteristic of blindness from cerebral disease. When, however, the amaurosis is due to some afl[ection of the spinal cord, the pupil is frequently con- tracted. See Myosis, page 108. The Causes of Amaurosis may be chiefly classed under the following headings : 1. From Disease of the Cerebrum — Amaurosis usually * On Defects of Sight in Brain Disease. Royal London Opli- thalmic Hospital Reports, vol. iv, p. 17. 244 DISEASES OF THE OPTIC NERVE. affects both ej-es ; they ma}^ be attacked simultaneously, or the blindness may be more advanced in one than the other, but as a rule both are ultimately involved. This can be reasonably anticipated b}^ remembering how in- timately the two optic nerves are associated within the brain by commissural fibres. Dr. Hughlings Jackson remarks : " The kind of amaurosis which we most fre- quently find with disease of the central nervous system is, in my experience, invariably double, although one eye may suffer before the other. I do not say that blindness of one eye does not occur loith other syiivptoms of disease of the nervous system, but that it does not occur from disease of the brain-mass."* Tumors of the brain, cere- bral hemorrhage, softening of the brain, hydrocephalus, meningitis, sj'philitic deposits, and embolism, may all be productive of amaurosis. 2. From Disease of the CerebeUum. — In some remarks which Dr. Hughlings Jackson kindly gave me on amau- rosis from this cause, he says it has been lon^ known that blindness may coexist with disease of the cei'ebel- lum, but it is by no means clear that the blindness de- pends on the want of that part of the cerebellum which the disease destroys. For, as the loss of sight occurs only when the disease is "coarse," such as from tumors, blood-clot, &c., he believes that it is induced b}^ the irri- tation of the foreign body 13'ing in the brain, and not from the destruction of any centre connected with sight. As a consequence of this irritation, the optic nerves be- come inflamed, and the ultimate loss of sight is due to this cause. 3. From Disease of the Sjnnal Cord. — Amaurosis may occur with paraplegia, and it is frequently met with in lo- * On Defects of Sight in Diseases of the Nervous Sj'stem. Koyal London Ophthalmic Hospital Reports, vol. iv, p. 390. AMAUROSIS. 245 coinotor ataxy, and especially Avhen the disease is in an advanced stage. The blindness is usually confined to one eye. Dr. Trousseau* says " both ej'es may be affected, although this rarely happens." The pupil in spinal amau- rosis is frequently contracted, and this is generally the case when the part of the cord affected is in the cervical region. 4. From Uterine Derangements. — A verj^ acute form of amaurosis, which will run its course to blindness in a few days or weeks, is occasionally produced by a sudden sup- pression of the menses. It is usually accompanied by intense headache, with vomiting or a feeling of nausea. In one case which I published, f so rapid was the loss of sight, that, in fifteen days from the first symptoms, tlie patient retained but little more than a mere perception of light with either eye. Examined with the ophthalmo- scope, the retinal circulation was seen to be interrupted ; the return flow of blood was impeded. Although the symptoms were those of pressure on some part of the cerebrum, yet, whether the pressure was caused by dis- tension of the vessels, or by an effusion of blood, lymph, or serum, could only be conjectured. Under the influ- ence of 10 gr. doses of the iodide of potassium, the func- tions of tlie uterus were restored at the next monthlj' pe- riod, and the patient began gradually to recover her sight. In three months she was able, with one eye, to read No. 1, and, Avith the other, No. 10 of Jaeger's test types. The report concludes by stating that the im- provement was still progressing. Amenorrhoea, or ir- regular and scanty menstruation, may also cause amauro- sis ; but the symptoms are more chronic than when in- * Trousseau's Clinicjil Medicine, translated by the Sydenham Society, vol. i, p. 156. f Medical Times and Gazette, August 1, 18G3. 21* 246 DISEASES OF THE OPTIC NERVE. duced by an acute suppression. (See Treatment of Neuro-Retinitis, page 234.) In some obscure manner amaurosis is occasionally con- nected with pregnancy. A remarkable instance of this form of blindness came under my care at the Ophthalmic Hospital, and will be found related in our Reports.* The amaurosis was recurrent; it commenced during the gesta- tion of the eighth child, and recurred in each succeeding pregnancy. After the birth of her eighth child, the pa- tient regained sufficient sight to read No. 10 of Jaeger, and to do needlework; but, after the ninth, her recover}' was less complete, and, in the sixth month of her tenth pregnancy, she had become blind with one e3'e, and could only count fingers with the other. 5. From loss of Blood. — Amaurosis may occur from a large and rapid loss of blood. I have known it come on suddenly from extensive flooding during parturition, and the blindness has been permanent. Cases haA^e also been reported, in which it has followed vomiting of blood. The loss of sight may be immediate, or it may be gradual. 6. From Reflex Irritation. — Amaurosis maj' be induced from injur}' or disease involving branches of the fifth nerve, at a distance from the eye. Several instances have been quoted by Mr. Hutchinson, f which illustrate, as he saj's, "more or less directly the influence of the sensitive nerves of the face upon the functions or nutrition of the eyeball." In some cases the blindness is i:)receded by intense neuralgia, whilst in others there has been a loss of sensibility on one side of the face. A very interesting case of amaurosis of one eye, consequent on acute abscess of the antrum, produced b}' a carious tooth, has been re- * lioyal London Ophtliahnic Hospital Reports, vol. iv, p. 65. t Ibid. p. 120. AMBLYOPIA. 247 corded by Mr. James Salter.* The loss of sight was permanent. 3Ionocular amaurosis may arise from any cause which induces pressure on the optic nerve of one eye onl}^, such as a tumor or some syphilitic exudation, either just within, or immediately external to the orbit ; or it may be pro- duced by embolism, or bj^ disease of the spinal cord. For the treatment of amaurosis, no definite course can be laid down; the blindness is secondary to so many dis- eases. The cause of the defective sight must be sought for by a careful examination into the history and the ac- companj'ing symptoms. The most hopeful cases are those which are acute and dependent on some sudden arrest of the function of one of the internal organs, or upon pre- vious sj'philitic disease, and where sufficient time has not elapsed for any organic changes to have taken place either from the pressure of inflammatory exudations, or from atrophy. Amblyopia {amSkuq, dull, a>, the eye) has the same signification as amaurosis (a/jLuupow, to render obscure), the former meaning dull vision, the latter obscure. These synonymous terms have created great confusion, as the}"" have not only been applied indifterentl}', but lately they have been used in combination ; thus, a form of blindness has been described under the title " Amaurotic Ambly- opia." It would be well to restrict the name Amblyopia to those impairments of sight which are apparently due to imperfect perception from defective innervation, or to a loss of the nervous sensibility of one e^^e from disuse. In this sense the word has been applied by man}- to de- note the dull sight which is so frequently found in one eye in cases of strabismus, wheie no structural change * Modico-Cbirurgiciil Transactions, vol. xlv. 248 DISEASES OF THE OPTIC NERVE. can be detected by the ophthalmoscope to account for the loss of power. The term amblyopia may be also rightly used to designate the dimmed vision brought on either by the retina being over-wrought, or by its being rendered dull and unimpressible from drink and de- bauchery. Hemeralopia — Day-sighf, N'ighf-hlind)7ess — is a defect of sight varying in degree from dimness to almost com- plete darkness after the sun has gone down. It is most frequentl}' met with amongst sailors, soldiers, and others who have been much in the tropics. It is due to a blunted sensibilit}^ of the retina, Avhich fails to appreciate fully the impressions which are produced b}' a dim light. Night-blindness is frequently met with in retinal aflec- tious, and especiall}' in retinitis pigmentosa; but the hemeralopia, to which I now refer, is a functional dis- ease, and quite independent of any structural change. Causes. — Although the constant exposure to strong glare exercises a certain influence in producing night- blindness, yet the predisposition to it is given by an im- paired and debilitated state of heath. In this opinion, all wlio have had much experience of this affection seem to be agreed. During the Crimean war, hemeralopia was frequent both amongst the soldiers and sailors, and the evidence of the medical officers coincided in attrib- uting it to either scurvy or debility from exposure and privation.* In a paper b}' Dr. Alexander Bryson, "On Night-blindness in connection with Scurvy, "f he says "that it most unquestionabl}- occurs much more fre- quently in scurvy than is generall}' supposed, but, in consequence of the simultaneous existence of some more * Royal Loiiilun Ophthalmic Hospital Reports, vol. ii, p. 35. t Ibid. 1.. 40. HEMERALOPIA. 249 serious sj-mptoms of a less ambiguous character, it fre- quently passes unnoticed." He then adduces some forcible examples of hemeralopia occurring with scurvy amongst ships' crews, all of which were successfully treated by giving the eyes rest, and curing the scorbutic s3'niptoms by a proper diet of fresh meat and vegetables ; and he concludes by expressing his opinion that the disease is " entirely dependent on an improper or erroneous diet." Hemeralopia has also been attributed to ague, or to some other form of marsh fever. My own experience, however, of the disease is, that it is peculiarly liable to attack patients whose eyes have been long subjected to excessive glare, and whose constitutions have been de- bilitated either from scurvy, ague, or from a diet deficient both in quantity and in qualit3% Examined loitk the Ophthalmoscope^ no change can be detected in the choroid, retina, or optic nerve, to account for the impairment of function. Treatment — If there is any evidence of scurvy, an anti-scorbutic diet should be prescribed, with two or three oranges, or the juice of one or two lemons dailj'. The citrate of potash may be also given twice or three times a day, and if there is ana?niia, each dose may be com- bined with gr. 3 to gr. 5 of the citrate of ammonia and iron. If ague or remittent fever can be traced as a possible cause of the disease, quinine should be freely given, and continued for at least six or eight weeks. The ej'es should be rested, and all exposure to glare or strong lights avoided. I have tried keeping the patient in absolute darkness for a week at a time; but the relief was not suf- ficient to compensate for so long an exclusion from light. Blisters to the temples and behind the ears, are perfectly useless, they only serve to irritate the patient, and do no good. 250 DISEASES OF THE OPTIC NERVE. Snow-blindness is a temporary loss of sight from the dazzling caused by brilliant whiteness. A similar con- dition is produced by the excessive glare of artificial light. I have had patients from the light-ships around the coast, who have complained that, after trimming the lamps at night, they have been for some minutes abso- lutely blinded, and that they have not completely re- covered from the paratyzing effects of the intense glare for some hours. The treatment consists in wearing dark neutral-tint glasses, to diminish the intensity of the light. Color -Blindness — Ghrovio-pseudopsis — Dichromic Vision — is a defect of sight, by which the power of dis- tinguishing colors is either diminished or lost. The ex- periments of Professor Maxwell on the mixture of the colors of the spectrum,* show, "that for the normal eye there are three, and only three, elements of color; and that in the color-blind one of these is absent." He has further proved, that " the elementary sensation which they do not possess, is that which is excited in the normal ej^es by the extreme red end of the spectrum." Hence, he concludes, that " color-blind vision is not onl3^ dichro- mic, but the two elements of color are identical Avith two of the three elements of color as seen b}' the ordinar3" e3'e ; so that it differs from ordinary vision only in not perceiv- ing a particular color, the relation of which, to known colors, ma}^ be numericall}" defined." According to the same authority', a color-blind person sees red and sea- green, as graj^; scarlet and green, as yellow; and rose- color and blue-green, as blue; whilst he distinguishes the shades of red from each other, and also the shades of green from each other. If such a person looks at a red * Philoeophical Transactions, 1860. COLOR-BLINDNESS. 251 and a, groen through a red glass, the green will appear darker, but the red will be nearly as bright as before; and, if he uses a green glass, the red will be darkened, but the green will be little altered. "In this manner," Mr. Maxwell saj'S, " I have made color-blind people dis- tinguish the colors of a Turkey carpet." If, therefore, he suggests, one who is color-blind had the courage to wear a pair of spectacles with one eye red and the other green, he would probably, in course of time, come to form a judgment of red and green things intuitively. He would never acquire our red sensation ; but if he really wished to know what things were red and what green, he would learn to do so as well as if one had been marked with an R, and the other with a G. Professor Pole, in his ac- count of his own color-blindness,* states that his vision was perfectly dichromic. He could distinguish clearly blue and yellow, and the colors produced by their com- bination, but he could not tell red from green. " The appearance of the green division in Chevreul's color circle," he saj^s, " corresponds with that of the red or opposite one." There are three varieties of color-blindness met with in practice : 1. The dichromic vision just described, in which the sensation of red is wanting. 2. The inability to distinguish shades of color. 3. Achromatic vision, or the want of power to recog- nize any color, everything appearing as either white, black, or gray. 1. The dichromic form of color-blindness is usually" a congenital defect, but it may also occasionally be the re- sult of disease. 2. The inability to distinguish shades of color may be * Philosophical Transactions, 1859. 252 DISEASES OF THE OPTIC NERVE. congenital, but it may also be induced from over-use, or the constant strain of the e3'es in looking at colors. I had a patient under my care at the hospital who had been engaged for many years in a color warehouse, and whose chief business consisted in sorting and matching colors. For this duty he had acquired a special reputation amongst his fellows. Gradually, however, his powers began to fail him, and when he applied to the hospital for relief, he could only distinguish whole colors, and had lost the faculty of discriminating shades of tint. 3. Achromatic vision is rare, and is, I believe, gener- ally produced by disease. Dr. J. J. Chisholm, of Charles- ton, S. C. (II. S. A.), has related a case of optic neuritis in which the patient's vision was, for a time, achromatic. " The restoration to chromatic vision showed itself," he says, " in a slowly-growing perception of blue shades. After some months, the shades of yellow could be per- ceived. Reds cannot yet be detected. All shades of red appear brown."* Dr. Argyll Robertson has also published a case of spinal disease, in which myosis and color-blindness ex- isted. The patient lost all perception of colors, although previous to his illness he used to distinguish them readily.f To Ascertain the Perfection of the Field of "Vision, the patient should be placed about one and a half feet in front of the surgeon, and having closed his sound eye with his hand, he should be told to look steadily with the affected one at the nose or the eye of the exam- iner. Whilst the eye is thus fixed, the surgeon should * lloyal London Oplithahiiic Hospital lleports, vol. vi, p. 214. f Eye Symptoms in Spinal Disease. Oliver and Bo3'd, Edin- burgh, 1869. THE OPHTHALMOSCOPE. 253 keep one or both of his hands moving gentl}^ along the line of the circumference of an imaginary circle which about corresponds with the normal field of vision, care- fully noting those points at which the patient says the hand becomes either indistinct or lost. If the patient should be unable to distinguish the movements of the hand at one and a half feet, it may be approximated to the eye, and a smaller circle be described ; the parts at which the sight is the most defective or wanting being still accurately observed. To ma]^ out the field of vision ^ the patient should be directed to stand in front of a black diagram-board, placed at twelve inches distance from him. Covering with his hand the eye w-hich is not under examination, he should fix the other on a small white cross which has been drawn in the centre of the board and on a level with his eyes. Whilst his eye is thus fixed b}^ steadily look- ing on the cross, a small white disc at the end of a piece of wire is to be moved in different directions over the board, and at whatever spot it is clearly seen, a -f is to be made; when only dimly recognized, a — ; and when not visible, an 0. Each series of symbols are now to be connected with lines, and a map will be thus drawn which w'ill fairly represent the patient's field of vision. To facilitate the copying and reduction of such a dia- gram, the board should be ruled in three-inch squares, when the drawing can be easily transferred to properly ruled paper. THE OPHTHALMOSCOPE. Ophthalmoscopes are divided into two classes : 1. The homocentric, with the mirror concave. 2. The heferocentric, with the mirror plane or convex, to the side of which is attached a movable arm support- ing a biconvex lens. 22 254 THE OPHTHALMOSCOPE. Tlie mirrors may be made of silvered glass or of pol- ished metal ; the latter is preferred, as the illumination is less intense than from the former, and is yet suflicient for all ophthalmoscopic purposes. There are jwi-table, fixed, and hinoculai- ophthalmo- scopes. The Portable Monocular Ophthalmoscopes are chiefly used, and of these the most eflicient are Lieb- reich's, Coccius's, and Zehender's. Liebreich's Ophthalmoscope (Fig. 25) consists of a polished concave metal mirror one and a quarter inch in diameter, and of about eight inches focal length, with a sight-hole about one line in diameter in the centre. This is cased in a rim of metal with a bact-piece perforated to correspond with the aperture in the mirror. At the lower and central part of the rim a handle is fixed, and at the side, on a level with the sight-hole, there is attached a jointed arm which supports a clip for an ocular lens, to be placed, when required, at the back of the mirror. This lens ma}^ be either concave or convex, according to the requirements of the person who uses the ophthalmo- scope. Coccius's Ophthalmoscope (Fig. 20) consists of a ^:>/o?/p metal mirror, set in a metal frame, which is furnished with a handle and clip for an ocular lens, as in Liebreich's ophthalmoscope. It has, however, in addition, a jointed arm at the top of the stem, with a clip for a large bicon- vex lens of about five inches focal length, which is placed, when the instrument is used, at a certain angle with the mirror, on which it collects the rays of light from the lamp. The following is Mr. Soelberg Wells's account of the mode of using Coccius's ophthalmoscope : " The collect- zeiiender's ophthalmoscope. 255 ing lens is to be tiivned towards the flame, which should be somewhat more than twice the distance of the focal length of the lens from the observer. The mirror is then to be set somewhat slanting to the lens and the eye of the Fig. 2.J.* patient. If the mirror is properly adjusted for the lens and the flame, we shall obtain, if we throw the image of the flame upon the palm of our hand or the cheek of the patient, a bright circle of light, with a small dark central spot, which corresponds to the opening in the speculum. The dark spot is then to be thrown into the pupil of the eye under examination, the surgeon placing the mirror close to his own e3^e, and looking through the aperture into the patient's eye, which should afford a bright lu- minous reflex. "f For the indirect examination a bicon- vex lens of from two to three inches focus will be required to be held in front of the eye, as with other ophthalmo- scopes. Zeiiender's Ophthalmoscope consists of a convex metal mirror, set in a metal frame, and furnished with * Copied from HulUe on the Ophthalmoscope, f "VVells's Treatise on Diseases of tiie -Eye, p. 292. 256 THE OPHTHALMOSCOPE. clips for an ocular niul a lateral biconvex lens, in the same manner as Coccins's. Of these three instrnments I prefer Liebreich's : the student can learn how to use it with more rapidity than either of the other ophthalmoscopes, and it answers well all the practical purposes for which it is required. Coc- cius's instrument is considered by many to be superior to Liebreich's, and its claims have been speciallj^ advocated by those who have long worked with it. The advantages which it has over Liebreich's, are, that hy means of the collecting lens the focal length of the mirror can be changed, and the degree of illumination increased or di- minished ; there is less reflection from the cornea ; and it is more efficient for direct examination. The merit which is claimed for Zehender's ophthalmoscope, is that it is the best for direct examination ; but for the inverted image it is inferior to the other two. A very portable and convenient ophthalmoscope is made by Messrs. Weiss. It consists of a very slightly concave silvered glass mirror, inclosed in a pocket-case with a two, or two and a half inch focus lens. The mirror is framed and backed with horn ; and the lens is encircled with a frame of suflicient dei)th to protect its central prominent part from being scratched when it is laid on the table. Fixed Ophthalmoscopes are too large and heavy to be of much sei'vice except for demonstration, or for artistic purposes. When once adjusted to the patient's eye, a number of students can look through the instrument in succession ; or a sketch of the fundus can be readily taken, as the eye is kept under observation whilst both hands of the surueon are free for drawing. The best of the fixed BINOCULAR OPHTHALMOSCOPES. 257 Ophthalmoscopes is Liebreich's, or a modification of it by Messrs. Smith and Beck. Binocular Ophthalmoscopes. — The adA'antages of using both eyes in making ophthalmoscopic examinations are A'ery great. With a binocular instrument a stereo- scopic view is gained of the fundus of the eye. Some parts are seen in relief, whilst others stand out in a manner which it is impossible even for the most practised observer to obtain with a monocular ophthalmoscope. In using a binocular instrument, the lamp should be placed behind and above the head of the patient. It is of course es- sential that the observer should himself possess binocular vision, and that the ophthalmoscope should be so adjusted as to enable him to look through both sight-holes and see a single object. The two best binocular instruments are, one by Dr. Giraud-Teulon, the inventor of the first bin- ocular ophthalmoscope, made by M. Xachetof Paris ; and the other b}' Messrs. Laurence and Heisch, made by Messrs. Murray and Heath of London. How TO WORK WITH THE OPHTHALMOSCOPE, — To Com- pletely explore the whole fundus of the eye and to ascer- tain the state of the lens and the vitreous, the pupil should be widely dilated with atropine ; but where the desired in- formation can be obtained witliout such a thorough in- vestigation, it will be unnecessary and undesirable to sub- mit the patient to this annoyance. The examination must be conducted in a darkened room, and with a lamp pro- vided with a bright steady flame. The most convenient light is a small gas lamp at the end of a movable arm, which can be turned in all directions and raised or lowered as may be required. The burner should be a porcelain argand, protected with a piece of wire gauze below to regulate the draught. The chimney should be a tube of 22^ 258 THE OPHTHALMOSCOPE. plain white glass, of a uniform diameter throughout its length. When gas cannot be obtained, a moderator or a reading lamp without the shade will answer almost as well. With all ophthalmoscopes, except the binocular, it will be found most convenient to place the lamp on the left-hand side of the patient, and with the flame on a level with, and a little behind the e3'es to be examined. To use a monocular hand ophthalmoscope — say Lieb- reich's — the observer sits or stands in front of the pa- tient, so that his ej^es are a little above the level of those under examination, and at about eighteen or twentj^ inches distance from them. He then with one baud holds the ophthalmoscopic mirror close to his owai e^^e, and at such an angle that he catches upon its polished surface the rays of light from the lamp, and reflects them into the eye of the patient. Looking through the sight-hole of the mirror into the eye thus illumined, he jiroceeds to make either an indirect or a direct examination of its fundus. For the indirect method he holds in his other hand, be- tween his forefinger and thumb, an object-glass of two or two and a half inch focus in front of the patient's eye, and at from one and a half to two inches distance from it, steadying the lens b}' resting his fingers on the forehead, as represented in the woodcut (Fig. 27). B^- moving his own head a little backwards or forwards as ma3' be re- quired, he soon succeeds in bringing into view a clearl3' marked inverted aerial image of the fundus of the eye he is examining. The size of the inverted image ma^' be increased bj^ placing an ocular convex lens of about ten inch focus in the clip behind the sight-hole of the mirror, and using at the same time an object-glass of from three to four inch focus. With this combination it will be necessary to ap- proach the head nearer to the patient's eye. In order to INDIRECT METHOD. 259 obtain a view of the various parts of the fundus in suc- cession, it is requisite to direct the patient to turn his eye in different directions, and for this purpose it is conve- nient to have fixed objects to Avhich to call his attention. Fig. 27. To see the optic nerve, the patient should be told to look at the tip of the observer's ear most distant from him ; thus if the right e^'e is under examination, he should look at the right ear of the surgeon. By this means the globe is slightly inverted, and the optic papilla is brought uuder observation. To examine the ^^ellow spot, the patient should be di- rected to look straight before him at the eye of the sur- geon, or through the sight-hole of the mirror. For the direct method, or the examination of the erect image, no object-glass will be required. The best oph- thalmoscope for this purpose is Zehender's or Coccius', either of which is to be preferred to Liebreich's. The surgeon will have to approximate the mirror to within one and a half or two inches of the eye under examina- tion. If either the surgeon or patient is myopic, a con- 260 ANOMALIES OF REFRACTION. cave ocular lens should be placed behind the sight-hole of the mirror. When it is desirable to fully explore the fundus, the pupil should be dilated with atropine. Lateral or Focal Illumination of the eye is an ex- tremely useful means for examining the surface of the cornea or the iris, and for ascertaining the state of the lens in cases of suspected cataract. The pupil having been first widely dilated with atropine, the patient is seated on a chair, and the lamp is so placed that its flame is on a level with, and a little in front of his eye, and at about two feet distance from it. A biconvex lens of two or two and a half inch focus, is then held so as to con- centrate a cone of light upon the e^'e, when, by a slight movement of the glass in ditferent directions, each part of the structure under examination is in turn illumined, until the whole of it has been satisfactorily explored. A second lens ma}' be held in front of the eye, to be used as a magnifier, if required. For a detailed account of the theory, and use of the ophthalmoscope, I must refer the reader to the excellent treatises b}' Messrs. Hulke and Henr}' Wilson, and to Mr. Carter's translation of Zander's work, with notes and ad- ditions by the translator. CHAPTER YI. ANOMALIES OF REFRACTION AND DISEASES OF ACCOMMO- DATION. Anomalies of Refraction and Diseases op Accom- modation. — The power which the eye possesses of bring- ing to a focus on the retina rays of different directions, is ANOMALIES OF REFRACTION. 2(51 termed accommodation. By this power the eye is able to distinguish clearly objects at various distances. The fact that we are unable to see distinctly at the same moment near and distant objects, is conclusive evidence that there must be a focussing i)o\ver within the eye. Accommoda- tion is a muscular although an unconscious effort, and must not be confounded with refraction^ which is a fac- ulty possessed by all eyes, of bringing certain ra^'s to a focus on the retina uuthoiit any accommodative effort, and is dependent on the shape of the globe and on the media within it. The experiments of Helmholtz with his oph- thalmometer proved conclusively that during accommo- dation for near objects, the lens, and especiall}' its ante- rior surface, is rendered more convex and approaches the cornea; and that the pupil contracts and advances whilst the periphery of the iris recedes. The agent through which the change in the lens is effected, is the ciliary muscle, but the mechanism by which this is accomplished has not yet been satisfactoril}^ demonstrated. The con- traction of the pupil during accommodation, Donders con- siders as probably only an associated movement. That the iris has no share in the process of accommodation was proved in a case under the care of Yon Graefe,* where he removed the whole of the iris, and afterwards ascertained b}' a careful examination, that the eye still possessed a range of accommodation which corresponded to the age of the patient. In a normal eye distant objects are seen without any effort of the accommodative power ; it is only for near ob- jects that there is active accommodation. This is proved by mydriatics — drugs which dilate the pupil and paralj^ze the accommodation. If we drop into the eye one or two drops of a solution of atropiaj sulphat. gr. 4, ad aqutii 3 1, * Arcliiv liir Ophtliahnologie, vii, 2. 262 DISEASES OF ACCOMMODATION. we not oul}' dilate the pupil, but in about forty miuutes we paralyze the accommodative power, that is, we relax it to its utmost. We then find that the patient is unable to define clearly near objects, but distant vision is unim- paired. An e3-e is said to be normally constructed or emme- tropic, when it is able by virtue of its own refractive power, and without any effort of the accommodation, to unite to a focus on the retina parallel or distant rays. There are two ways in which the refraction may differ from that of the emmetropic eye. The axis of vision may be too long, so that parallel incident raj's are brought to a focus in front of the retina, as in myopia ; or the axis of vision may be too short, as in hypermetropia, where parallel rays are united behind the retina. We have now to consider in succession the following conditions of the eye, and the treatment Avhich is suited to each : Myopia, Astigmatism, Hypermetropia, Presb3-opia. The three first-named are anomalies of refraction, as the impairment of sight they produce maj^ be altogether independent of any faulty state of the accommodation. Presbyopia, however, must be regarded as a normal state occurring in an emmetropic eye as a natural result of in- creasing years, and without any necessary defect of its power of refraction. MYOPIA. Myopia, or Short Sight, is usually dependent on a too great length in the antero-posterior diameter of the globe, so that the rays of light coming from a distance are brought to a focus in front of the retina, upon which circles of diffusion are formed in the place of a clearly-defined image, and the object, therefore, appears confused and MYOPIA. 263 indistinct. Myopia ma}^, however, be due to a too great refractive power in the eye, without any abnormal increase in the length of the globe, as in those exceptional cases of spasm of the ciliary muscle, in which an undue ro- tundity is given to the lens. Nearly all the cases of my- opia are dependent on the first-mentioned cause, and the extension of the antero-posterior diameter of the globe will be found to arise from a prolongation of the posterior half of the eye. It is seldom that there is any change in the diameter in the anterior or corneal half. This increase in the length of the globe is usually accompa- nied by a thinning of the sclerotic, and a partial atrophy of the choroid, and is recognized by the names Posterior Htaphyloma., or Sclerotico-choroiditis j^osterior. It is usu- ally found in all cases of severe myopia. Graefe saj^s that it is always present when the myopia exceeds ^, that is, when a stronger concave-glass than one of five-inch nega- tive focus is required to correct it ; but a posterior sta- phyloma will often be seen in myopia as low as y'g or ,^^^. The staph^'loma may be a uniform prolongation of the posterior coats of the eye ; but it is generally a more or less marked ovoid, bulging between the yellow spot and the outer margin of the optic disc. The great length of a highly myopic eye may be usually seen b}^ drawing the outer canthus away from the globe with one finger, whilst the patient is made to look as much inwards as possible, by directing his attention to an object on the other side of his nose. Myopic patients can usually see clearly near objects, but they are unable to make out those at a distance, and in endeavoring to do so thej^ instinctivel}^ partially close the eyelids, to diminish the palpebral aperture. In this manner they cut off many of the peripheral rays which emanate from the object they are looking at, and by thus 264 DISEASES OF ACCOMMODATION. limiting the circles of diffusion they obtain a more sharpl}^- defined image. Myopia maybe hereditary, congenifal, or acquired. It is generally hereditary, but vot congenital, in that it does not usually manifest itself until after eight or nine years of age. Myopia will be often found to have existed in families for many past generations. Acquired myopia is occasional!}" seen in watchmakers, steel-plate engravers, and others, who for many years have l^een in the habit of applj'ing their eyes for several hours daily to fine work, or to literary pursuits. Like all other bodily defects, when once acquired it may be transmitted, and so become hereditary. No doubt, to insure this result, it is neces- sary that the eye should have been specially nsed through- out several generations. M3'opia may be thus regarded as one of the evils of civilization and high mental cul- ture. The great demand which scientific and manufac- turing pursuits make on the eyes, causes them to gradu- ally attain through successive ages an increased growth and development. Up to a certain point this is productive of improved vision — of sight which is good for both near and distant objects ; but beyond a fixed limit the eyes become too large, and myopia is the result. Ophthalmoscopic Appearances op a Myopic Eye. — Bi/ direct examination, that is, by aid of the mirror with- out the use of the object lens, the structures of the fundus ma}^ be seen at some inches from the eye, and if the pa- tient be made to move his head in one direction, the reti- nal vessels will appear to travel in the other, showing that the image which is seen is inverted. The reverse of this occurs in the direct examination of h3'permetropic ej'es, when the parts at the fundus will seem to move with the head, proving that the image is erect. By an indirect ophthalmoscopic examination, that is, MYOPIA. 265 by the aid of both the mirroi' and object lens, the oi:)tic nerve and vessels appear rather smaller and brighter than in an emmetropic eye. In most myopic eyes, evidence of a posterior staph3'loma is seen in a small white band or crescent generally on the apparent inner side of the optic nerve. This is known as the myopic arc or crescent. It is caused by the prolongation backwards of the scle- rotic, and consequent stretching of that portion of the choroid which corresponds to the staph3doma. This ex- tension of the choroid induces atrophj^ and thinning of its texture, so as to render transparent that part of it which is adjacent to the optic nerve, and upon which the greatest pull is exerted, and thus to allow the white shining surface of the subjacent sclerotic to gleam through. Occasionally the choroid is completely de- tached around a portion of the margin of the optic nerve. The width of the arc is usually proportioned to the de- gree of the myopia, and in severe cases it will sometimes extend entirely round the optic disc, or instead of a cres- cent there will be a large, white, irregular patch, over which the retinal vessels will be seen coursing. See arti- cle Sclerotico-Choroiditis Posterior, page 220. Treatment of Myopia. — In examining a mjopic e^'^e, the points to be decided are : 1. The degree of mj^opia and the range of accommo- dation. 2. Whether the myopia is stationary or progressive. 3. Whether it is simple or complicated. 1. The Degree of Myopia and Range of Accommoda- tion.'^ — Note at what distance from the eye the patient * The best test-types are those prepared by Dr. Snellen, of Utrecht. They may be obtained of "Williams & Norgate, Covent Garden, London. 23 2GG DISEASES OF ACCOMMODATION. can read No. 1. This is his far point. If it be at fi, 8, or 10 inches, the myopia is termed ^, |, or j'^, as with a concave lens of 6", 8", or 10" focus, he ought theoreti- cally to be able to see clearly distant objects ; practi- call}^, however, he will require glasses of a lower focal power. Next determine his near jyoinf, and this is done bj' as- certaining how close to the e^'e he can read the same type ; the space between the near and far points will in- dicate the range of the accommodation. Having pro- ceeded so far, find out b^^ trial with successive glasses the weakest concave lens with which the patient can see No. XX at 20 feet. If no glass will bring his sight up to this standard, his acuteness of vision is impaired, and this defect is due to some other cause than simple mj^o- pia. See Complications of Myopia, page 268. Each eye should be tested separately by closing the one which is not under examination, telling the patient to place his hand over it. If one eye is more mj'opic than the other, it is, as a rule, best to give spectacles with both glasses of the same focal power as that which is suited to the least short-sighted eye. There are, however, exceptional cases where patients may be allowed to wear spectacles with glasses of different foci for the two eyes, but it is seldom satisfactoiy. In testing with glasses, each lens should be placed as close to the eye as it would be worn in the spectacle frame, as its strength is in- creased if it is held at a distance. If there is an insuflicienc}^ of the internal recti mus- cles, so that the patient is unable to converge both his e^^es on a near object, and this defect is not corrected by the use of glasses, it will be necessary to divide one or both of the external recti. Tlie external muscle of the most defective eye should be first divided, and if after an interval of a few days it is found that the effect has not MYOPIA. 267 been sutllcient, a, similar tenotomy should be performed on the other eye. General Rules for the Selection of Glasses. — When the myopia is below ts'q, no spectacles should be worn, but the patient should be furnished with glasses in a folding frame, which he can appl}' to his eyes when looking at objects beyond his range of vision. In low degrees of myopia, such as from ^'^ to j'^, if the accommodation is good, one glass will suffice for the pa- tient, 'and with it he will be able both to read and see distant objects. But if the accommodative power of the eye is much impaired, the patient will often require a reading-glass of a low power. When stronger glasses are required, as in cases of myopia from about jV to 4? it will be well to give the patient spectacles with weak lenses for reading, and stronger concaves for wearing in the streets or when looking at things at a distance. In high degrees of myopia, as from ^ upwards, the patient should not, as a rule, be allowed to wear con- stantly glasses which completely neutralize the myopia, they will often fatigue the eye and produce too much dazzling. He should be ordered, for constant use, the concaves which suit him best for reading and enable him to see well eight or ten feet in front of him, and, in addi- tion, he should be given a pair of glasses in folding frames, of a focus which will represent the ditlerence between those he requires for reading and distance. These he ma}^ hold in front of his spectacles, when looking at ob- jects beyond the power of the glasses he has on ; thus, a patient who requires — | for distance, and — y\^ for read- ing, may be ordered spectacles with — j% for constant wear, and a double eyeglass with — ^ for occasional use in front of his spectacles ; for ^ — .^ = ^. If the glasses dazzle, or, if the eyes are irritable, much comfort may be often gained by ordering the lenses to be tinted with co- 268 DISEASES OF ACCOMMODATION. bait blue ; and this is especially beneficial if the e3'es have to be much used with artificial light. 2. Whether the 3Iyopia is stationary or progressive. — In most young people the myopia is progressive ; it is, therefore, of the utmost importance that the rules which are given under the heading of General Directions, should be strict^ followed, in order to retard, if possi- ble, its increase and render it stationary. In stationary mj^opia of a low degree, the sight may steadil}' improve as age advances, and, ultimately, the patient may be able to discard the use of glasses, but this is rather exceptional. In m3'opia of a high degree, there is alwaj's a strong tendency to increase. If the progress is rapid, it is usually accompanied with symptoms of irrita- tion, which require careful management. The patient complains of musca?, flashes of light and globes of fire ; the eyes will flush easily when reading, or often without an apparent cause, and they look red and irritable. With si^ch symptoms, the use of glasses should be for a time abandoned, or only those of a low power allowed, suffi- cient to enable the patient to perform the duties abso- lutel}' required of him. A leech to eaci temple, repeated ever}' two or three days, for a few times, will sometimes give great relief A small blister, of the size of a shil- ling, may also be applied behind the ears, and repeated from time to time, so as to keep up a little counter-irrita- tion ; or some stimulating liniment may be used for a similar purpose. The eyes may be frequently bathed with a cold lotion (F. 35, 37), which may be applied over the closed lids with a fold of linen when the patient is Ij'ing down. The most important treatment, however, consists in rest to the eyes, by abstaining from all work, and especially that which induces a stooping position of the head. 3. Whether the Myojna is simple or covqjlicated. — If iMYOPIA. 269 suitiil)le concaA'e glasses fail to make the patient read No. XX, Snellen, at twent}^ feet, there is superadded to the m3^opia some other defect to account for his impairment of vision. Myopia may be complicated : 1, with amblyo- pia or weak sight, due to defective sensibility of the retina; 2, with astigmatism ; 3, with an increasing poste- rior staph^doma and atrophj^ of the choroid ; 4, with de- ficienc}^ of power of the internal recti muscles (muscular asthenopia); 5, with opacities of the cornea; 6, with opacities of the vitreous ; 7, with choroidal or retinal hemorrhage ; 8, with partial detachment of the retina. For the treatment of all these complications, the reader is referred to the different sections under which they will be found in the index. General Directions for Myopic Patients. — Avoid all stooping positions of the head, as thej' tend to cause con- gestion of the ej'es. In reading, sit with the head thrown back, and bring the book to the e3-es instead of taking the e3'es to the book. Never, if it can be avoided, read books printed in narrow, double columns ; the having to relax frequently the accommodation, as the eye travels from one short line to the next, tends to induce fatigue. Never read in a moving carriage ; the repeated jolts dis- place the words on which the eye is fixed, and tire the eye hy requiring it to keep readjusting itself. If the ej'es grow fagged whilst reading, rest awhile, and do not re- sume work until the^^ are refreshed. Avoid working by an artificial light, and especially' gas which flickers. The best lamps are the so-called " reading lamps," provided with a shade which throws their light on the object to be seen, and leaA'es the rest of the room in comparative dark- ness, into which the ej-e can roam when feeling fatigued. When the ej^es are tired, or hot and irritable, the best ap- plication is cold water, with which the eyes, the lids be- ing closed, may be bathed; or a gentle stream of cold 23* 270 DISEASES OF ACCOMMODATION. water may be carried against the closed lids by means of the siphon eye-doiiche. Hypermetropia is the reverse of myopia ; for whereas in myopia the optic axis was too long, and parallel ra^s, or those emanating from distant objects, were brought to a focus in front of the retina, in hypermetropia the antero- posterior diameter is too short, and the focal point of par- allel rays is behind the retina. The result of this defect is that only convergent raj'S can be brought to a focus on the retina. The h3^permetropic eye. is conseqnentl}' un- able to receive correct impressions of things at a distance when in a state of repose, that is, with its accommodation relaxed, but it has to bring into action its focussing power, in order to converge sufficiently' the parallel ra^'s. The strain on the accommodation is therefore in proportion to the nearness of the object. Adopting Donders's classification, h3-permetropia may be diA'ided into acquired and original. The acquired is occasionally met with in old people, generally above 60 or 70 3'ears of age, when it is associated with presbyopia. Hj^permetropia may thus be often found in an originally emmetropic eye. The patient not only requires convex glasses for reading and looking at near objects, but the refractive power of the eye has become so reduced that he also needs convex glasses for distance. Another form of acquired hjqoermetropia is found in cases of what Donders calls " aphakia," or absence of the lens from the dioptric system of the eye.. This may occur from ex- traction of the lens for cataract, or from a dislocation of the lens out of the field of vision from an accident. In both of these cases convex glasses are required for dis- tance. Original hypermotrojva ma}' be said to exist in two states, the manifest and the latent. HYPERMETROPIA. 271 The manifest is that degree of hypermetropia wliich the patient exhibits before the accommodation has been paralyzed with atropine. The latent is the amount of hypermetropia which is found after the accommodation has been paralyzed with atropine, and which was not manifest so long as the patient exerted his focussing power in looking at distant objects. Donders further divides h3'permetropia ijito absulute, relative^ and factiUative. Absolute is when the e3'e can neither read fine print, nor tell clearly distant objects. With the strongest con- vergence of the eyes the patient cannot accommodate for parallel rays. This form is seldom met with in the young, as with them there is nearly always a certain amount of accommodative power, which enables them to overcome a portion of the hypermetropia. Relative hypennetropia is when, in order to see clearly a near object, say at a distance of sixteen inches, the eyes are obliged to converge as if looking at one at twelve inches. The patient can only accommodate for the real point, by converging the visual lines to another point nearer to the eyes ; in fact, by giving to them a periodic convergent squint. Facultative hypermetropia is when the patient can see clearly distant objects, cither with or without convex glasses, and he can also, with an effort which is almost unperceived, read and write Avell, but the eyes are spe- cially liable to suffer from asthenopia, when called upon to perform much continuous close work. Such eyes also soon become presbyopic. Treatment of Hyj^ermefropia. — Find out the degree of hypermetropia, and then furnish the patient with such glasses as will best remedy his defect. To ascertain the degree of Hypermetropia. — First direct 272 Di.-EASES or accommodation. the patient to look at Xo. XX, at 20 feet distance, and find out the strongest convex gkiss with which he can clearl}' make out that t^pe. The strength of the lens will indicate the degree of manifest hypermetropia : thus if an eighteen or twentj'-inch focus convex glass be required, the patient is said to have a manifest hypei'metropia of ^'g or tt'q. He should then be directed to read Xo. 1, with this glass, and, if he can do so with facilitj', he may be allowed a pair of spectacles, with lenses of the same focus, for constant use ; but if he should be unable to see the type, or orAy to make it out with difficult}', stronger glasses should be tried in succession until the ej^es are suited. The spectacles which are thus furnished to the patient will probably, however, only suffice him for a time, as they do not neutralize his latent h^-permetropia, and this will gradually become manifest as the patient, by the aid of his glasses, ceases to strain his accommodation for distance. After a time he wdll probably', therefore, require stronger glasses. In low degrees of hypermetropia, for l)ractical purposes this examination may be sufficient, and suitable glasses may be thus given to the patient ; biit in all severe cases the amount of latent hypermetropia should also be ascertained. To do this, the accommoda- tion of the eye should be first paralj^zed by dropping into it a few drops of a solution of atropine gr. 4 ad aquje s 1 ; and when the full effect has been gained, tr}- what convex glass will enable the patient to see Xo. XX at 20 feet. Xow, an ordinary emmetropic eye, thus treated, would be able to read, unaided b}' glasses, Xo. XX at 20 feet, for without ajiy effort of accommodation it can unite par- allel rays on the retina; but the hj^permetropic eyQ will neeel a convex lens, and one of a greater power than that which was called for before the instillation of the atro- pine. The focal power of the lens now required, will give the degree of latent hypermetropia. As a rule the patient HYPERMETROPIA. 273 cannot wear, constantly, glasses of the strength necessary' to neutralize the latent h3pernietropiai as, from having been long accustomed to use unconsciously his accommo- dation for distance, he is unable to completely relax it, and strong convex glasses would confuse and fatigue the eye. He should therefore first be ordered weaker glasses, and these may be changed from time to time for stronger ones, as may be necessary. Peculiarities of the Hijpemnetroinc Eye. — It is smaller in all its dimensions than the emmetropic eye, but espe- cially in the antero-posterior diameter, so that the globe ha« a flattened appearance. This can be distinctly seen if the patient is directed to look as far inwards as possible whilst the outer canthus is drawn outwai'ds with one finger. It will then be noticed that the curve of the e3e over which the external rectus curls to its insertion is short and ab- rupt, and that the globe looks flat and small for the orbit. Bonders says : " The h3'permetropic eye is in general an imperfectly developed eye. If the dimensions of all the axes are less, the expansion of the retina also is less, to which, moreover, a slighter optic nerve and a less number of its fibres correspond."* Ilxamined with the ophthal- moscope, an erect image of the fundus of the hA'perme- tropic eye can be seen with the mirror without the use of the object lens, and on the patient moviug his head the retinal vessels will be seen to travel in the same direction. Hypermetropia is very hereditary ; many members of a family of which one or both the parents are hyperme- tropic, are frequently found also to suffer from this defect of the e^es. Reaults of Hypermetropia. — It is the most frequent cause of convergent strabismus, and of asthenopia or weak sight. * Duiidcrs on the Acconiniodatiun and Refraction of the Eye, 274 DISEASES OF ACCOMMODATION. PRESBYOPIA. Presbyopia or Long Sight is one of the first of the legion of troubles which advancing j-ears bring npon all of us. In true presbj^opia the near point is removed from the eye, but distant vision is unimpaired. The first inti- mation the patient has of commencing presbAopia is that the type which he could once see clearly at from eight to twelve inches, is now indistinct, and in order to read it, he is obliged to hold the book at a greater distance. As presbyopia advances, the failure of sight for near objects increases, and this is especially noticeable in the evening, when the patient seeks a strong light to work by, because Avith it the pupil contracts and the circles of diffusion are rendered smaller. Presbyopia is caused by a diminished power of accom- modation, and probablv also b}' senile changes in the structure of the lens. It creeps on imperceptibh^, the near point being gradualh' removed from the eye as age advances, until the patient is unable to discern any small objects without the aid of convex glasses. Bonders sa^s : " The term presb3opia is, therefore, to be restricted to the condition, in which, as the result of the increase of years, the range of accommodation is diminished, and the vision of near objects is interfered with." It is, he remarks, " no more an anomal}- than are gray hairs or wrinkling of the skin."* Treatment of Presbyopia It is a question often asked, when ought convex glasses first to be used ? Bonders says : " So soon as, by diminution of accommodation, in ordinary work, the required accuracy" of vision begins to fail, there is need of convex glasses. The test is, that * Donders on the Accommodution and Ecfraction of the Eye, p. 'ilU. ASTIGMATISM. 275 with weak glasses of from ^'g to ^'^j at the same distance as without glasses, the accuracy of vision is manifestly improved."* It is an error to suppose that presbyopic patients should postpone the use of glasses for as long a period as possible. By so doing they subject themselves to an amount of discomfort which could be avoided, and without any advantage to compensate for the sense of fatigue, heat, and occasional redness of the eyes which an overstrained effort of the accommodation induces. In selecting glasses for presbyopic patients, those should be chosen which enable him to read with ease No. 1, at about ten or twelve inches from the eye. If stronger glasses are given, they are apt to induce fatigue. When convex glasses are first called for, it will generally' only be necessary to wear them in the evening, as by day the patient will be able to perform all his duties without their aid. But soon he will take to his glasses by day, and then a pair of stronger ones will be required for evening use. Whenever, therefore, he has to increase the power of his glasses, he should take his evening pair into day use, and obtain stronger ones for his evening's work. ASTIGMATISM. Astigmatism. — " Ametropia," says Donders, " com- prising the lesions of refraction, is resolved into two op- posite conditions : myopia and hypermetropia. Every lesion of refraction belongs to one of these two. Some- times, however, it happens that, in the several meridians of the same eye^ the refraction is very different. In one meridian the same eye may be emmetropic, in the other, ametropic ; in the several meridians a difference in the degree, and, even in the form of ametropia, ma}^ occur."f * Donders on the Accommodation and Refraction of the Eye, p. 217. t Ibid. p. 449. 276 DISEASES OP ACCOMMODATION. This defect, dependent on a want of symmetry of the meridians of the eye, has been termed astigmatism. The exi)hination of this anomaly is the following: the cornea in a nornial e^'e is a segment of an ellipsoid, and, as its horizontal and vertical axes are of different lengths, it follows that its curvatures in these directions must also differ; and that vertical and horizontal rays falling upon such a surface, must be unevenly refracted, and, there- fore, unite into two separate foci. As a rule, the vertical meridian has a shorter focal distance than the horizontal. Hence, it is that, in most eyes, vertical and horizontal lines are not seen with equal clearness from the same point and at the same time. So far, astigmatism may be considered a natural defect, due to a difference of the vertical and horizontal curva- tures of the cornea, and which, in a minor degree, is com- mon to all eyes. It is only when there is a marked asym- metry between the meridians of the cornea, that it at- tracts notice, and calls for the aid of cylindrical glasses. There are two distinct forms of astigmatism : the ir- 7'egidar and the 7-egular. Irregular Astigmatism. — Bonders divides this form into normal and abnormal. a. Normal irregular astigmatism is due to a peculiarity in the structure of the lens. The principal phenomenon, he says, attending this irregularity, is monocular poly- opia. This midtiplication of the object is to be explained by there being, from some cause, an aberration of the rays as they pass through the diff'erent sectors of the lens, and consequently ''an imperfect coincidence, even after accommodation, of the images of the different sect- * Donders on the Accommodation and Refraction of the Eye, p. 518. ASTIGMATISM. 277 /?. Abnormal irregular oMigmatism may arise from some defect of either the cornea or lens. From the Cornea. — We have examples of this form of irregular astigmatism in conical cornea; occasionally after the extraction of cataract, and after corneal ulcera- tions. From the Lens. — Irregular astigmatism may be caused either by a change in the structure of the lens, as is some- times seen in the early formation of cataract, or by its displacement, as in cases of partial dislocation of the lens into the anterior chamber or vitreous. Regular Astigmatism is due to a difference in the focal lengths of the meridians of the eye, and is to be corrected by proper cylindrical glasses. It is with this form that we have now to deal. Regular astigmatism may be acquired and congenital. The acquired may be produced by perforating wounds of the ejre, and especially those which are near the margin of the cornea ; thus it is occasionally met with after the operations of iridectomy and extraction of cataract. Ulcerations of the cornea usually give rise to irregular astigmatism ; a case, however, is related by Bonders, in which, after a perforating ulcer of the cornea, the astigmat- ism was sufficiently regular to be corrected by a cylin- drical glass. Regular Astigmatism may be divided into: 1. Simple astigmatism^ that is, when one meridian is emmetropic, and the other either hypermetropic or my- opic. 2. Compound astigmatism, when both meridians are either myopic or h3'permetropic ; but the defect in one meridian is greater than in that of the other; thus, if the case is one of compound mj-opic astigmatism, in the hori- 24 278 DISEASES OF ACCOMMODATION. zontal meridian, the myopia may be 5'^, whilst iu the vertical it may be j'^. 3. 3Iixed astigmatism, that is, where there is hyperme- tropia in one meridian and myopia in the other. Such cases are rare. To ascertain the Presence of Astigmatism. — First test the patient's eyes with spherical glasses, and determine whether they are mj'opic or hypermetropic, and if either, what glasses most nearl}' neutralize his defect of sight. Having, however, failed to restore, b}'' glasses, his acute- ness of vision, the question is whether his impairment of sight is due to astigmatism or to other causes. To find this out, place at one end of the room a set of thick, vertical, and horizontal lines, and let the patient walk to- wards them, and stop the moment either of them becomes distinct. If he can, at a certain point, see clearly one set of lines, whilst the others are cloud}^ and blurred, he is astigmatic. A similar conclusion may be drawn if the patient be made to look at a point of light through a per- foration in a metal screen at a distance of 15 feet, when, owing to the astigmatic eye being unable to unite accu- rately to a focus vertical and horizontal ra^'s, the point will appear dx'awn out to a vertical or horizontal line, ac- cording to whether the eye focusses correctly the hori- zontal or vertical rays. The patient should now l)e directed to look through a slit about jL of an inch wide in a disc of metal, which is to be slowly rotated in front of the eye, so as to bring the slit opposite each of the ditferent meridians in suc- cession. If, in a certain position of the slit, he is able to make out Xo. XX at 20 feet, the case is one of simjde af!tigmatism. The e3'e is emmetropic in one meridian and myopic or hjpermetropic in the other. The patient ma}' then be tried with a weak cylindrical convex or concave lens, which he must rotate in front of ASTIGMATISM. 279 the ej'e, until he places the axis in that direction which gives him the most correct vision. Should the glass first tried not quite answer, others of a slightly higher or lower focal power may be held up in turn, until the eye is suited. Si)ectacles, with similar cylindrical glasses, may be then given to the patient ; but in ordering them, the instruc- tions given below should be followed. Comjyound Astigmatism. — First ascertain the concave or convex glass, according to whether the patient is my- opic or hypermetropic, which most improves vision ; and whilst he holds this before his eye, place in front of it a cjdindrical glass of similar curvature but of low power, and slowly rotate it, until the axis of the cylinder is in the right direction. If this glass fails to afford the re- quired improvement, try other cylindricals in succession, until the one which gives the greatest benefit has been selected. For convenience of testing the spherical and cylindrical glasses together, a double spectacle-frame should be used, in which the spherical lens should be placed next the eye, and the cylindrical outside, so that it can be easil}^ rotated with the finger. Each e3-e should be tried separately, the hand being placed over the one which is not under examination. Having selected the combination of spherical and cylindrical glasses, direc- tions should be sent to the optician to furnish the patient with spectacles with the proper spherico-cjdindrical lenses. In the written instructions given to the optician, the focal power of each glass should be separately noted, and the direction in which the axis of the cylindrical. glass is to be worn, marked by the sign of an arrow. It should be also mentioned that the spherical face of the lens is to be l)laced next the eye. The glasses should be fitted in frames with circular eye-pieces, so that the axis of each may be accurately adjusted to the e3e before the frames are screwed up. 280 DISEASES OF ACCOMMODATION. Mixed Astigmatism. — For the relief of this form, hi- C3iindrical glasses will be required. Find out the couvex piano-cylindrical lens which will neutralize the hyperme- tropia in the one meridian, and then the concave piano- cylindrical which will correct the myopia in the other meridian. Place now the two lenses in a double spec- tacle frame, with the axis of the C3'linders at right angles to each other, and rotate the two together in front of the ej'^e, so as to ascertain in what direction of the axis the patient has the best sight. Having decided these points, similar lenses may be ordered to be united by Canada balsam, or a similar bi-cylindrical glass may be ground by the optician. ASTHENOPIA. Asthenopia or Weak Sight is a sj-mptom due to several affections of the ej-e. The patient complains that reading, writing, or the maintenance of fine work which requires a close application of the ej'es, induces fatigue ; that when thus engaged the object becomes dim and con- fused, and sometimes suddenly- disappears ; that if he rests his eyes for a few minutes, he is able to resume his work, but in a short time he is again obliged to desist from a recurrence of similar sjniptoms. Asthenopia maj' depend — 1, on hypermetroiaia ; 2, on an insufRcienc}^ of power of the internal recti, which ren- ders a prolonged convergence of the eye difficult and some- times impossible. 1. Asthenopia due to hypermetropia, is called also ac- commodative Asthenopia. It arises from the excessive strain on the accommodation which the hypermetropic eye has to exert to focus the diverging rays of near ob- jects. Fatigue is consequently soon induced, the accom- modative eflbrt is first partially relaxed, and the object ASTHENOPIA. 281 under attention, being thrown out of focus, becomes con- fused and dim ; in a few minutes all elTort of accommoda- tion is suspended and the impression is lost. After a short rest the patient can resume his work, but the recur- rence of the same confnsion of sight soon compels him to give up and to cease from his employment. Treatment. — Properly fitted convex glasses for reading, writing, sewing, or all close work. (See Hypermetropia, p. 3T0.) This form of asthenopia is often much increased by anaemia and debility. In such cases tonics, and espe- cially^ the preparations of iron, are of great service and should be prescribed (F. 65, 66). 2. Asfhenojna from inHufficiency of the internal recti, so frequently met with in mj^opia, is called muscular asthenopia, to distinguish it from the jDrecediug form. It is due to a want of sufficient power in the internal recti to maintain a steady and prolonged convergence of the eyes on a near object. The patient complains that after reading for a short time the letters become confused, and the lines seem to overlap or run into one another. This is caused by a relaxation of one of the internal recti and a consequent eversion of the ej'e, giving rise to slight diplopia. Even when these S3'mptoms are absent, the great effort which is required to maintain convergence when there is an excess of power in the external recti muscles induces such an amount of fatigue and aching of the eyes as to compel the patient to give up work. To ascertain if there is an insufficiency of the internal recti, direct the patient to look at the end of your finger, which is to be held at ten or twelve inches from his ejes, and then slowly approach it towards them, telling him to continue looking fixedly at it as it draws nearer. If there is an insufficiency, the eyes will be/ unable to maintain the necessary convergence as the finger advances to within six inches, and one of them will first waver and then 24* 282 STRABISMUS. gradually roll outwards. Sometimes this eversion of the e3'e is almost spasmodic, so quick and sudden is its move- ment. Often in such cases there is a difference in the focal power of the two eyes, and then the one which de- viates is the more m3'opic, or, in other respects, the more defective of the two. The degree of insufficiency of the internal recti muscles may be accurately tested by the means of prisms. (See article on this subject, page 299.) If after a careful examination there is found to be such an insufficiency of the internal recti muscles, that the^^ are unable to maintain a joint and prolonged convergence of the e3'es for near objects, the external rectus of one or both ej'es should be divided. It is best to divide one at a time, unless the insufficiencj' is very marked, and the eye to be selected for the first operation should be the one which is the more defective and generall}' Manders out- wards. The external rectus of the other eye can be after- wards divided if the effect gained by the first operation is not sufficient. CHAPTER YII. STRABISMUS. Bonders defines strabismus as " a deviation in the direction of the eyes, in consequence of which the two yellow spots receive images from different objects."* Strabismus may be either convergent or divergent ; it is seldom that the deviation is solely upwards or down- wards. In most cases there is a preponderance of power in * Bonders on the Accommodation and Kefraction of the Eye, p. 291. STRABISMUS. 283 either the internal or external rectus muscle, so that the balance between them is destroyed, and the ability to steady the two eyes simultaneousl3' on an object is lost. Whenever an attempt is made to look at a given point, one e^^e rolls either inwards or outwards according to whether the squint is convergent or divergent ; the optic axes are no longer parallel, and the impressions of the image fall on different parts of the two retinae. Monocular strabisvms is when the deviation is constant in the one eye. It is generally associated with impair- ment of sight in the squinting eye. Alternating or binocular strabismus is when the devia- tion occurs alternately, first in one eye and then in the other. The patient can "fix" with either eye, but is un- able to direct the two together towards the same point. When one eye is fixed, the other rolls inwards, and vice versa. In alternating strabismus the sight of the two eyes is nearly equal. Strabismus ma}^ be either peiHodic or jpersistent. A ]3eriodic squint comes on only at times, as when the patient is reading or looking fixedly at an object, or after the eyes have been fatigued. It may be caused by some eccentric irritation, as from ascarides, or from dentition, but in the large majority of cases it is due to hjperme- tropia. A periodic squint may be occasionally benefited by judicious treatment; but more frequently the strabis- mus increases, and ultimately becomes persistent. For ti'eatment of periodic squint, see page 289. The Ilouements of the Squinting Eye. — In some cases there is an actual limitation of movement in the squinting eye, and its range outwards, if the squint is convergent, or inwards if it is divergent, is impeded. This may be due either to an acquired increase of power in the squinting muscle, as in some cases of hypermetropia ; or it may be caused by a loss of power in the antagonistic muscle, as in 284 STRABISMUS, m3^opia, where there is frequently an external strabismus consequent on an insufliciency of the internal recti, or as in cases of paralytic squint. Generall}^, however, the range of action of the squint- ing eye is not limited, but displaced, and this is especially noticeable when the sight of the two eyes is equal, and the squint alternates. Thus, before an operation for an internal strabismus, the space over which the eyes move may be three-quarters of an inch; after the operation the range may still be the same, but it will be transposed, and although the e3'e will travel over no greater distance than before, yet it will be enabled to go more outwards, and consequently less inwards. Strabismus may be induced, 1st, by some anomaly in the refraction of the e3^es, as in hypermetropia and myopia ; 2d, from defective sight in one eye. AVhatever cause prevents binocular vision tends to produce squint, no matter whether it be from great differences in the re- fraction of the two eyes as from ambljopia, or from opa- cities of the cornea ; 3d, strabismus may be produced by paralysis of one or more of the nerves supplying the muscles of the eye. To ascertain and note the extent of the strabismus^ the patient should be first told to look at an object about twenty inches distant, when it will be found that whilst he "fixes" with one e^-e, the other rolls either inwards or outwards, as* the squint nuxy be. A mark is then to be made with a pen on the edge of the lower lid of the squint- ing e3'e opposite the centre of the pupil. The sound eye must now be covered with the hand, and the patient di- rected to look at the object with the squinting eye, and the position of the centre of the pupil is again to be marked on the edge of tlie lower lid. The space between these lines will indicate the deuree of the strabismus : STRABISMUS. 285 thus we speak of a strabismus of 1'", 2"', or more, according to the interA-al between tlie markings on the lid. The movement which the squinting e3-e makes when the sound eye "fixes" upon an object, is termed the primary deviation. TJie secondary deviation is the extent of movement the sound eye makes when excluded b^^ the hand, whilst the squinting eye fixes itself on the object. The strabismus is said to be concomitant v^hen the primarj^ and secondary deviations are equal. The squinting eye is not fixed, but follows the other in its movements. The plan adopted by Mr. Bowman for determining the degree of strabismus, is the following: The patient is made to look at a near object held at the extreme outer limit of his field of rision, first on one side, then on the other; and the extreme limit of movement of each eyQ inwards and outwards is then noted with reference re- spectively to the lower punctum and the outer canthus; the pupil being the part of the eye used to mark the movement inwards ; the outer edge of the cornea the movement outwards. In noting the case on paper, the diagrams of the position of the two eyes should be placed on the same line, as if facing the observer; that of the right eye on the left-hand side. The following may be taken as an example : Fig 28. <^ /• • >l a 5 <^ d a, b, Right eye. c, d, Left ej-e. a. Extreme range outwards; the outer edge of (he cornea fails to reach the can- thus. 6, Extreme range inwards; the pupil passes bej'ond the piinctum. c, Kx- treme range inwards: the pupil does not reach the punctum. d, Extreme range outwards ; the outer edge of the cornea passes beyond the canthus. In each case the exact distance admits of being re- 286 STRABISMUS. corded. In this manner the relative strength of the internal and external recti of the two eyes nia}' be esti- mated, and the resnlt marked down in a single line, so as to show, at a glance, in which eye the preponderance of power of either muscle exists. The degree of strabismus ma}^ be also carefully esti- mated by a " Strabismometer " invented by Mr. J. Z. liaurence. " It consists of an ivory plate, moulded to the conformation of the lower eyelid, the free border cor- responding to that of the lid. This border is graduated in such a manner that, while its centre is designated by 0, Paris lines and half lines are marked off on each side of 0. Attached to the plate is a handle. The applica- tion of this strabismometer is obvious. The ivory plate is applied to the lower eyelid, the borders of the two cor- responding. If the cornea is central, the vertical diame- ter of the pupil corresponds to ; if inverted, to a gradu- ation on the inner side of 0; if everted, to one on the outer side of 0." * Convergent or Internal Strabismus is usually de- pendent on hypermetropia. In 17 per cent, of the cases of convergent strabismus, Donders found that there was hypermetropia.f The explanation of this fact is the fol- lowing. Owing to the peculiar shape of the hypermetropic eye, the accommodative powder is called into constant ac- tion, and, for near objects, the strain is very great. In projjortion to the effort to accommodate is the degree of convergence of the eye, so that when a hypermetropic eye is looking at a near object, it converges more than a nor- mal or emmetropic eye would do, because the stress on * Optical Defects of the Eye, by J. Z. Laurence, p. 107. t Donders on the Accommodation and Refraction of the Eye, p. 292. DIVERGENT STRABISMUS. 287 the accommodation is greater. This excessive action of the internal recti muscles causes them to acquire in- creased strength, and gradually to preponderate OA'er their antagonists the external recti, until ultimatelj^ a convergent strabismus is established. In hyperraetropia the strabismus usually first appears at the time the child begins to apply his eyes to close work — as in learning to read — when the efforts of accom- modation and convergence are brought into more active play. The degree of strabismus is not necessarily pro- portioned to the extent of the h3-permetropia. In very hypermetropic e^^es the sight is so defective, and so little benefited by any accommodative effort, that the patient ceases to strain his eyes, and consequently convergent strabismus is less frequent than in eyes with a lower de- gree of hypermetropia, where, b}' a strong endeavor to accommodate, the sight is materially improved. In hy- permetropic strabismus there is frequently a considerable difference in the refraction of the two ej-es. Defective vision in one eye, combined with hypermetropia, but irre- spective of it, tends strongly to convergent strabismus. Another cause of internal strabismus is paral3^sis of the sixth nerve. See page 310. Divergent Strabismus is generally' associated, l,with mj-opia. According to Donders, about two-thirds of the cases are due to this cause ; and if with the myopia there is a large posterior staphyloma, the tendency to divergent strabismus is increased. In m3opia there is frequeutl}' an insufliciency of power in the internal recti, and a pre- dominance being thus given to the external muscles, di- vergent squint is produced. This insufficiency may be partly caused by the peculiar lengthened shape of a highly myopic eye, which not only mechanically impedes con- vergence beyond a certain point, but also diminishes the 288 STRABISMUS. fulcrum upon which the internal recti act. If a well- marked hj'permetropic eye be contrasted with a highly myopic one, this will at once be evident. As the internal recti are inserted in front of the horizontal equator of the eye^ the abrupt curve of the almost globular hyperme- tropic e3'e, round which the muscles curve to their inser- tion, gives to them an excess of power and an nndue facility of action, which favor convergent strabismus ; whilst in the highly mjopic eye the conditions are re- versed, the globe is lengthened, the curve of its equator is diminished, and from its elongated shape its facility of movement is reduced. Under these circumstances the tendency- in mj^opia is for the internal recti to lose power, and for the eye to diverge. Another explanation of the predominance which the external recti so often acquire over their antagonists in myopia, is to be found in the great refractive power of the mj'opic eye, which diminishes the necessity for ex- treme convergence in looking at near objects, and favors divergence in striving to look at those at a distance. 2. Divergent strabismus may be caused by a diflference in the refractive powers of the two eyes when both are mj'opic. For all close work the better eye is used, and the defective eye, failing to receive an impression of the object sufficiently strong to stimulate it to convergence, rolls outwards. 3. Defect of sight, amounting to or approximating blindness, will produce divergent strabismus. 4. Divergent strabismus may follow an improper or ill-advised operation for convergent strabismus. 5. Divergent strabismus maybe produced b}' paralysis of the third nerve. See page 307. Treatment of Strabismus. — Inquire carefully into the patient's history, and endeavor to ascertain the duration TREATMENT. 289 and cause of the squint. Test the vision of both e^'cs, note their range of action, find out whether the strabismus is periodic or persistent, and measure the extent of the de- viation. If there is a faulty state of the refractive powers of the eye, tr}'^ to neutralize the defect with proper glasses. When periodic squint is suspected to arise from asca- rides, dentition, or gastric derangement, the first treat- ment must be the removal of the source of irritation, and when this is accomplished, the e3'es may possibly resume their normal position. If, however, the periodic squint is due to some anomaly in the refraction of the eye, an attempt should be made to rectify the defect by the use of properly fitted glasses, and if the trial is made suffl- cientl}^ early there is a fair chance of success. In all cases of strabismus which are dependent on a faulty state of the refractive powers of the ej^e, as in hypermetropia or myopia, the eyes should be provided with proper glasses, which should be worn even if an operation be afterwards performed. Having decided on an operation, it at once becomes a question whether it will be necessary to divide the ten- dons of the corresponding muscles in both eyes, or whether a tenotomy in one eye will suffice. Generally, it is better to operate on both eyes, and to divide each tendon as close to the globe and with as little disturb- ance of the adjacent tissues as possible. In this way the eflfect to be obtained is apportioned between the two eyes, and the result, I think, is better than when by a more free division of the subconjunctival fascia and a separation of it from the neighboring parts, the operation is confined to the one eye. In many cases, however, it is prudent to operate first on the one e^'e only, and then to wait to as- certain the exact effect it has produced before proceeding to divide the tendon in the other eye. This rule should be observed in the treatment of strabismus due to a great 25 290 STRABISMUS. defect of sight in one e3'e, and especiall^^ if tliere is a marked limitation of movement in tlie squinting eye ; it should also be followed in slight cases of alternating stra- bismus. The operation for strabismus which I prefer is the one most frequently adopted at the Moorfields Hospital. It is strictly a subconjunctival operation, in the sense that the division of the tendon is accomplished beneath that membrane, the opening in it for the necessary introduc- tion of the instruments being opposite the inferior edge of the tendinous insertion of the muscle. Fig. 29. The Moorfields Operation for Strabismus. — The lids are to be separated by a stop-speculum. The surgeon with a pair of finely-toothed forceps takes hold of the con- junctiva, and often at the same time of the deep fascia over the lower edge of the in- sertion of the rectus tendon, and with a pair of blunt-pointed scissors makes a small open- ing through both these structures. If the fascia has escaped the snip of the scissors, it must be seized with the forceps and divided. The blunt hook (Fig. 29) is now passed through the apertures in the conjunctiva and deep fascia, and behind the tendon, which it renders tense by being made to draw it for- wards and towards the cornea. The points of the scissors are next to be introduced, and slightl3^ separating them, one blade is passed along the hook behind the tendon and the otlier in front of it, when by a succession of small snips the tendon is divided subconjunc- tivall}' on the ocular side of the hook. The operation is now conqjleted; but be- fore withdrawing the speculum, Mr. Uowman TREATMENT. 291 usually makes a small counter-puncture in the conjunc- tiva, by bulging it on the end of the hook in the situation of the upper border of the tendon after its division, and by then snipping it with the scissors; the object being to allow any of the effused blood immediately to escape, in- stead of diffusing itself over the sclerotic. This operation is equally applicable to the division of either the internal or external rectus muscle. It must, however, be remembered that the tendon of the external rectus is inserted into the globe in a line much farther back than that of the internal muscle. Graefe's Operation for Strabismus. — The eyelids having been separated by a speculum, the assistant with a pair of forceps draws the eye outwards if the internal rectus is to be divided, and in- Fio. 30. wards if the operation is to be on the external ^"^N^ rectus. The operator then with a pair of finely-toothed forceps seizes hold of a fold of the conjunctiva and subjacent tissue close to the cornea, and at a point a little below the centre of the insertion of the muscle. This he cuts through with a pair of scissors, sjlightly curved on the flat, and then burrowing with their points a little distance above and below the opening he has made, he freely detaches with a few snips the subconjunctival tissue from the muscle. The squint hook (Fig. 30) is now passed beneath the lower border of the tendon, which is to be divided with the scissors as close as possible to its insertion into the globe. After the tendon has been cut through, the divided conjunctiva should be raised with one hook, whilst the operator with another hook explores the wound both upwards and downwards to see if any 292 STRABISMUS. l^art of the tendon or of its lateral expansion has escaped division. If the whole tendon has been cut through, the exploring hook will glide readily up to the margin of the cornea ; but if its progress should be checked by catching behind some undivided part of the tendon, the scissors must be again used to sever that which still remains uncut. Liebreich's Operation for Strabismus. — The follow- ing is Dr. Liebreich's account of his " modification of the operation for strabismus," which w^as first published in the "British Medical Journal," December 15, 1866: "If the internal rectus is to be divided, I raise with a pair of forceps a fold of conjunctiva at the lower edge of the in- sertion of the muscle ; and, incising this with scissors, enter the points of the latter at the opening between the conjunctiva and the capsule of Tenon ; then carefully sep- arate these two tissues from each other as far as the sem- ilunar fold, also separating the latter, as well as the car- uncle from the parts lying behind. When the portion of the capsule which is of such importance in the tenotomy has been completely sei^arated from the conjunctiva, I divide the insertion of the tendon from the sclerotic in the usual manner, and extend the vertical cut, which is made simultaneously with the tenotomy, upwards and down- wards — the more so if a very considerable effect is desired. The w^ound in the conjunctiva is then closed with a suture." " The same mode of operating is pursued in dividing the external rectus, and the separation of the conjunctiva is to be continued as far as that portion of the external angle which is drawn sharpl^^ back when the eye is turned outwards." The advantages which he claims for his operation are: "1. It affords the operator a greater scope in appor- tioning and dividing the effect of the operation between the two eyes. TKEATMENT. 293 " 2. The sinking back of the caruncle is avoided, as well as every trace of a cicatrix, which not uufrequently occurs in the common tenotomy. " 3. There is no need for more than two operations on the same individual, and, therefore, of more than one on the same eye." Treatment of Strabismus after the Operation. — As a rule, no local application is required for the eyes, beyond frequently washing them with a little tepid water to clear them from the slight conjunctival discharge which usually follows for a few days after the operation. If the e3''es are hot or painful, a fold of linen wet with cold water may be laid over the closed lids, but the eyes should not be tied up with a bandage, as it is apt to increase the sense of heat and to add to the discomfort of the patient. AVhen the tendon of one eye only has been divided, the eye which has not been operated on should be covered Avith a single turn of a bandage immediately after the operation, so as to compel the patient to use the scpiint- ing eye, and thus to keep it in a central position until the divided tendon has acquired its new insertion. If there is much ecchymosis on the second or third day after the operation, the eye may be frequentl}^ washed with a little weak lead lotion (F. 42) ; or, if there should be a muco-purulent discharge, a mild astringent lotion (F. 39, 40) may be used three or four times daily. Divergent Strabismus following the Division of ONE OR BOTH THE INTERNAL ReCTI MuSCLES This re- sult may occur from the division of both internal recti when one only was required ; or it may follow a too free division of the subconjunctival fascia ; or it may arise from the tendon having been divided at too great a dis- tance from its insertion into the globe. In both of the 25* 294 STRABISMUS. last-mentioned cases the muscle recedes too much, and takes its new insertion into the globe so far back that it loses more of its poAver than is necessar}' for the correc- tion of the squint, and, consequently', gives to the exter- nal rectus a predominance which makes the eye diverge. With this form of strabismus, there is nearly alwa^'s as- sociated a sinking back of the caruncle, a defect which gives an unsightly prominence to the globe, and favors its ev'ersion. Treatment. — If divergence follow shortly after an opera- tion for a convergent strabismus, in which the internal recti of both eyes have been divided, a subconjunctival tenotomy should be performed on both the external recti, and this should be done even though the divergence be slight, as, when once established, the eversion will steadily increase. If, however, the divergence is the result of a too free division of the internal rectus and adjacent tis- sues of one exje^ then the external rectus of that e^^e only should be divided ; and, if this fails to correct the out- ward deviation, the tendon of the internal rectus must be brought forward by an operation at a subsequent pe- riod. Whenever the divergence is considerable, and the power of inversion limited, the simple subconjunctival division of the external recti will not restore the eyes to position, but the following operation, which was sug- gested by Mr. Critchett, must be performed on one or both e3'es, according to the circumstances of the case. Operation for bringing forward the Insertion of THE Internal Rectus Muscle. — The lids are to be separated with the ordinary spring speculum, and the ej'e is to be drawn inwards whilst the operator divides subconjunctival!}^ the tendon of the external rectus. The division of this muscle, at the commencement of the operation, facilitates the further proceedings. A vertical TREATMENT. 295 cut is now to be made with a pair of scissors through the conjunctiva and deep fascia in a line corresponding with the inner margin of the cornea, but, at 1^'" or 2'" from it, and then, with a few successive snips, the conjunctiva and subjacent fascia are to be separated from the inner side of the globe as far back as the inner caruncle. In doing this, care must be taken to divide the new insertion of the internal rectus, so that, in drawing forwards the tis- sues which have been thus detached from the globe, the tendon of the internal rectus will be raised with them. A vertical slip of the conjunctiva and fascia is now to be cut away, and the edges of the wound are then to be brought accurately together with sutures. To accom- plish this, three stitches of the finest silk will be required ; the centre one should be inserted first ; it should be passed through the slip of conjunctiva which was left at the edge of the cornea, and through the deep fascia and conjunc- tiva close to the caruncle, so that, when fastened, the eye will be drawn inwards, and the caruncle raised. The up- per and lower stitches are next to be introduced, and the assistant then gently inverts the e3^e whilst the threads are being tied. When all is completed, the e^^e should have a decided inteinial strabismus, as the after result is always considerably less than that which is obtained at the time of the operation. For the first twentj^-four hours after the operation, a fold of linen, wet with cold water, should be applied over the closed lids, and it may be con- tinued as long as the e^^e feels hot or painful. The stitches should be removed about the fourth or sixth day after the operation. 296 TARALYSIS OF CILIARY MUSCLE. PARALYSIS AND SPASM OF THE CILIARY MUSCLE. Paralysis of the Ciliary Mlfscle. — This affection is usually occasioued by some depressing illness, and especially fever and diphtheria. It is generally first no- ticed during the convalescence, when it is discovered accidentally by the patient. The paralysis varies greatly in its extent, but it is seldom complete. It mostly attacks children, but I have met with it once in an adult, an ac- count of which case I published in the " Lancet."* Paralysis of the ciliary muscle may be induced arti- ficially by frequent instillations into the eye of a strong solution of atropine (F. 14). Symjjfoms A loss of the accommodative power of the eye in proportion to the degree of the paralysis; things far off are seen clearly, but those which are near are either very misty or quite undistinguishable. The far |X)int of vision is unaltered, but the near point is carried to a distance from the eye. With a convex glass near objects are again rendered distinct ; the strength of the lens which an emmetropic eye affected with paresis requires for near vision, affords a fair estimate of the loss of power it has sustained. In a severe case the patient may be unable to see distinctly No. 16 of Jaeger, and yet with proper convex glasses read with facility No. 1. The following account of a child who was under my care, suffering from paralysis of the accommodation of the eye, is a good ex- ample of this disease. f W. 11., set. 11, a pale, delicate, but bright and intelligent lad, was brought by his father to the hospital on account of what appeared a sudden great impairment of vision of both e3^es. His history was, that up to a fortnight pre- * Lancet, May 11, 1861. f Ibid., October 14, 18G2. SPASM OF CILIARY MUSCLE. 297 viously he had always had good sight, and could read and write with perfect ease. Six weeks before coming to the hospital he had a low fever, from which he made a fair recovery, but was much reduced hj it. One day, shortly after his illness, he discovered, on attempting to read, that he was unable to do so, but that he could distinguish ob- jects at a distance. Examined with Jaeger's test-types, he could only read No. XVI at fifteen inches from his e3'es, but he could with facility tell the hour of the hospital clock at twenty-six feet. With a convex lens of 24" focus he could read at twelve inches No. XII ; with a lens of 18" focus No. VIII; with one of 12" focus No. IV; and with a 9" focus lens No. I. This bo}^ was treated with purgatives, iron, good diet, and perfect rest to eyes, and within a month he was able to read No. I perfectly with either eye, and could see as well as ever he did. The prognosis is favorable. All the cases I have seen have ultimately recovered. Ti^eatment. — Absolute rest to the eyes; no convex r glasses should be given to allow the patient to read. For i, children, the preparations of barlv or iron (F. 110, 111, \ 116, 117) should be prescribed, with change of air. For \ adults, the mist, acidi cum cinchona (F. 61), or the mist. I ferri perchlor., either with or without small doses of strych- \ nia (F. 69, 70). As a local apj^lication^iho, Gycs ma3^be frequently bathed with cold water, or a cold douche may be used with the lids closed. Spasm of the Ciliary Muscle is a rare but an occa- sional complication of hypermetropia, which it masks by rendering the q\% temporarily myopic, so that distant vision is improved by concave glasses. , It is usually in- duced from overstraining hypermetropic eyes in repeated endeavors to read or do close work, without the aid of 298 DIPLOPIA. proper convex glasses. It is productive of ])ain and a feeling of tension of the eyes after using them for a short time at near objects, as in reading, writing, &c. This affection may be diagnosed by the ophthalmoscope, when, in spite of the apparent myopia, the eye exhibits a hyper- metropic refraction. It may also be detected b}' placing the eye completely under the influence of atropine, so as to paral^^ze the ciliary muscle, and then testing the re- fraction with convex glasses. See article Hypermetropia, page 2t0. Spasm of the ciliary muscle may be caused artificially by applying the Calabar bean to the eye. See article Calabar Bean, page 110. Treatment. — Order the patient to abstain from all work, and use the guttoe atropioe (F. 14) twice daily for several days. The eye may be then tried with convex glasses, and having ascertained the degree of hjq^ermetropia, suitable spectacles may be ordered, but they should not be worn until the eyes have had at least live or six weeks' complete rest. DIPLOPIA. Diplopia, or double vision, is produced b}' any cause which prevents the optic axes from being directed jointly on the same point, so that the impressions cannot fall on corresponding parts of the two retina. Two objects are seen, a true and a false one, the latter varying in position with respect to the former according to the strabismus which is given by the excess of power in one or more of the ocular muscles. The existence of diplopia of course implies that the patient has binocular vision. Thei'e are two forms of diplopia, homonymous and crossed. Homonyynous or direct diplopia is met with in conver- gent strabismus, when the rays from the object fall in one ACTION OF PRISMS. 299 eye on the retina internal to the j-ellow spot. The false impression is projected outwards, and, if emanating from the right eye, is seen on the right or outer side of the true object. Grossed dijplopia occurs in external or divergent stra- bismus, when the rays from the object are brought to a focus in one eye on the retina external to the yellow spot. The false image is projected inwards across the nose : thus, if it proceed from the right eye it is seen on the left of the true object. THE ACTION AND USES OF PRISMS. The rays of light as they pass through a prism are de- flected towards its base ; hence it is, that if a prism is placed in front of the eye with its base towards the nose, the rays being bent inwards will be brought to a focus at a point internal to the yellow spot. The patient would now have diplopia ; but in order to unite the two images, and bring them on corresponding parts of the two retinie, he squints involuntarily outwards, and if the prism is a weak one, he succeeds in overcoming the displacement. The strabismus which is thus produced is called a correc- tive squint. But if the prism is strong, the patient is unable in this manner to correct the displaced image, and he has diplopia. Prisms will be found useful — 1. To ascertain the presence of binocular vision. 2. To test the strength of the muscles of the eye. 3. To wear as spectacles to correct diplopia. 1. To ascertain the j)7^ese^ice of Binocular Vision, that is, to detei'mine whether the patient uses both eyes in looking at an object. Place a prism of about 12° in front of one eye with its base outwards, if there is at once a corrective inwards squint, we may be satisfied that the 300 ACTION OF PRISMS. patient eiijo^ys binocular vision. If, however, there is no movement of the eye, and no diplopia, it shows that the patient does not nse that eye, but that he is looking with the other, and has not therefore binocular vision. If now the prism is placed before the eye which he does use, it will at once move slightly inwards, but it will not be a corrective squint, for the other eye will at the same time go an equal distance outwards, showing that it is only an associated movement. This mode of examining the eye is often of great service in detecting impostors, who, for some reason known only to themselves, are feigning the loss of sight of one e^'e — in many cases for the sake of compensation after injur3^ 2. To test with Prisms the relative Strength of the Iluscles of the Eye. — A normal eye can overcome a prism of from 16° to 24° with its base turned outwards ; but with its base inwards, only one of from 6° to 8° — that is to say, by a corrective squint it can so readjust the dis- placed image on the^ retina, that there is no diplopia, but binocular vision. In order to determine the degree of in- sufficiency of power of the internal recti, try what is the strongest prism wath its base turned outwards each eye is able to overcome. A lighted candle should be placed seven or eight feet in front of the patient, at which he is to be directed to look. If he is short-sighted, sufficiently powerful concave glasses should be given to him to enable him to see the light distinctly. Prisms of increasing strengths should now be held in succession with their bases outwards before one e^e, until it is decided which is the strongest he can see through without diplopia. The power of the prism which he can thus overcome, compai-ed with that which a normal eye can master, will indicate the degree of insufficiency of the internal rectus of that eye. The other eye must then be tested in a similar manner. It will be thus sometimes found that the strength of the ACTION OF PRISMS. 301 internal mnscles has been so reduced, that instead of being able to correct the displaced image produced by a prism of 16° to 24° as in the normal eye, they can only overcome one of from 4° to 6°. Conversely, the strength of the external recti may be ascertained by testing the eyes with prisms with their bases directed inwards. An- other method of measuring the strength of the muscles of the eye is as follows : A normal eye can onl}' overcome a prism of from 1° to 2°, if the base be turned either ujd wards or downwards. Place, therefore, in front of the e3'e a prism of a higher degree, and diplopia will be produced ; the false object will be projected either directly above or below the true one. If the prism is held with its base upwards, the false image will appear below ; and if the base is placed down- wards, the wrong impression will show itself above the true one, but they will both appear in the same line. This, however, is on the supposition that the external and internal recti of the two ejes exactly balance each other. If they do not^ the false object will not only ap- pear either above or below the true one, but it will be cast either to its outer or inner side, according to the predominance of power of the external or internal recti, and the diplopia will be then either crossed or homony- mous. A slip of red glass placed in front of one of the ej'es will at once determine the form of the diplopia, by giving a colored tint to one of the objects, and thus in- dicating which of the two is the false impression. The extent of the insufficiency ma}^ then be ascertained by trying what prism, placed in front of the one with its base upwards, will restore the false and true images to a di- rect line one above the other. Of course, if the diplopia is found crossed, the prisms must be tried before the e^-e with their bases turned inwards ; and, if homonymous, with their bases placed outwards. If the diplopia is 26 302 PARALYSIS OF MUSCLES OF THE EYE. crossed, it indicates an excess of j>owcr in the external recti, and consequently an insufficiency of the internal muscles ; and the reverse if the diplopia is homonymous. To tvear as Spectacles to Correct Dij)lojna — In cases of paralytic strabismus, prisms are often of great service, and especially during the progress of recovery from palsy of the sixth, or partial paralysis of the third nerve, in which the internal rectus is the only muscle, or the one principally affected, and where from special reasons the patient objects to keep the eye covered to avoid the diplopia. The spectacles should be furnished with a piece of plane plate glass for the sound eye, and with a rightly adjusted prism for the paralytic one. Whilst using the prism, the patient should be kept nnder obser- vation, as, if the case is progressing to a favorable termi- nation, the prism will require to be frequently changed for another of a lower degree, as the paralj'zed muscle gradually regains power, until, at last, its use ma}^ be abandoned. PARALYTIC AFFECTIONS OF THE MUSCLES OF THE EYE. The subject of paralysis of the separate nerves which suppl}^ the muscles of the ej^e, is involved in considerable obscurit}', as although in man}^ cases the diagnosis of tlie paralysis is clear, 3'et in a vast number it is difficult to assign awy satisfactory explanation for the sudden or gradual loss of power in the structures supplied by one particular nerve. Either the third, fourth, or sixth nerve may become paralyzed, without there being evidence of disease in any other portion of the nervous system. The loss of power may be sudden, or it may be gradual, the paralytic symptoms increasing daily until they have reached a certain point, at which, for a time, they usually remain stationary. After a variable interval, the nerve, CAUSES OF PARALYSIS. 303 as a rule, begins to recover its tone, and the parts sup- plied by it ultimately resume their normal action. The immediate result of paralysis of one of these nerves is a strabismus, caused by a loss of the balance between the muscles of the affected eye. This is termed a jyaralytic sti^abismus, to distinguish it from those forms of squint which are dne to some anomal^^ in the refrac- tion of the eye. The paral3^tic strabismus has this char- acteristic, that whereas, in the concomitant squint, the primary and secondary deviations are equal; in the para- lytic, the secondary is greater than the primary. This is easily seen by making the following examination. If the sound eye be covered with the hand, and the patient be directed to look at a given point, the primary devia- tion or movement of the paralyzed eye will be far less than the associated or secondary movement of the sound one. Paralysis of one or more of the ocular nerves may be caused by — a. Intra-cranial disease. /5. Intra-orbital disease. y. Blood-poisoning, such as syphilis, rheumatism, and gout. 8. Reflex irritation. a. From Intra-cranial Disease. — When paralysis of the ocular muscles proceeds from disease of the brain, it is seldom confined to the structures supplied b}^ one par- ticular nerve ; or if during the early s^^mptoms only one nerve is involved, there are usually other indications of cerebral mischief. The patient totters or trips in walk- ing, or has pain or giddiness in the head, or, perhaps, has some loss of power in the muscles of expi-ession, or a diminution of sensibility in the skin of the face. /?. From Intra-orbital Disease. — Pressure upon any of 304 PARALYSIS OF MUSCLES OF THE EYE. the ocular nerves in their course along the orLit to the eye will cause a partial or complete paral3'sis of their functions. This may be induced by a tumor within the orbit, or by an orbital node, or by some inflammatory or specific exudation either around the nerve or within its sheath. y. From BJood-jJoisom'ng. — To either sj^philis, rheuma- tism, or gout, many of the cases of paral^'sis of one of the motor nerves of the eye are to be attributed. A thick- ening of the fibrous sheath of dura mater, through which the nerve runs in its passage to the orbit, or some inflam- matory exudation peculiar to the affection from which the patient suffers, may compress the nerve and paralyze its functions. We have illustrations of analogous forms of local palsy in the paralysis of the muscles of the face, from palsy of the portio dura of the seventh nerve, and in facial anaesthesia from palsy of the fifth. Both of these examples may undoubtedly be due to a pressure on the nerves, either from an inflammator}^ thickening of neigh- boring structures, or from some morbid deposit depend- ent on a blood-poison. 8. From Refiex Irritation. — It is always difficult to ob- tain direct evidence to prove that the functional disturb- ance of a nerve is dependent on distant irritation. I think, however, that there can be no doubt but that many of the forms of local paralysis which are met with both in the child and the adult are due to this cause, and that frequentl}^ the palsy of an ocular nerve may also arise from it. The most striking illustrations of this class of disease are to be found in the cases of infantile paralj'sis, where a single muscle, as the tibialis anticus or the long extensor of the toes, or a group of muscles, as the flexors or the extensors of the leg, become suddenly deprived of power. Mr. William Adams, in speaking of intautile paralysis, says : " It is frequently neither preceded nor PARALYSIS OF THE TIIIllD NERVE. 305 accompanied by any cerebral sjnnptoms, and, even when such symptoms show themselves, they are generally of a transient character." And further on he remarks: "This form of paralysis generally takes place during the period of first dentition, and would seem to be connected with the irritation attending this process ;" and, " that a marked characteristic of this affection is a tendency to spontaneous cure."* On inquiring into the history of many of the cases of pais}' of an ocular nerve, no s3^mptoms of S3'^philis, rheu- matism, or gout are to be detected, and there are no evi- dences of brain disease or mischief within the orbit. A further investigation, however, will frequently discover as the cause of the palsy some eccentric irritation in a disorder of the liver, stomach, or some other portion of the intestinal canal. The analogy between infantile paralysis and some of the cases of palsy of the ocular muscles at once becomes manifest. In both, cerebral symptoms may be wanting, or may have been only transient ; in both, remote irrita- tion may be the exciting cause of the palsy. In children it is usually dentition, and in adults a derangement of the abdominal viscera; and, lastly, in both we have the same tendencj' to spontaneous cure. The nerve which is, I be- lieve, the most frequently affected from reflex irritation, is the sixth. Before describing the symptoms which indicate paral}^- sis of one or more of the muscles of the ej'e, I will first briefly refer to the anatomy and function of each of the motor ocular nerves. The Third Nerve — mofot^ oculi — is the largest of the three motor nerves which supply the muscles of the e3'e. * Chib-Foot, by William Adams, pp. 61, fl2. 26* 306 PARALYSIS OF MUSCLES OF THE EYE. In its course along the outer wall of the cavernous sinus it divides into two branches, superior and an inferior^ which enter the orbit through the sphenoidal fissure, pass- ing between the two heads of the external rectus. a. The superior division supplies. The levator palpebrse. The superior rectus. [i. The inferior division supplies. The internal rectus. The inferior rectus. The inferior oblique, and a branch to the lenticular ganglion (its short root). In addition to the above-named, the third nerve through its branch to the lenticular ganglion supplies, under the name of the ciliary nerves, the muscular structures within the ej'e, the ciliary muscle, and sphincter pupillse of the? iris. In the outer wall of the cavernous sinus the third nerve communicates with the ophthalmic division of the fifth, and with the cavernous plexus of the s^ympathetic. The functions of the third nerve are : to preside over the action of the muscles to which it sends branches, and, under the influence of light upon the retina, to effect the contraction of the pupil. " The motor action of the third nerve may, therefore, be excited through the optic nerve. There can be no doubt, indeed, that this is the ordinary method b}^ which contraction of the pupil is produced during life ; the stimulus of light falling upon the retina excites the optic nerve, and through it that portion of the brain in which the third nerve is implanted."* Paralysis of the third nerve may be either comj^Iete or 2:>a7^tial. * Todd and Bowinau's Physiological Anatonij-, 1st edit., vol. ii, p. 103. PARALYSIS OF THE THIRD NERVE. 307 When the paralysis is covijylefe, there is an al)sohite loss of i^ower in all the structures of the eye supplied b^' the third nerve. The levator palpebr^e being palal^zed, the upper lid droops over the 'eye, and cannot be raised by the patient. The superior, inferior, and internal recti, and the inferior oblique muscles, have ceased to exercise any control over the movements of the globe, and the eye is under the dominion of the external rectus and the su- perior oblique, which, acting together, draw the globe outwards and slightly downwards. A strong divergent strabismus is thus given to the eye, and the patient has crossed diplopia, the false object appearing across the nose on the other side of the true one. See Crossed Diplopia, page 298. But, in addition to this, the pupil is widely dilated, and from paralysis of the ciliary muscle the accommodation is destroyed. From the complete re- laxation of so many of the ocular muscles, there is gener- ally a slight protrusion of the globe. If the patient be directed to close the sound eye, he will generally walk with an unsteady gait, and miss the objects he endeavors to seize. Such are the symptoms of a complete paral3'sis of the third nerve ; but it is seldom, except in cases of cerebral disease or of tumors in the orbit, that all the branches of the nerve are thus affected. Partial paralyKis of the third nerce mny exist in two forms. a. There may be a diminution rather than absolute loss of power in all the structures which the nerve supplies, and the patient then exhibits the sjiuptoms already- de- scribed, but modified in degree. The ptosis is only par- tial ; the pupil is dilated but not to its utmost, and the accommodative power of the eye is diminished ; there is a divergent strabismus with crossed diplopia, but it is not extreme, and, with an extraordinary- effort, the pa- 308 PARALYSIS OF MUSCLES OF THE EYE. tient can draw the eye either slightly- inwards, upwards, or downwards. /5. In many eases, however, of partial paralysis of the third nerve, some of its filS,ments only are affected. The loss of power may be confined to one or more of the recti muscles, an}' one of whicli may be separately paralj'zed ; but the pals}^ is seldom, if ever, limited to the inferior oblique. The muscle which is the most frequently in- volved, is the internal rectus ; it is rare for the superior or inferior rectus to be paral^'zed whilst the intenial muscle remains intact. The pupil is generall}' more or less dilated, but I have seen it in exceptional cases of its normal size ; the levator palpebrae frequently retains its influence over the upper lid, even when one or more of the muscles of the eye are paral^'zed. There is always some diplopia, the false object var^'ing in position with respect to the true one, in accordance with the muscle or muscles which have lost their power, thus : In paralysis of the internal rectus^ there is a divergent strabismus, but the eye can be turned upwards or down- wards. The diplopia is crossed, and the false object is on a level with the true one. In paralysis of the superior rectus^ the e3'e is displaced downwards and outwards b}' the combined action of the inferior and external recti and superior oblique muscles, whenever an attempt is made to look up. The diplopia is crossed, and the false object is above the level of the ti'ue one. In paralysis of the inferior rectus^ the eye deviates upwards and outwards by the combined action of the superior and external recti, and the inferior oblique mus- cles, when an effort is made to look down. The diplopia is crossed, and the false object is projected below the level of the true one. PARALYSIS OF THE FOURTH AND SIXTH NERVE. 309 The Fourth Xerve — the trochlear — the smallest of the cerebral Jierves, passes along the outer wall of the cavern- ous siuus, and enters the orbit by the sphenoidal fissure. It then mounts above the other nerves, and running close to the periosteum of the roof of the orbit, it applies itself to the orbital surface of the superior oblique muscle. As it traverses the Avail of the cavernous sinus, it communi- cates with the s^-mpathetic through filaments from the carotid plexus, and as it enters the orbit, it occasionall}'^ gives a branch to the lachrymal nerve. The function of the fourth nerve is entirel}' motor. In paralijsis of the fourth nerve^ the earh' symptoms are often obscure and easily overlooked ; but when the palsy is complete, they are usually sufficiently marked to be diagnosed by a careful examination of the eye. It should be remembered that the function of the superior oblique, in health, is to roll the eye downwards and out- wards, and that therefore no defect of sight, arising from a want of power in this muscle, Avill be noticed b}' the pa- tient so long as his e^-es are fixed on objects above the horizontal mesial line. The Hympfoms which characterize pais}" of this muscle are, that whenever an attempt is made to look down- wards, the affected eye is drawn slightly upwards and inwards, and the patient has homonymous diplopia, the false object appearing to the outer side and below the level of the true one, and slanting towards it. The in- terval between the true and false impressions, both in latitude and elevation, are increased as the globe is ver- tically depressed. The Sixth Nerve — aJnlKeens — crosses the cavernous siuus, lying close against the outer side of the internal carotid arter3\ It enters the orbit through the sphenoidal fissure, passing between the two heads of the external 310 I'AK. \ LYSIS OF MUSCLES OF THE EYE. rectus, to the ocular surface of which muscle it is dis- tributed. In its passage through the cavernous sinus, it receives s^^mpathetic filaments from the carotid plexus, and a branch from Meckel's ganglion. The function of the sixth nerve is entirely motor. In pcn-alysis of the sixth nerve there is a marked in- ternal strabismus; the e3-e, when the palsy is complete, cannot be drawn outwards beyond the mesial line of the orbit, but it can be turned freely in all other directions. There is homonymous diplopia, the false image being projected to the outer side of the true one. If, with the sound eye closed, the patient endeavors to seize an object, he misses his aim, the hand passing to its outer side. In walking, he generally turns his head rather towards the side opposite to that of the affected ej'e, so as to avoid the diplopia by not looking outwards. From cerebral disease or from tumors of the orbit, all the ocular muscles ma}- be paralyzed; the eye is then rendered prominent and stationary in the centre of the orbit. The p7'ognosis of the paralytic affections of the mus- cles of the eye, is determined b}' the following considera- tions. a. Tlie Cause of the FaraJi/sis. — When the loss of power pi'oceeds from some syphilitic, rheumatic, or gout}' dis- ease, or from some reflex irritation, the prospect of re- covery, under suitable remedies, is favorable. When, however, the paralysis arises fi'om intra-cranial mischief, and is associated with other cerebral symptoms, the prog- uosis is bad. y5. TJie Extent of the Pcn-ohjsis, whether it is partial or complete, or confined to the muscles supplied by one nerve, is an important point to decide. The prognosis is alwavs most favorable when the paralysis is partial and PARALYSIS OF THE SIXTH NERVE. 311 limited to one ocular nerve, and when there are no other symptoms of disease of the nervous system. y. The. length of time the Paralysis has lasted. — If the loss of power has been persistent, and no improvement has taken place in spite of judicious treatment, the prog- nosis is unfavorable. There are, however, man}^ cases in which recovery progresses to a certain point, and tlien ceases ; tlie paralyzed muscle does not completely regain its former tone, and a sliglit strabismus with diplopia remains. For such patients much may be done by local treatment. Treatment. — If the paral^'sis is due to s^'pliilis, rheuma- tism, or gout, the patient must be treated constitutionally, with tlie medicines suited to these special diseases. In most cases benefit is gained from small and repeated doses of the iodide, or the iodide and bromide of potas- sium (F. 74, 77), or of the iodide of potassium combined with iron (F. 73). The bowels should be freel}^ oiaened by a purgative ; and counter-irritation may be used behind the ear, either by rubbing in a stimulating liniment, or by applying a small blister. In syphilitic cases, pil. hy- drarg. subchloridi comp. gr. 5, may be given every other night for a short time, or a little of the unguent, hydrarg. may be rubbed night and morning into the temple of the affected e^'e. Where reflex irritation may be reasonably expected to be the cause of the paralysis, as in certain cases of palsy of the sixth nerve, the source of the mis- chief must be sought for in some functional derangement of abdominal viscera. The important connection between the sixth nerve and the sj^mpathetic is, I think, quite suf- ficient to account for its being prejudicially influenced by visceral irritation. To relieve the diplopia, which is so distressing to the patient, the aflTected eye should be excluded, either by being covered with a bandage, or by the use of a pair of 312 PARALYSIS OF MUSCLES OF THE EYE. spectacles witli large curved glasses, one of wliich has been completel}' darkened. In certain cases, prisms are of the greatest service in uniting the double images, but it must be remembered, in using them, that they will have to be repeated!}^ changed, as the palsied muscle re- gains its power. For the internal strabismus, from para- lysis of the external rectus, the prism must be placed with its base outicards ; and for the external strabismus, from paralj'sis of the internal rectus, the prism must be used with its base inwards. When the paralysis is probably dependent on a local affection of the nerve, as from some rheumatic or gouty effusion, fai'adization is often of the greatest service, but it should not be recommejided if there is any reason to suspect cerebral disease. Under one or other of the methods of treatment I have described, the majority of the cases of palsy of one of the ocular nerves will steadily progress to complete recover3\ There are, however, occasionallj^ instances when the remedies fail, and the muscle having regained a certain amount of power ceases to improve. When this happens, and the strabismus and diplopia haA'e continued stationar}' for some months, an operation maj' be per- formed with advantage, to restore the balance of power between the muscles. If the paralytic strabismus be di- vergent, the external rectus may be divided ; and should this fail, the internal rectus may be brought forward, as recommended in the article Strabismus, page 293. If, however, the remaining strabismus be convergent, the internal rectus must be divided. FOREIGN BODIES WITHIN THE EYE. 313 CHAPTER yill. special injuries of the eye. foreign bodies within the eye. The lodgement of a foreign body within the Eye is one of the most serious injuries which can happen to that organ, and tlie importance of ascertaining correct!}', as soon as possible after the infliction of an injur}-, wliether there is a foreign body within it, cannot be over- estimated. The prognosis of the case rests entirely on the elucidation of this one point. Every penetrating wound of the globe should be spe- cially examined witli reference to the possibility of tliere being a foreign body within the eye. The dangers of a foreign bod}^ within the eye are : 1. The risk of the eye beiug completel}' destroyed by the inflammation which its presence may excite. 2. If the eye has been destro^'ed by the inflammatory action which the foreign body has induced, the stump, or that which remains of the eye, will be liable to repeated attacks of inflammation so long as the foreign body con- tinues imbedded in it; and with each attack there will be an increased danger of the other eye becoming afl[ected with sympathetic ophthalmia. All the evidence we can collect ma}^ be in favor of there being a foreign body within the eye ; 3'et if we cannot see it, and we have no reason to believe that it is buried within the lens, we must wait for symptoms, and treat them as they arise. The progress of the case will, as a rule, quickly determine whether there is a foreign body 314 SPECIAL INJURIES OF THE EVE. within the e^'e, although in some exceptional instances it excites but little if any irritation. The symptoms which strongly favor the presumittion that a foreign body is within the eye when a careful ex- amination fails to detect it, are : a. An increase or a continuance of the inflammation primarily excited by the injury in spite of all the reme- dial agents which may have been used to arrest it. /5. If the first inflammator}' symptoms have subsided, the continuance of a subacute choroido-iritis or choroido- retinitis, uninfluenced by proper local and constitutional treatment. y. The non-union of the corneal wound, when the cornea has been the part of the eye involved in the in- jury ; or the only partial closure of the wo'und, leaving a fistula through which there is a constant drain of the aqueous, causing the iris to lie in contact with the cornea. 8. Severe and continued pain in the e3'e, unpropor- tioned to the apparent existing inflammation, and un- alleviated by the ordinary local applications and medi- cines. Treatment of For-eign Bodies xcithin the Eye. — In all cases of foreign body within the eye, the treatment un- doubtedly is — if it can be seen and the removal of it is practicable — to take it awa}^ But the object may be so placed that it can be seen, yet from its situation an at- tempt to remove it will incur a risk of loss of the eye, or, from the difficulty of reaching it, the operation will probablj' fail. How, then, should we act ? M}' answer to this is : 1. If it is creating irritation, endeavor to remove it, as, though failure may be the result, jet a chance has been afforded to the eye, which, had it been successful, might have saved it. INJURIES OF THE EYE FROM ESCHAROTICS. 315 In all cases where the surgeon deems it right to at- tenii)t the removal of a foreign body from within the eye, he ought to have a discretionary power, that if he fail to find it, he may remove the globe whilst the patient is still under chloroform, if ciix-umstances render it ad- vii>aljle. 2. If, however, the foreign body is creating no irrita- tion, and there is a fair amount of vision, and an attempt to remove it would greatly hazard the eye, it shoidd be left alone ; but the patient should be either kept under constant observation, or be cautioned that as soon as any symptoms of irritation show themselves, either in the in- jured or the sound e^'e, he must seek the aid of his sur- geon. In every case wdiere the eye is destroyed for visual })urposes by the inflammation induced by a penetrating wound, and there is reason to believe that a foreign body is lodged within the globe, the only treatment to be adopted is to excise it. It has ceased to be an organ of vision, and at some future period it may, and very ; probably will, become a source of much danger to the f sound e3'e. INJURIES OF THE EYE FROM ESCHAROTICS. Quick. Lime, or lime before it has been slaked by the addition of water, is the most destructive agent that can come in contact with the surface of the eye. If it is in sufficient quantity, and is allowed to remain long enough in apposition, absolute destruction of the part ensues, a slough follows, and complete loss of the eye is a not in- frequent result. In the smallest quantity it is a most powerful irritant ; a spasmodic contraction of the orbicu- laris tightly closing the lids upon the globe, and a copious flow of tears follow the introduction of even a particle of 316 SPECIAL INJURIES OF THE EYE. lime into the eye. The epithelium is at once whitened and destroyed, aud a sharp clear line will indicate the boundary of the part which has been aflected b}" the lime ; outside this boundary the conjunctiva is excessively red and more or less chemosed ; and the lids, if the injury is severe, are oedematous. If the epithelium only is destroyed, it will be replaced, and no markings of the injury will remain ; but it is sel- dom, if ever, that the action of unslaked lime is thus limited ; the Mhole thickness of the tissue with which it comes in contact is usuall}' destro3'ed b}' it, and dense contracted cicatrices are the result. Mortar, Lime, Plaster, and the other combinations of lime used for building purposes, differ only in degree from lime in the way in which the}' affect the eye. Their action is not quite so rapid or so acute as unslaked lime ; still, if the}' are allowed to remain a sufficient time in contact with the eye or with the conjunctiva of the lids, similar results are produced ; sloughs may be formed, and suppuration ending in complete destruction of the eye may follow. Treatment of Injuries from Lime,, Mortar,, &c. — The first course to be adopted, is to remove as quickly as pos- sible erer}' particle of lime from the e^e, and, at the same time, to arrest the further destructive action of anj* frag- ments which maA' be still sticking to the conjunctival epithelium. For this purpose, a little sweet oil should at once be dropped into the e^e, and, the upper and lower lids being everted in turn, the bits of lime should be gently lifted away with a fine sjiatula or spud. Having removed all that can be seen, the upper lid being everted and the lower one drawn down b}' the finger of an assist- ant, a stream of tepid water should be gently syringed over the front of the eye and the inner surfaces of the BURNS AND SCALDS OF THE EYE. 317 litis, SO as to wash away an_y small pieces which may have escaped notice ; but, before closing the lids, two or three more drops of oil should be dropped into the eye. If the patient is seen b}' the surgeon ve7'y earHy after the accident, the eye may be s^a-inged out with a little weak vinegar and water, or the dilute acetic acid and water, about the strength of one drachm to one and a half ounces of water. An acetate of lime is thus formed, which is innocuous ; but, for this treatment to do good, it must be resorted to immediately after the introduction of the lime ; and, as such a chance is rarel}^ attbrded the surgeon, the use of olive oil in the first instance will generally be found preferable. For the first two or three days after the in- jur^', soothing applications are best suited, and the cold water dressings to the e^^e should be continued, or a lo- tion of belladonna may be substituted if the eye is very painful. Opiates should be given at night if the pain pre- vents sleep. Burns and Scalds op the Eye. — Hot fluids, accord- ing to the intensity of their heat, redden, vesicate, or even destroy the conjunctival surface of the eye or lids with which the}" come in contact. They produce the same immediate eflTect on the conjunctiva of the eye as they do on the skin covering the body.; but the delicacy of the textures of the eye, and the importance of the in- tegrity of each for the well-doing of the whole, render what would be a slight scald elsewhere, a severe injury to the eye. Treatment. — When the patient is first seen, a few drops of olive oil should be dropped into the e^^e, the lids should be then gently closed, and some cotton-wool laid loosely over them, which should be kept in its place b}' a single turn of a light bandage. The dropping of oil into the eye may be repeated two 27* 318 SPECIAL INJURIES OF TUE EYE. or three times during the (lay, and each time the bandage is removed, the eye and lids shoukl be waslied with a gl^-- cerine lotion (F. 44), free of any discharge which may have accumulated. If the lids are severely burnt or scalded, previously to applying the cotton-wool, lint soaked in carron oil or equal parts of lime-water and linseed oil, should be laid over them ; but, if the burn or scald is oul^' slight, a little ung. cetacei on lint will be sufficient. Opiates should be given internall}' if the patient is suffering much pain : they not only give ease and procure slee}), but the}^ exercise a specially beneficial control over the suppurative action which has to follow. Strong Sulphuric and Nitric Acids act chemically on the tissues of the e^^e, and, if in sufficient quantity, cause disorganization of the parts with which they are brought in contact, producing superficial or deep sloughs. The action of a strong acid on the eye, even in the smallest quantity, is that of a powerful irritdflt ; it pro- duces great pain and smarting, more or less oedema of the lids, and a constant flow^ of tears, with intolerance of light, which may last for many days, even though the actual injury inflicted does not extend beneath the epithe- lium of the ocular conjunctiva. The rapid flow of tears, however, which the irritation of the acid instantly excites, quickl}' dilutes it ; and if it is only a drop or a small splash which has entered the eye, the injur}' which it inflicts is comparatively slight and completel}^ remediable. Treatment of Injuries from strong Acids. — If the pa- tient is seen verj^ shortly after the accident, the e3'es should be gently syringed out with some weak alkaline solution, such as potasste bicarb, or soda" sesquicarb. gr. 5, aqute destillat. s 1, to neutralize any acid which may INJURIES FROM ACIDS. 319 yet remain ; or if this cannot be at once obtained, tepid water sliould be used. A little olive oil should be then drop[)ed iuto the eye, and this may be repeated two or three times a da}^ if it gives ease. The lids being closed, a layer of cotton-wool should be laid loosely over them, and a single turn of a bandage passed round the head to keep it in its place. When the lids are much burnt with a strong acid, an alkaline dressing should be used for the first twenty-four hours, and lint dipped in the liniment, calcis cnm creta (F. 29), should be laid over them, then a layer of cotton- wool, and a turn of a bandage over the whole to keep all in situ. The ordinary carron oil or equal parts of lime- water and linseed oil, may be afterwards substituted for the chalk dressing, and continued until the sloughs begin to separate. YiNEGAR, DILUTE AcETic AciD, Or any of the weak or dilute acids, act as irritants to the eye ; and although they do not immediately- destroy any of the tissues with which the}^ may be brought into contact, yet they often give rise to an ophthalmia which is the cause of much suffering, and in some instances even of danger to the eye. The primary treatment recommended in the cases of injury from strong acids is equally applicable to those occa- sioned b}^ the weak or the dilute. If seen early, the al- kaline solution should be used, and afterwards either soothing or astringent applications, to allay irritation, and to check, if necessary, undue secretion from the con- junctiva. In all injuries to the eyes from chemical agents, a solution of the antidote should be first used, if the pa- tient is seen sufltlcientl}' early to render its application of service. As in the cases of injury from an acid, an alka- line solution was recommended ; so in those from a strong- alkali, such as caustic potash or soda, an acid solution of 320 SPECIAL INJUUIKS OF THE EYE. one drachm of vinegar, or of the dihite acetic acid, to tiie ounce of water, should be syringed over the front of the eye and palpebral surfaces of the lids. INJURIES FROM PERCUSSION CAPS, GUNPOWDER, AND SMALL SHOT. rercussion Caps. — One of the most frequent sonrces of injuries to the eye from the use of guns, which is met with in civil practice, is from fragments of percussion caps fl^'ing otf when they are exploded b}* the hammer of the gun. This accident very rarely happens when the cai)s are of the best quality, such as are sold b}^ respectable gunsmiths for ordinary sporting purposes. It is almost invariably occasioned b}' toj' guns, bought as playthings for children, or used by itinerants at fairs and other places of public resort, for firing at a target for nuts. These common percussion caps are sold at a very low price, and are made of a brittle alloj^ instead of the best copper. In their explosion small scales are detached from them and driven with such velocity that if the}' strike the eye they usually penetrate it. Unfortunately, the victim of such accidents is more frequently some bystander or passer-by than the person who is shooting. In nearlj^ everj- case, total loss of the eye is the ultimate result of the injur}^, and in several which have come under my care, the end has been still moi-e disastrous ; the other eye has become aflected with sympathetic ophthalmia, and it also has been irreparabl}^ destroyed. Treatment. — See Treatment or Foreign Bodies in THE Eye, page 314. Gunpowder. — The near explosion of gunpowder may affect the eye in four different ways : 1. By the concussion it produces when exploded in close contiguity to the eye. GUNPOWDER. 321 2. From the burning or scorching of the surface of the ej'e, and the lining membrane of the lids. 3. From depositing in the external tissues of the eye specks of unexploded powder. 4. From grains of powder being driven with suflicient force to penetrate the globe. Treatment of Gunpowder Injuries. — The first object is to remove all loose powder, if there is an}', from the sur- face of the eje, and from between the lids and the globe. This ma}' be done by everting the lids and gentl}^ squirt- ing a stream of tepid water over the front of the e3'e, and the conjunctiva of the lids, with a syringe, or small India- rubber bottle, and afterwards hy lifting away, with a fine s})atula or small scoop, any particles of powder which may be adherent from being entangled with mucus, or with the conjunctival epithelium. The cornea should be then carefully examined, and all the unexploded grains which may be found imbedded in it should be removed with a fine needle or spud. Those grannies which are lodged deepl}^ in the true corneal tissue, and are out of the field of vision, may be left if thej^ cannot be easil}^ lifted away, as more harm will be done by injudiciously picking at them than their presence can excite. Specks of unexploded powder which are lying on the sclerotic surface of the eye may be removed, but no great effort should be made to detach them, as, beyond the slightly unseemly appearance, they seldom, if ever, do harm. Having taken awa}' all the unexploded powder, a little castor or olive oil should be dropped into the eye, and soothing applications used externally. A lotion of bella- donna (F. 32) will relieve pain, and b}' keeping the pupil dilated act beneficially in case an}- general inflammation of the ej'e should follow. 322 SPECIAL INJURIES OF THE EYE. Injuries from Small Shot, commonly used for Sporting Purposes. — The velocity and direction of the shot when it strikes the eye determine very mnch the ex- tent of the injury which it inflicts. 1. S2:>ent Shots. — If the shot is vcarhj f^penf, it may merely produce a slight concussion with ecchyniosis of the conjunctiva, from which the eye may quickly recover. If, however, there should be some irritation, it may gen- erally be subdued b}' the application of two leeches to the temple, the use of the belladonna lotion to the eye, and a few days' absolute rest. 2. Glaiwmg Shots. — A shot at full speed may strike the eye in its transit without penetrating it, and leave a deep furrow, which may very closely resemble a penetrating Avonncl. 3. Penetrating Shots. — The lodgment of a shot within the e3^e will produce all the severe symptoms which have already been described in the section on Foreign Bodies AViTiiiN THE Eye. As a rule, the eye may be considered as lost after such an accident. The passage of the shot into the eye generally inflicts such irreparable damage on the different tissues through which it passes, that all sight is at once extinguished. The eye at first becomes acutely inflamed, and occasionally suppui-ates ; but generally the acnte s^nnptoms subside, and a low form of deep-seated inflammation sets in, which ends in softening and shrink- ing of the globe. So long, however, as the shot remains within the eye, it is a constant source of danger, and may at any time give rise to an attack of s3-mpathetic oph- thalmia in the sound eye, which may cause its destruc- tion. See Treatment of Foreign Bodies -within the Eye, p. 314. EXCISION. 323 EXCISION OF THE EYE. The patient shoiild lie on his back on a couch with his face towards the light, and the eyelids be separated by the stop-spring speculum. With a pair of fine single- toothed dissecting forceps a fold of the con- junctiva and subjacent fascia is to be seized close to the cornea, and divided wuth a pair of blunt-pointed scissors, curved on the flat, as in Fig. 31. Through this opening one blade of the scissors is to be passed, whilst the other re- mains external to the e3^e, and then with a few clips the conjunctiva and fascia covering the globe are to be cut through in a circle around the cornea. An ordinary strabismus-hook (Fig. 29, p. 290) is then to be introduced in turn be- neath the tendons of each of the recti mus- cles, which are to be divided with the scissors close to their insertions in the sclerotic. Having made certain that the recti muscles are completely divided, one finger of each hand should press back the tissues on either side of the e^-^e, so as to push the globe forwards and partiall}^ dislocate it through the opening which was made in the conjunc- tiva at the commencement of the operation. By this simple mano3uvre, the next step, the division of the optic nerve, is facilitated. The cut end of the tendon of either the internal or external rectus muscle should now be seized with the forceps, and the e3'e drawn over to one side, whilst the scissors, with the blades shut and the curve towards the globe, are passed backwards between it and the surroumding tissues. As they round the j^os- terior curve of the eye, the blades should be opened, when, after gently urging them a little further onwards, the optic nerve will come within their grasp, and may be 324 SPECIAL INJURIES OF THE EYE, then divided. The eye may now be lifted with the fingers forwards, and the obliqne mnseles, or any other tissues which may be still adherent, cut through with the scis- sors, and the operation will be completed. When all the bleeding has ceased, the opening in the conjunctiva, through which the eye has been enucleated, may be closed by drawing the edges together with a fine thread, which is passed through them at different points and then tied. This is a finish to the operation, and gives an appearance of neatness to it at the time. It is not, however, essential, as the parts are afterwards com- i:)letely drawn together b}- cicatrization. In the excision of inflamed e3'es it is positivel}^ prejudicial, as it prevents the free escape of inflammatory exudations, and thus favors orbital cellulitis. Treatment after Excision of the Eye. — As a rule, the patient recovers so rapidl}^ from this operation that but little after-treatment is required. A fold of wet lint should be kept over the lids, and all discharge from the wound carefully washed away from time to time with a little warm water gentl}^ sj'ringed into the orbit with a glass S3'ringe. The wound usuall}' cicatrizes in from three days to a week, but a slight muco-purulent discharge from the orbit often continues for two or three weeks afterwards. This may be checked by a lotion of alum or tannic acid (F. 38, 47), which should be used with a syringe three or four times daily. It frequentl}" happens, that on looking into the orbit the cause of the continuance of the discharge may be seen in a small fungoid granulation sprouting from the cicatrix of the conjunctiva. This should be removed by a single snip with a pair of curved scissors. If, however, instead of progressing thus favorabl}', symptoms of orbital cellulitis come on, warmth should be applied to the wound by frequent fomentations of hot water or decoction of poppy -heads, and afterwards ARTIFICIAL EYES, 325 by a liuseed-meal poultice over the lids and brow. If the opening in the conjunctiva has been closed by a suture, it should be at once removed. It is good practice in such a case to make a free incision through the wound in the conjunctiva into the cellular tissue of the orbit, so as to give free vent to all inflammatory exudations as they are effused. B\' thus encouraging suppuration and favoring the exit of the pus, the urgent symptoms will probably be at once relieved. The bowels should be freely acted on by a purgative, and the patient should be kept very quiet in a darkened room. It is seldom that any un- toward s3'mptoms follow the operation of excision of the e3'e. Artificial Eyes. — In an ordinary case, from six weeks to two months after the operation is the best time for commencing the use of a glass eye. Time should be al- lowed for complete cicatrization to be effected, and for all swelling and discharge to subside before an artificial e^^e is introduced within the orbit. One of the most frequent inconveniences produced by too soon wearing an artificial eye is a chronic conjuncti- vitis with a muco-purulent discharge, which is often very troublesome to arrest. Another and a more serious an- noj'ance is an inflammation of the conjunctiva and sub- mucous tissue in the line on which the edge of the artificial eye rests, sometimes going on to ulceration. As the re- sult of this, cicatrices are often formed, which render the adjustment of another eye very difficult, and sometimes impossible. When a lost eye has been removed on account of the sound one suffering from sympathetic ophthalmia, an arti- ficial e^'e should not be allowed until all the sympathetic symptoms have been arrested, and the eye has remained quiet for at least six months. 28 326 ARTIFICIAL EYES. The following excellent rules are given to the patients at the Ro3'al London Ophthalmic Hospital who have had the misfortune to lose an eye. Instructions for Persons wearing an Artificial Eye. — It should be taken out every night, and replaced in the morning. To take the Eye out. — The lower eyelid must be drawn downwards with the middle finger of the left hand ; and then, with the right hand, the end of a small bodkin must be put beneath the lower edge of the artificial eye, which must be 'raised gentl}^ forwards over the lower eyelid, Avhen it will readily drop out. At this time care must be taken that the eye does not fall on the ground, or other hard place, as it is very brittle, and may easil^^ be broken by a fall. To put the Eye in. — Place the left hand flat upon the forehead, with the fingers downwards, and with the two middle fingers raise the upper ej-elid towards the e3-e- brow, then, with the right hand, push the upper edge of the artificial eye beneath the upper eyelid, which may now be allowed to drop upon the eye. The eye must then be supported with the middle fingers of the left hand, whilst the lower eyelid is raised over its lower edge with the right hand. After it has been Avorn dail}^ for six months, the pol- ished surface of the artificial eye becomes rough ; when this happens, it should be replaced by a new one. Unless this is done, uneasiness and inflammation ma}' result. EPIPHORA. 327 CHAPTER IX. DISEASES OF LACHRYMAL APPARATUS. Epiphora, or a watery ej'e, is an overflow of tlie tears. This overflow is not caused by an undue secretion of the lachrymal gland, but by some imperfection in the lach- rymal apparatus, through which the escape of the tears is retarded ; the}^ consequently accumulate in the lacus at the inner angle of the eye, and from tune to time flow over the margins of the lid on to the cheek. The ex- posure of the eye to cold or wind aggravates the epiphora, by stimulating the lachr3anal gland to an increased secre- tion of tears. Epiphora may arise : 1. From a displacement of the punctum loithout any mechanical obstruction in the canaliculus, lachr3'mal sac, or nasal duct. a. In old people a relaxed orbicularis frequenth^ allows the lower lid to fall from the globe and become slightly everted, and thus to draw awa}^ the punctum from its proper position with respect to the globe. /?. A similar result is seen in lippitudo, p. 342, and in all cases of ectropion of the lower lid. 2. Obstruction of the canaliculus : a. From closure of its opening into the sac. /?. From some foreign body (frequently an eyelash) or from a small chalky concretion. y. From a tarsal cyst or stye pressing upon the canal- iculus. ?>. Obstruction in the lachrymal sac or nasal duct : a. From blennorrhoea or chronic inflammation of the sac. yS. From dacryo-cystitis or acute inflammation of the sac. 328 DISEASES OF LACHRYMAL APPARATUS. f. From stricture. 8. From mechaiiical obstruction by tumors. Treatment. — As epiphora is to be regarded oidy as a symptom of derangement in some part of the lachrymal apparatus, the cause must be first detected, and then en- deavors made to remove it. When the punctum is dis- placed, the canaliculus should be slit up, and means should be taken to restore the lid, if diseased, to a healthy state, or, if everted, to its normal position. Foreign bodies or concretions in the canaliculus should be extracted. Sometimes this can be accomplished with the aid of a pair of iris forceps withov;t any cutting oper- ation ; but, if nol, the canaliculus must be laid open, when all difiiculty will be removed. The treatment of the other causes of epiphora which have been mentioned, will be found under their respective headings. Chronic Inflammation or the Lachrymal Sac — BlennorrhcBa — Tumor of Sac — Mucocele — is a disease of slow progress and long duration. The patient generally is unable to say when it commenced, so long has he suf- fered from a watery eye ; but an increase in the severity of the symptoms has induced him to seek advice. This is the tale of a large number of such cases. Symptoms. — Constant epiphora. The finger placed over the membranous portion of the sac, will detect a fulness, sometimes amounting to an absolute protuber- ance, and a moderate pressure on this will cause a regur- gitation of thick viscid mucus or muco-puruleut secretion through one or both puncta. The degree of distension of the sac varies with the duration and severit}^ of the disease. In some cases there is a mere thickening and dilatation of the upper extremity of the sac, which may be felt with the finger just below the tendo palpebrarum ; whilst in severe and long-standing cases the sac is so en- INFLAMMATION OF SAC. 329 Fig. largcd as to be expanded along the border of the orbit, and to appear as a tumor the size of a bean, corresponding in position to the inner half of the lower lid. From the constant exuda- tion from the canaliculi, the eye becomes ir- ritable, the caruncle red, and the edges of the lid excoriated. The sight is also fre- (piently dimmed from films of mucus floating in the tears across the cornea, and the pa- tient is troubled by having repeatedly to wipe away the accumulated tears from the inner angle of the eye. Treatment. — The first course to be pursued is to slit up the canaliculi, and examine with a probe the lachrymal sac and nasal duct, to determine if there is a stricture or any other change in the mucous track to account for the long-continued obstruction and discharge. A stricture may exist in three places : a. At the point whex'e the canaliculus joins the sac. /3. At the line of junction of the lachrymal sac with the nasal duct. y. Close to the opening of the nasal duct into the nose. The first and second are the most frequent sites for stricture. a. A stricture at the point where the ca- naliculus joins the sac, is recognized by the obstruction the probe meets with as it is passed onwards ; instead of entering the sac and striking against the internal bony wall of the canal, its progress is arrested by the outer membranous wall of the sac, which, when pressed upon by the point of the probe, draws inwards the mar- 28* OoO DISEASES OF LACHRYMAL APPARATUS. gill of the lid, and imparts a feeling of elastic resilience. For such a case, the following course should be adoi>ted. A guarded knife should be passed as a probe along the slit-up canaliculus until it reaches the sac, when failing to iind the opening of the duct, the guard is to be drawn back, and, with a little pressure, the point of the blade will be made to enter the membranous portion of the canal. A free opening should now be made in the sac, and the knife, having been withdrawn, the narrow end of a Weber's conical sound (Fig. 32), should be passed through the wound into the lachiTinal canal. The pa- tient should be seen daily for the first few days after the operation, and afterwards CAcry third or fourth day, in order to insert between the lips of the wound a Weber's sound, or Bowman's dilator to keep the opening in the sac from closing during the cicatrizing period, /?. If the stricture should be at the junction of the lachiymal sac with the nasal duct, a probe should be in- troduced twice a week until it passes with fa- J'lG. o3. cility ; or the narrow end of Weber's conical sound ma}', wdth a little steady pressure, be urged through the stricture, and hy a rapid di- latation assist the progress of the cure. It is to these cases that Dr. Stilling's plan of incising internally the mucous membrane of the lach- lymal canal seems suitable. The canaliculus having been laid open in the usual way, he first passes a Weber's conical sound (Fig. 32), to as- certain the position of the stricture and also to dilate sufHcientl}' the opening in the membran- ous sac to allow of the easy passage of his knife (Fig. 33). Having withdrawn the sound, he introduces his knife, with w-hich he incises the mucous membrane of the canal at the site of the stricture in three or four diflerent places until the blade can be freely turned in all directions. INFLAMMATION OF SAC. 331 From the reported eases, the success of this treatment is so great, that frequently no further passage of the probe is necessarj^ If after having dilated, the stricture, a muco-puruleut discharge continues, the sac should be washed out two or three times a week with an astringent lotion (F. 38, 47). y. When the constriction is at the lower end of the nasal duct close to its opening into the nose, the stricture should be rapidly- dilated at the first introduction of the probe by a steady forcible pressure, and the communica- tion with the nose be at once restored. A probe should be afterwards passed a few times, at interA'als of two or three da3^s, to keep the orifice patulous. In the treatment of stricture of the lachrymal passage, it is seldom necessary to use stjdes. Occasional!}', how- ever, when the constriction is close to the opening of the canaliculi, they will be found of service ; but their use should not be continued for more than a few days. The best form of style is a piece of silver wire of the thickness of a large-sized probe, cut to the length of the canal, rounded at one extremity, and the other drawn out so finely as to allow of its being bent at an acute angle to the shaft to prevent its slipping into the sac. Mr. Couper speaks favorably of probes made of the Laminaria digi- tata, which he has used to dilate the stricture. After their introduction they rapidly absorb moisture from the canal, and swell out to three or four times their original size. In those cases where there is much distension of the sac, it will be necessary to persevere in washing out the lachr^nnal canal with an astringent injection, and at the same time to give the patient some slightl}' stimulating- lotion (F. 19, 20) to drop twice a day into the inner angle of the eye. By steadily continuing this treatment the dilated sac will usually shrink to its normal dimensions. 332 DISEASES OF LACHRYMAL APPARATUS. On two occasions where the membranous portion of the canal Avas so dilated as to form a tumor Avhich ex- tended bej'ond the centre of the loAver lid, I cut down upon the swelling, and excised the whole of its expanded anterior wall. Both patients made \evy satisfactory re- coAcries. It is an operation, however, which is never needed except in extreme cases. Acute Inflammation or the Lachrymal Sac — Da- crijo-cyxtitis — usually attacks only one lachrymal sac, al- though I have seen both involved at the same time. It is generallj' preceded by epiphora or water}^ eye, and it will occasionally follow an acute attack of catarrhal ophthal- mia, when it appears as if the conjunctival inflammation had spread b}^ an extension along the caualiculi to the mucous membrane of the sac. The symjjtoms are most acute — pain, heat, redness, and swelling over the sac, extending to both the upper and lower e^'elids, which ai'e frequent!}^ so edematous as to be closed over the eye. The pain is often excessive ; the slightest pressure with the finger on the sac being almost intolerable. These s^'mptoms continue to increase, when suddenly the patient experiences a sense of relief. The in- flamed sac distended with pus has given way, and the discharge has escaped into the cellular tissue between the skin and the membranous sac. A superficial abscess is now formed, and the pus gradually makes its way to the surface, and points a little below the tendo palpebrarum. If the disease is allowed to progress untreated, the puru- lent contents of the sac are discharged through the iilce- rated opening on the face ; the inflammation subsides, and the parts slowly regain their normal appearance ; but fre- quently a fistula remains in the site of the wound which communicates directly' with the sac, and through which there is a constant flow of tears on to the cheek. The FISTULA OF THE LACHRYMAL SAC. 333 earl^' s^-mptoms of acute inflammation of tlie sac closely resemble those of a severe attack of catarrhal ophthalmia, as the}^ are often associated with a muco-puruleut dis- charge from the e3-e ; but in all cases of doubt the pressure of the finger OA'er the lachrymal sac will, by the pain it l^i'oduces, at once remove all obscurit^y. Treatment. — During the acute stage when pus is form- ing, fomentations of hot water, or of decoction of poppy- heads, should be frequently used, aud in the intervals a warm linseed-meal poultice may be applied over the part. As soon as there is reason to believe that the sac is dis- tended with pus, an external opening is to be made to give vent to it. An ordinarj' cataract knife should be made to enter the membranous sac a little below the tendo palpebrarum, and as the blade is withdrawn the incision should be carried downwards and outwards through the skin and deep tissues to the extent of about half an inch. A small strip of lint is then to be placed in the wound to prevent its edges uniting, and a linseed-meal poultice applied. In three or four days' time, when all the swell- ing has subsided, the canaliculi should be slit up, and one of Bowman's probes, or the narrow end of Weber's sound, be passed into the sac. If any stricture is detected, the probes ought to be passed twice a week for a short time. If after a fortnight or three weeks a muco-purulent dis- charge should continue, the sac must be washed out with an astringent lotion (F. 38, 40, 47), either with an india- rubber bottle with a properl}' constructed tubular nozzle, or, what is far better, with one of Wells's lachrymal sac syringes. This operation should be repeated twice a week until all discharge ceases. Fistula of the Lachrymal Sac is one of the results which occasionally follow acute inflammation and abscess of the sac. A small sinuous track exists between the sac 334 DISEASES OF LACHRYMAL APPARATUS. and the integument, through which the tears ooze on to the cheek. I have also seen a lachrymal fistula remain after the patient has given up the wearing of the old- fashioned stAde, which was introduced by an opening made in the sac through the skin just below the tendo palpebrarum. Lachrymal fistula is occasionally associ- ated with necrosis or caries of the bones foi'ming the lachrj^mal canal. Treatment. — In all fistulre connected with mucous ca- nals, the course to be pursued is, first to cure the stric- ture and restore the mucous track to a healthy state, and the fistula will then generall3' close of itself. This rule holds good in lachr3'mal fistuloe, and for this purpose the canaliculi should be laid open, and a probe passed into the sac and nasal duct to ascertain if there is any stricture or disease of the bonj^ walls. If a stricture be detected, it must be dilated with probes, or with Weber's sound, in the manner already directed in page 329. Should there be a chronic thicken- ing of the mucous membrane, with a muco-purulent dis- charge, the sac must be washed out twice or three times a week with an astringent lotion, hy means of an india- rubber bottle or Wells's lachrymal sj^ringe. If this treat- ment fail, the fistula should be laid freel}' open, into the sac, with a cataract knife, the point of which is to be passed through the fistulous opening on the face, into the membranous portion of the canal. Into the wound, thus made, a piece of lint is to be introduced, but it should be removed in twenty-four hours, after which the cut edges may be allowed to unite. This treatment, com- bined with the use of probes and syringing out the sac, seldom fails to cure the fistula. In those cases, howevei', where the fistulous opening on the fiice is large, as when a stj le has been long worn and afterwards abandoned, it EPIPHORA. 335 will be often found of service to pare the edges of the opening, and unite the raw surfaces with a fine suture. Epiphora from Mechanical Obstruction by Tumors. — The cavity of the lachrymal canal may be partially or completely occluded by tumors, which either take their origin from within the sac, or from those ^^*^- ^^• which grow from the antrum, the nostril, or from the base of the skull. It would be out of place here to discuss the nature and treatment of such growths; they will be found fully described in works on general surgery. It is sufficient to in- dicate that epiphora may be caused by the pres- ence of tumors either within or in the neighbor- hood of the laclnymal sac, that the surgeon may not disregard the possibility of their existence in obstinate cases which have persistently resisted all treatment. To SLIT UP THE Canaliculus. — There are sev- eral ways in which this operation may be per- formed. 1. The canaliculus may be laid open on Crit- chett's director (Fig. 34). The patient being- seated in a chair, the operator stnnds behind his head, and introduces the point of the instrument, which he holds between his finger and thumb, along the canaliculus, and then drawing the lid outwards, with his ring-finger, to render the parts- tense, he, with the other hand, slits up the duct, b}' passing a cataract knife along the groove of the director. Care should always be taken to keep the incis- ion external to the caruncle, as if the edge of the knife, as it is run along the director, is turned too much 336 DISEASES OF LACHRYMAL APPARATUS. towards the eye, the canalicuhis will ])e divided only up to the canmcle, beneath which the remainder of the duct will tunnel, unless, indeed, the caruncle be divided, which it is always desirable to avoid. 2. The canaliculus ma}' be slit up by Wecker's liG. 3o. ]^iiife^ which consists of a fine blade of the shape and size represented in Fig. 35, with a minute but- ton at its extremity. This is introduced into the punctum, and run along the canal, when, b^' slightly raising the hand, and giving to the blade a cutting movement, it is made to divide the canaliculus to the extent required. 3. The canaliculus ma}' be laid open by a pair of fine scissors. Obliteration op the Lachrymal Sac is an operation which has been frequently performed by some Continental surgeons of eminence, in cases of obstinate chronic inflammation, which have resisted other modes of treatment. Various means have been adopted for the purpose of destrojing the mu- cous membrane of the lachrymal canal, such as lajiug open the sac by a free external incision, and apph'ing to its interior either the actual cautery-, the galvano-cautery, or nitrate of silver, potassa c. calce, chloride of zinc, or some other strong caustic. My own feeling is decidedlj^ averse to this mode of treatment ; the few patients who have come under my notice, after having been submitted to it, have stronglj' prejudiced me against the operation. They have been illustrations of the difficult}', well known to all practical surgeons, of destro3ing a mucous canal. In each case the lachr3'mal sac was not obliterated, but the nasal and canalicular openings were completely closed, and as a result there was a quantity of pent-up secretion, which distended the sac, and formed a globular tumor REMOVAL OF LACHRYMAL GLAND. 337 below tlie tendo palpebrarum. There are few cases of chronic lachr3'mal disease which will not ultimately yield to well-directed and continuous treatment. Removal of the Lachrymal Gland. — Mr. Zachariah Laurence, in Xo. 12 of the "Ophthalmic Review," advo- cates strongly the removal of the lachrymal gland as a radical cure for lachrymal disease. He states, as the re- sult of his own experience of this treatment in abscess of the lachrymal sac, "that, after a varying time, the secre- tion of pus from the mucous membrane of the sac de- creases and finally disappears." After discussing fairly the merits of this operation, and the mode of performing it, he cites some of the evil consequences which may fol- low. "In most cases," he saj^s, "slight conjunctivitis ensues ; this, in one case, ran on to inflammation of some of the deeper structures ; which, however, gradually sub- sided under appropriate treatment, without inflicting any permanent injury to the e3^e. But by far the most serious result which may follow the operation, is ptosis of the upper eyelid. This was, in almost every case in which I observed it, of purely inflammatory origin, and graduallj' subsided spontaneouslj', but in a few instances it was apparently due to a partial division of the levator palpebra?.'' When, from au}' cause, it has been decided to excise the lachrymal gland, the operation adopted by Mr. Zach- ariah Laurence,* may be performed. An incision is to be made immediately below the upper and outer third of the orbital ridge, through the skin and the fascia connect- ing the periosteum of the orbit with the upper edge of the tarsal cartilage. The gland is then to be carefully felt for with the finger, and having made out the exact * Ophthalmic Review, No. 12, p. 367. 29 338 DISEASES OF LACHRYMAL APPARATUS. l)osition, it is to be seized with a, i)air of hooked forceps, and drawn forwards out of the wound, whilst its celhilar connections are carefully severed with the knife. Free hemorrhage often accompanies the operation, but the bleeding may generally be arrested by a stream of cold water from a sponge. The wound should not be finally closed until all bleeding has ceased. Diseases of the Lachrymal Gland are extremely rare; so seldom, indeed, is the gland affected, that in the Reports of the Royal London Ophthalmic Hospital for ten 3'ears, from 185t to 1801 inclusive, out of a yearly average of over 12,000 new cases, only twenty of "dis- eased lachrymal gland " are recorded. No doubt the lachrymal gland is often secondai'ily involved in malig- nant tumors of the orbit, but this is apt to be overlooked, from the fact that the gland is either excised, unnoticed, with the morbid growth, or else it is sloughed out by the action of the caustics, which are afterwards used to de- stroy any portions of the tumor which may have been left behind. Although the lachrymal, like all conglomerate glands, enjo3-s a special immunity from disease, yet it is not altogether exempt, and to those affections to which it may be subjected, I shall now refer. Inflammation of the Lachrymal Gland — Dacnjo- adenitis — may be either chronic or acute ; generally-, liow- ever, it is the former. It may occur without any appar- ent cause, or it may arise from injury. Symptoms. — When chronic^ thei'e is tenderness and en- largement of the gland, which can be felt by the finger, beneath the outer part of the edge of the roof of the orbit. There will be probably also some oedema of the oculo-pal- pebral fold of conjunctiva, and redness of the lid. If there is much swelling of the gland, the e^-e will be dis- placed dowuwai'ds and inwards. CYSTS OF THE LACHRYMAL GLAND. 339 If the inflammation is acute ^ there will be more pain, redness, and swelling in the region of the gland, with (L'dema of the lid, and chemosis of the conjunctiva. These symptoms may subside under treatment, or they may go on to the formation of pus. Treatment. — For the chronic inflammation of the gland small doses of the iodide of potassium (F. 74), or of the iodide of ammonium, ma}'^ be given, and an ointment of ammonii iodid. gr. 30, adipis gi'. 240, may be gently rubbed, night and morning, over the swelling. For the acute symptoms, one or two leeches may be applied to the temple, and a warm linseed-meal poultice over the eye. If the inflammation should continue, and pus form, an incision should be made in the line of the orbit to give vent to it, as soon as there is sufficient evidence of its presence. Cysts of the Lachrymal Gland — Bacryops — may arise from acute inflammation and abscess, or from injury. Their formation is apparently caused b3' an obstruction, more or less complete, of one of the excretory ducts, in which the secretion of the gland accumulates; the walls of the canal become distended, and a small elastic tumor shows itself in the localit^'^ of the lachrj-mal gland, over which the skin is freely movable. In a paper by Mr. Hulke on this subject, in vol. i of the " Ophthalmic Hos- pital Reports," he sa3's : " The most characteristic and striking sign of dacryops is the sudden enlargement which the tumor undergoes when the patient cries." If the cyst attains a large size it may seriously interfere with the movements of the eyelid. Treatment. — The most efficient method of dealing with these cysts is b}^ the establishment of a permanent ttstula on its inner or conjunctival surface, by which the tears may constantly drain away. For the mode of accomplish- 840 DISEASES OF LACHRYMAL APPAllATUS. ing this, sec Treatment of Fistula of Lachrymal Gland, in the next section.. An attempt to dissect the cyst out through an incision of the skin is apt to lead to the formation of a permanent external fistula. FiSTLLA OF THE LACHRYMAL GlxVND — Dacryops Jistu- losus — may be the result of an abscess of the lachrymal gla»d which has burst externally ; or of a cj'st of the gland or of an incised wound. There is a minute opening in the upper and outer surface of the lid, through which the tears from time to time trickle. Treatment. — The edges of the fistulous opening ma}'^ be pared with a fine scalpel, and be then brought together with a single wire suture ; or the eud of a fine-pointed cauter}', having been made hot, ma}- be introduced into the fistulous orifice ; or the galvano-caustic apparatus may be used in a similar manner. The plan of treatment, however, which was adopted bj' Mr. Bowman, in a case recorded by Mr. Hulke, * was so successful that I will quote it in detail. " A single thread of silk was armed with a needle at each end, and one of the needles was introduced into the fistulous orifice in the skin on the outer surface of the ej-elid, and carried for a short dis- tance upwards; it was then made to pierce the fibro-car- tilage of the lid and the conjunctiva, and the thread was drawn out at the inner surface of the lid. A similar manoeuvre was repeated with the other needle, and the thread was drawn out at the inner surface of the lid, at the distance of a qxiarter of an inch from the first, and a little nearer the attached border of the lid. Li this wa}- the C3'st was pierced at two points by the thread, which encircled in a loop the small intervening })ortion of tissue. The two ends of the thread were then brought * Kuyal London Ophthahiiic Hospital Kuports, vol. i, p. 288. IIYI'EIITIIOI'IIY OF LACHRYMAL GLAND. 341 out a,t the outer commissure, and secured upon the tem- ple with a piece of sticking-plaster. The presence of the thread occasioned very slight annoj^ance ; the conjunc- tiva lining the upper ej'clid became a little swollen and injected ; and tears continued to flow from the orifice in the skin, but less abundantly. Ten days afterwards, the thread was replaced by a thicker one, which produced more irritation, and the conjunctiva immediately around it became slightly granular. An attempt was now made to close the aperture in the skin. It was drawn out with a forceps and cut off with scissors, together with the little l)iece of skin immediately around it. The edges of the wound were brought together with two serres fines, which were replaced, in the evening of the same day, by slips of plaster. When she was next seen, after an interval of four days, the wound had quite healed, and the fistula in the cutaneous surface of the lid had perfectly closed." In another week the thread was withdrawn, and the small bridge of tissue which had been encircled by the loop, cut out. " This opening in the conjunctiA'a continned patent, and there was no further collection of mucus nor tears in the cj'st." Simple Hypertrophy or Chronic Enlargement of THE Lachry'mal Gland is occasionally met with. The enlarged gland forms an unsightly prominence in the upper and outer part of the orbit. Treatment. — The iniguent. ammonii iodid. gr. 30 ad adipis gr. 240, may be rubbed into the swelling night and morning, and small doses of the potass, iodid., or of the syrup, ferri iodid., may be given twice a da}'. Should this treatment have no effect, the unsightly prominence may be excised, or the whole gland may be removed. In a case lately under the care of my colleague, Mr. 29* 342 DISEASES OP TUB EYELIDS. Streatfeild, he removed the protnuliiig portion and left the remainder of the gland. The patient made a satis- factory^ recovery, and has since continued ■well. CHAPTER X. DISEASES OF THE EYELIDS. Tinea Tarsi is a disease of the follicles of the eye- lashes. It is chronic in its progress, difficult to com- pletel}^ subdue, and very recurrent. In the early stage, the margins of the lid are red and irritable ; there is at first an excessive secretion from the follicles of the cilia, which accumulates during the night, and causes the lids to be gummed together in the morning. As the disease advances, the discharge becomes purulent and cakes into scabs, which adhere to the margins of the lids and to the lashes. Small pustules then form at the roots of the lashes, and these burst and leave superficial ulcerations, which are generalh' covered with yellow crusts. The eje- lashes gradually fall out, and the edges of the lid lose their sharp outline, and become rounded, thickened, and everted. With the eversion of the tarsal borders, the punctum lachrymale is drawn away from the globe, and there is a slight but constrmt overflow of tears, which ex- coriates the lids and keeps up the redness and irritation. To this, the extreme stage of tinea tarsi, the term lipjn- hido has been applied. Tinea tarsi is very common amongst all classes, but especially amongst the poor. It is frequently associated with debility and constitutional derangement, and is one of tlie sequences of scarlatina, lueasles, and whooping- TINEA TARSI. 343 conoli. Patients who have once suffered from it arc very apt to haA'e recurrences when from any cause their health fails. Treaimenf. — One of the most important elements in the treatment of tinea tarsi is strict cleanliness. The lids should be bathed with warm or tepid water night and morning, and all scabs of dried secretion be removed be- fore the application of any of the remedial agents. On going to bed, a little of the unguent, h^-drarg. nitratis dilut. (F. 102), or of the unguent, hydrarg. nitric-oxj'd. dilut. (F. 103), should be smeared on the tarsal edges; and in tlie morning, after the lids have been thoroughly cleansed from all the discharge which has accumulated on them during the night, they should be bathed with a mild astringent lotion (F. 39, 40). The lotion may be also used several times during the day. In children, when the 63'elashes are very long, it is often of service to cv;t them off' close to the lids with a pair of scissors, as the lids are more easily kept clean when there are no lashes upon which the discharge can cake. This plan of treatment is usually sufficient to cure a slight case of tinea; but where there are superficial ulcerations or pustules at the roots of the cilia, other means must be adopted. Each morning after the lids have been freed from all discharge, a solu- tion of nitrate of silver, gr. 5 to gr. 10 ad aquje s 1, should be applied with a camel's-hair brush to the pustules or ulcerated spaces between the lashes ; or they may be touched twice or three times a week with a stronger solu- tion of nitrate of silver, or with the diluted nitrate of silver points (F. 5). In the worst cases, where the edges of the lids are rounded, thickened, and excoriated, Avith the puncta drawn away from the globe, the canaliculi should be laid open in the manner directed at page 335, so as to form conduits along Avhich the tears may flow into the sac ; and a weak solution of nitrate of silver 344 DISEASES OF THE EYELIDS. should be painted daily on the red excoriated margins. Where there is great irritabilit}- and excoriation of the tarsal edges, I have found much benefit from the use of the lotio boracis (F. 48). Whilst ordering local applica- tions to the lids, attention must also be paid to the state of the patient's health. Tonics of irou and quinine usu- ally do good, but in very chronic cases, accompanied with a thickened and eczeniatous state of the lids, small doses of the liquor arsenicalis given twice or three times a day will be often of service. It is, however, a medicine which should be seldom prescribed for jouug children. Hordeolum — i. be i-ememl)ertMl lliat even if it is a little too large, a fur- ther contraction of it will take place during the healing process, which will reduce it to its required size. 3. (jrreat care should be taken to leave a good pedicle through which the vascular sujiply of the new lid may be maintained until it ha»s become united with the parts be- neath it, and a fresh source of nourishment has been es- tablished. It is also advisable, in adapting the skin to the lid, to avoid twisting the pedicle on itself more than is absolutely necessary. 4, Before uniting the edges of the new lid to the sur- rounding skin, all bleeding should be arrested. Nothing tends more to delay primar^^ union than a clot of blood between the opposed surfaces. In nearl}" all cases where a plastic operation is required, it will be well to shorten the tarsal margin of the lid in the manner already described, so as to slightly diminish the size of the palpebral aperture. If the exposed portion of the conjunctiva is much thick- ened and granular, a portion of it also should be removed with a pair of curved scissors. Having completed the operation, a layer of wet lint should be laid over the lids, upon which a light compress of cotton-wool should be fastened with one or two turns of a roller, for the purpose of keeping the parts in appo- sition, and of maintaining a certain amount of warmth. PARALYTIC AND SPASMODIC AFFECTIONS OF THE EYELIDS. Ptosis, or a drooping of the upper ej'elid over the eye, may be due: «. To paralysis of the third nerve, or to that branch of it which supplies the levator palpebnii superioris muscle. ,i. To injury of the levator palpebrie. y. It may be congenital. PTOSIS. 359 '1. Partial ptosis may be occasionally mot with in old people, apparently dependent on a redundancy of wrinkled integument. Ptosis may be either complete or partial. In the former, the greater part of the cornea, and the whole of the pupil is covered by the lid, which cannot be raised by the will of the patient ; in the latter, the pupil is only partially hidden, and the lid can be slightly uplifted by a strong effort. The causes which ma}' produce paralysis of the third nerve, or of one or more of its branches, have been already mentioned in the section on Paralytic Affections of THE Muscles of the Eye, page 302. Ptosis from injury may be induced by a wound of the upper lid, lacerating the levator palpebr^e muscle so as to impair its function. TreatmeM. — In recent cases of ptosis arising from pa- ralysis of the third nerve, or of the filament of it which goes to the levator palpebrse, the course of treatment recommended for paralytic affections of the ocular mus- cles, page 311, must be followed. If, however, medicinal agents fail, relief must be sought from some operative proceeding. For congenital and traumatic ptosis, inter- nal medicines will be of no avail. In deciding on an operation for ptosis, it is a question w'hat amount of drooping of the lid will render surgical interference advisable. My own feeling is, that if the paral3'sis is partial, and without any effort on the part of the patient half the pupil is exposed, no operation should be performed. If, however, the palsy is complete, or only a portion of the pupil can be uncovered by a great effort, an attempt should be made to permanently raise the lid, and place it, as much as possible, under the dominion of the occipito-frontalis muscle. The various operations for ptosis are based on the one 360 DISEASES OF THE EYELIDS. endeavor to place the up[)er lid uuder the action of those fibres of the occipito-frontalis which are mingled with the orbicularis. This end may be accomplished in several ways. The following is, however, the most satisfactory operation. A horizontal incision is first made through the skin of the upper lid, about 2'" from its tarsal margin, and along its entire length; the lips of the wound are then sepa- rated b}' drawing them apart, and by a little dissection beneath the integument, until a considerable portion of the orbicularis, covering the lid, is exposed ; this is then seized with a pair of forceps, and a horizontal strip of the muscle, about a quarter of an inch in width, is excised. The edges of the wound are then brought together with three sutures, each of which is made to pass through the upper cut portion of the orbicularis. In this manner the lower part of the lid is brought under cover of the upper fibres of the orbicularis, into which the middle and outer fibres of the occipito-frontalis are inserted, and thus a certain amount of control over the upper lid is given to that muscle. In addition to this, the power of closing the lids is diminished b}- the excision of the broad baud of the orbicularis. An attempt to relieve ptosis b}' simply excising a piece of the skin of the upper lid, is generally unsuccessful. Paralysis of the Orbicularis Muscle — Lagophthal- mos — is caused by paralysis of the portio dura of the seventh nerve, and is usually associated with pais}' of the other facial muscles. It is generall}^ due to some local affection of the portio dura, either as it traverses the bony canal in its passage from within the skull, or after it has emerged from the st3-lo-mastoid foramen. It may, also, arise from disease of the brain, as in cases of hemiplegia. According to Dr. Trousseau, it is when the facial palsy is PARALYSIS OF THE OHBICULARIS MUSCLE. 361 dependent on local causes, and not on brain disease, that the paral^'sis of the orbicularis is most complete. The knowledge of this fact is used by him as a point in diag- nosis; "hence," he says, "if a hemiplegic patient be asked to shut his eye, he does it completelj^ enough to hide the globe of the eye, whilst the eyeball remains uncovered in cases of paralysis of the seventh pair."* The diseases which lead to paralysis of the portio dura of the seventh nerve are, syphilis, rheumatism, and goitt, either of which may cause pressure on the trunk of the nerve, from an exudation in its immediate vicinity, or from an inflammatory thickening of the nerve-sheath. Palsy of the facial ma}^ also be induced by the nerve being compressed by tumors near the angle of the jaw, by exposure of the side of the face to cold currents of air, and from inj^r3^ The sympfovi.H of palsy of the orbicularis are, an inabil- ity to close the e^'elids, and, in exceptional cases, where the paralysis is complete, the patient has not the power even to approximate them. A peculiar stare is thus given to the ej'e, from which the affection has received the name of lacjophthahnos^ or "hare's ej^e." The lower lid having lost the support of the orbicularis, falls away from the globe, and the punctum becoming everted, the tears flow over the cheek, and the tarsal margins are apt to become excoriated. The most distressing symptoms, however, from a loss of power of the orbicularis, arise from the ex- posure of the eye, from the imperfect closure of its lids, to the contact of foreign particles, and the irritating ef- fects of wind and glare. The treatment of palsy of the orbicularis is the same as that described for the paral3tic affections of the ocular * Trousseau's Clinical Medicine, translated by the Sj'denham Society, vol. i, p. 3. 31 362 DISEASES OF THE EYELIDS. muscles, see page 311. ^^'llen, however, the pamlysis of the facial nerve is clue to some local cause, as the presence of a tumor or an enlarged gland near the exit of the nerve from the stylo-mastoid foramen, special attention must be devoted to its removal. To protect the eye from exposure, a shade or some other light covering should be worn bj'' the patient. Blepharospasm, or spasmodic contraction of the orbic- ularis, causing the lids to be tiglith* grasped upon the globe, occurs in all affections of the eye in which photo- phobia is a prominent symptom. It is caused by some irritation of the fifth nerve, inducing a reflex contraction of the orbicularis. a. It is met with in severe cases of the purulent oph- thalmia of infants ; and in most of the diseases of tlie cornea, especially those which are marked bj' ulceration. The continued spasm will sometimes cause entropion, by folding in the tarsal margins of the lids. This spasmodic entropion generally happens to the lower lid. /?. It frequently- occurs in granular ophthalmia, when from spasm of the orbicularis it is often difficult to evert the lids to treat the granulations. •f. It may accompany the simple hypertesthesia of the retina which is occasionally seen in amemia and debility-. 8. It is present in most cases of lodgement of foreign bodies in the ej^e. e. It may also be associated with neuralgia of the fifth nerve, especially of its supra-orbital branch. The treatment must consist in the endeavor to arrest the spasm by the removal of the source of the irritation. "When a foreign body is suspected, the lids should be care- full}^ everted, and the surface of the cornea scanned over, as if a particle of grit or dust can be detected, the taking it away will at once remove all spasm. NICTITATION. oGo For the mode of dealing with the various aftectioiis of the cornea, or Avith granulations of the lid, the reader must refer to the sections under their respective headings. In si)asm of the orbicularis arising from anaemia and de- bilit}', cinchona with small doses of the tincture of bella- donna will be found ver^' useful, or some of the pi'epara- tions of iron may be ordered. The eyes in all cases should be protected from exposure to glare b}' dark neutral-tint glasses, and if the intolerance of light is severe, a few drops of the solution of atropine (F. 13) may be dropped twice or three times a day into the eye. When the blepharospasm is associated with neuralgia of one of the branches of the fifth nerve, quinine should be given in full doses, and the pain be relieved by the sub- cutaneous injection of from gr. i to gr. ^ of the acetate of morphia (F. 24), according to the age and suffering of the patient. If pressure with the finger on the infra- and supra orbital branches of the fifth nerve will decide which of the two is the cause of the reflex spasm of the orbic- ularis, that nerve ma}^ be subcutaneously divided with a tenotomy knife. Nictitation, or a Irequent blinking of the lids, is a peculiar nervous affection, in some patients quite involun- tary, and in others only to be suppressed by a strong effort of the will. It is sometimes associated with chorea ; it then becomes most manifest when the patient is self- • conscious. In extreme cases the nictitation ma}'^ be so frequent, and beyond the control of the will, as to inter- fere with all duties which require a close application of the e3'es. Treatment. — If an}* source of irritation can be detected to account for this reflex action of the orbicularis, it must be at once removed. Inquiry should be made concerning the functions of the visceral organs, and means be taken 364 DISEASES OF THE EYELIDS, to rectify any derangement. If there is chorea, some preparation of iron will usually do good, and esj^ecialh' if the patient is ordered at the same time bracing country or sea air with a cold siiongiiig bath every morning. ULCERATIONS OF THE EYELIDS. Syphilitic Ulcers of the Lid are generally second- ary ; it is rare to meet with the primary sore in this lo- cality. I have, however, seen a chancre on the eyelid; it was in a child under two years of age, and was followed by a copious secondary eruption. No doubt the virus ■was conveyed to the lid through the finger of the mother or the nurse of the child. Secondary syphilitic sores on the lid resemble very much in appearance epithelial ulcers, for which they may be easilj^ mistaken. They usually' commence close to the tarsal margin, which they partially destroy, leaving a notch which is very characteristic of the disease. The ulcer will often heal at the point where it first commenced, whilst at the same time it extends itself in the opposite direction. In this respect it ditiers from the rodent or epithelial sore, in which there is no real repair of any portion of the ulcerated surface. The previous history of the patient, when it can be truthfully obtained, is also an imi)ortant guide in the diagnosis; but in cases of doubt a week or ten days' treatment with anti-sj'philitic remedies will usuall}^ decide the true origin of the disease. Ti'eatment As an application to the sore, a weak mer- curial ointment (F. 102, 103). Internally, a mixture with iodide of potassium (F. 74), and pil. h^drarg. subchlorid. comp. gr. 5 eveiy other night, or the liq. hydrarg. per- chlorid. may be given (F. SO) two or three times daily, or the iodide of potassium and i)erchloride of mercury may be combined in the same mixture. If the patient be a CANCER OF THE EYELID. o(J5 chilli, the hydrarg. cum creta (F. 121) must be given every uight, or night and morning, and, during the day, small doses of the mist, ferri iodid., or the mist, potassii iodidi cum ferro (F. 114, 115), KoDENT Cancer of the EIyelid generally commences as a small piuiijle in the skin, near the tarsal edge, which idcerates and then scabs over, but does not heal. It usu- ally gives little or no pain ; indeed, the attention of the patient is often called to it for the first time only by a sense of itching, which causes him to scratch it with one of his tinger-nails ; and to this scratch is frequently attrib- uted all the after progress of the disease. Examined be- tween the fingers, the ulcerated surface will be found to have a hard base and margin. It is not simply an ulcer, but it is a new growth or infiltration in the skin, which induces ulceration of the surface as fast as the deposit takes place. In its onward slow creeping progress, more skin is involved, and the dimensions of the ulcer are in- creased ; but repair does not follow destruction. There is no true cicatrization in rodent cancer, although here and there parts of the wound may be imperfectly scabbed over. For a detailed account of all that can be said of rodent cancer, I must refer the reader to the excellent monograph on this subject by my friend and colleague, Mr. Charles II. Moore. For the treatment of rodent cancer, and the diagnosis between it and epithelial can- cer, see the next section. p]piTHELiAL Cancer of the Eyelid closel}^ resembles the rodent ulcer, for which it ma}^ be easily mistaken. There are, however, certain characteristics which may serve to distinguish the one from the other. Epithelial cancer usually selects as its starting-point a locality where the skin joins the mucous membrane ; thus, the edge of 31* '666 DISEASES OF THE EYELIDS. the eyelid near the caniiicle mid the lip are favorite sites for tlie disease; whereas, rodent cancer adcai/s starts in the skin. Ei)ithelioma also invades the lymphatics and involves the neighboring glands, whilst in rodent cancer the glands are unaffected. The first appearance of epi- thelial cancer, and, up to a certain stage, its after pro- gress, are very similar to rodent cancer, but in the later periods of the disease there is a marked difference. JNIr. Moore says: "Advanced cases of the two diseases could hardly be confounded. There is at that period much more solid substance in the epithelioma, and the gaps which it makes by destroying the normal parts, though equally great, are less openly cavernous than in the ro- dent cancer."* Treatment of Epithelial and Bodent Cancer. — Excise the whole of the disease, carrying the incision into the sound skin, so as to be certain that none of the morbid growth is left behind. Arrest all hemorrhage by means of ligature, and if necessary with the actual cautery, and then thoroughly soak the surface with a solution of chlo- ride of zinc, gr. 40 ad aquse 5 1, or touch it over with the solid chloride of zinc. A little simple dressing is now to be placed over the wound, which should be allowed to heal by granulation. If in the course of cicatrization a\\y suspicious-looking granulations spring up, they must be at once desti'oyed b}' sprinkling on them a little of the chloride of zinc powder (F. 6). There are other ways of dealing with rodent and epithelial cancer, such as destroy- ing them with the strong nitric acid, or with the liq. hy- drarg. nitrat. acid, or with the chloride of zinc, but I much prefer first excising the disease, and then using the chloride of zinc in the AvaA' I have described. * Rodent Cancor, p. 24. TUMORS. 3G7 TUMORS OF THE EYELIDS. Tarsal Cysts — Meibomian cysts — Chalazion — usually occur as small isolated tumors in the upper and lower eyelids. There may be two or three of them in the same lid, but they are independent growths, and in no way connected. They generally grow to about the size of a small pea, but they will occasionally attain much larger dimensions. They are developed from the follicles of the Meibomian glands, of which they seem to be a morbid expansion. To the linger they feel like small shot in the lid ; and externally they give a nodulated appearance, which makes the patient anxious to be rid of them. They vary in consistence, and in the character of their contents. In some instances they are filled with a solid or thick ge- latinous material, whilst in other cases their contents are either a transpai'ent or semi-opaque curdy fluid, or, if the cyst has been inflamed, pus. When first noticed, a tarsal cyst is usually small and firm ; as it grows, it approaches the inner surface of the lid, its contents undergo a degen- erative softening, and the conjunctiva immediatelj' cover- ing the tumor becomes thinned and of a bluish color. In this state the cyst may remain for many months or even years without any apparent change, when, from some un- explained cause, it may inflame and supjjurate. Treatment. — The best time for operating on a tarsal C3'st is when the conjunctiva covering it looks thin and bluish, as its contents are then more easily turned out than at an earlier stage of the disease. The surgeon standing behind the head of the patient, who is seated on a chair, should with one finger evert the lid, and with a cataract knife make an incision through the length of the conjunctival wall of the cyst in a line parallel with the tarsal margin ; if the tumor is large, another smaller in- 308 DISEASES OF THE EYELIDS. cision may also be made through it at right angles to the first. With a fine scoop the whole of the contents of the C3'st are then to be evacuated, and this is best done by giving to the scoop a slight rotatory movement, Avhich helps to break up the material within the cyst, whilst it also scratches the lining membrane, and sets up sutlicient inflammatory action to cause the obliteration of the sac. For two or three days succeeding the operation a probe should be passed along the line of the incision, to pre- vent the lips of the wound uniting before the cavity is closed. When the contents of the cyst are so solid that the whole cannot be shelled out, it is a good plan to apply to the interior of the sac a probe charged with nitrate of silver; free suppurative action will be thus induced, and in all probability a cure will be effected. No attempt should ever be made to dissect out a tarsal cyst by an incision through the skin of the lids. NiEVUS OF THE E YE LID may be limited to the skin, or it may include the whole thickness of the lid, and extend through the palpebral cartilage. Sometimes it is an extension of a similar but larger growth within the orbit, with which it freel}- communicates. Treatment. — In treating naevi of the lid it is of great importance to avoid destruction of healthy skin, lest a bad ectropion should follow the means adopted for the cure of the disease. A small supei'ficial arterial na'vus may be often dissected out ; or it may be destroyed by the actual cautery, using the finely pointed cautery made specially for eye purjjoses, with which the naevus may be touched at two or three points. Where the growth extends more deeply, one or two threads soaked in a strong solution of the perchloride of iron may be drawn through it, and be allowed to remain until suppuration has connnenced, when they may be removed. DERMOID CYSTS — EPICANTHUS. 369 When the iioevus is too large to be dealt with in either of the ways mentioned, it must be ligatured. The plan recommended by some surgeons of injecting nrevi with solutions of iron or of tannin is dangerous to life, and should not be practised. There are several cases on record where this mode of treatment has terminated rapidly in death. Sebaceous or Dermoid Cysts occur usually in two lo- calities, — at the upper and outer margin, and at the lower and inner edge of the orbit, just over the nasal process of the superior maxillary bone. They are con- genital, and although the}' often appear to the touch to be superficial and loosely attached, they are in reality placed deeply, lying in a depression of the bone, beneath the orbicularis, and very adherent to the surrounding parts. The}' are filled with sebaceous matter, and con- tain numerous fine hairs. Treatment. — They should be dissected out through a single incision, made over the centre of the prominence of the tumor, and in a line corresponding with the curves of the brow or the orbit. Care should be taken to remove the whole of the cyst, as when portions of it are left, it will sometimes re-form. The operation, although appa- rentl}' ver}' slight, is one which often requires consider- able neatness and dexterit3^ In remoA'ing the cyst at the lower and inner angle of the orbit, much trouble is frequently exi^erienced from the angular or the frontal branch of the ophthalmic artery being divided, and the consequent brisk hemorrhage which follows. It is sel- dom that a ligature is required ; pressure with the finger for a few minutes will usually suffice to stop all the bleeding. Epicanthus. — This term is applied to a crescentic fold 370 INJURIES OF THE EYELIDS. S of skin, which slightly overlaps the inner canthus of each e3'e. By increasing the breadth of the integument be- tween the e^yes, a peculiar Chinese expression is given to the face, which is sometimes distasteful to the i)atient or his relatives. p]picanthus is congenital, and usually de- creases as the child grows and the bridge of the nose is developed. It is seldom that it interferes with sight. Treotnient. — It is onl}- in extreme epicanthus that any operative proceeding should be adopted. In such cases a vertical elli[ise of skin ma}^ be excised from the centre of the si)ace between the eyes, and the edges of the Avouud united with sutures. In this way the crescentic folds of integument will be unravelled, and the canthus of each eye exposed. INJURIES OF THE EYELIDS. EccHYMOSis OF THE Ei'ELiDS, or, as it is commonly called, "a black e^'e," is an etfusion of blood into the cellular tissue of the lids and of the parts surrounding them. It ma}" be limited to one or both eyelids, or it nia}" extend to the cellular tissue of the face around the orbit. The blood is generall}' absorbed in the course of a week or ten days, during which time the discoloration gradually fades away, but, in doing so, passes through a variety of shades which must be familiar to all. It is very rare that anj' suppuration follows. A black eye is occasionally complicated with fracture of one or more of the frontal or ethmoidal cells. This casualty is recognized by an emphysematous state of the eyelids and of the cellular tissue around the orbit. When the patient blows his nose, air is forced through the fis- sured bone into the neighboring cellular tissue. In no case have I ever seen eni|)hyscma of the lids productive of any harm, though the discomfort it occasions is always ECCHYMOSIS. 371 great. The patient should be eautioued not to blow his nose for some days ; the fissured bone will then soon be- come closed, and, if no fresh air is forced into the cellu- lar tissue, that which is alread3'^ there will rapidly disap- pear. Pricking the integument with a fine needle to give vent to the air is seldom if ever necessary, and should not be resorted to except in cases of extreme tension of the skin, a condition which is not likely to occur from a sim- ple fracture of a frontal or an ethmoidal cell. Treatment. — The application of cold immediately after the blow will limit the effusion of blood, and so diminish the extent of the after discoloration, and ma^-, therefore, shortl}^ after the receipt of the injur}-, be advantageousl}^ used. This is best done by cold evaporating lotions, or by applying ice in an india-rubber bag to the eye, or by a fold of wet linen being laid over the eye, and frequently moistened with iced water. The practice of ^iuncturing the swollen parts, as recommended and frequentlj- adopted by prize-fighters, is essentiallj^ wrong. It may, and no doubt does, afford a temporary relief to the swelling when it is great, but it renders the part liable to suppuration and er3'sipelas, neither of which would have been antici- pated if the skin had not been cut. A remedy which has for many j-ears received considerable credit, is a poultice of the black bryony root. It is " made b}- mixing some of the black brj-ony root scraped finelj' with a little crumb of bread. This is placed in a muslin bag over the palpe- bral for several hours together ; and usuall}- it has an ex- cellent effect in promoting the action of the absorbent vessels."* It is, however, a drug which cannot always be pi'ocured : the best place to seek for it is from one of the herbalists in Covent Garden Market. The tincture of Arnica montana has also acquired a great repute for * Tyrrell ou Diseases of the Eye, vol. i, p. '20J. 372 INJURIES OF THE EYELIDS. the power it is supposed to i)ossess, of favoring the ab- sorption of blood in cases of ecchymosis. It may be ap- plied pure over the part with a camel's-hair brush, or it may be used as a lotion (F. 49). Abscess of the Eyelid. — From contusion or lacera- tion of the integument of the lid, acute inflammation and suppuration of the subjacent cellular tissue may follow. The eyelid becomes red, swollen, and shining, and un- mistakable evidence of pus is soon manifested. The treatment is the same as for an abscess in any other part of the body. As soon as it is clear that pus has been formed, an incision should be made to give vent to it, and a warm poultice should be afterwards applied. The only point which requires special notice, is the wa}^ in which the abscess should be opened. The incision should be made w^th a fine sharp knife in the horizontal direc- tion, and in a line with the orbital fold of skin just be- yond the lid. The cicatrix will be then a mere line, and from its situation it will be scarcely observable. Wounds of the Eyelids may be divided into two classes : 1. Those which involve onl}^ the skin of the lid. 2. Those which have cut through its tarsal border. 1. Wo^mds which involve only the skin of (he lid., require the same treatment as similar wounds in any other part of the integument of the body ; but from the delicacy' of the skin in this localit^^, and the importance of avoiding as far as possible, an unseemly scar, more careful ma- nipulation is needed to bring the edges into accurate ai> position. 2. Wounds which, have cut through the tarsal border of the lid. — In lacerations of the e3^elid there are two forms of injury to which its tarsal margin is exposed: WOUNDS OF THE EYELIDS. 373 a. The cartilaginous border of the lid wvaj be cut or torn through at any part. /?. The rent may pass through the canaliculus, tearing it away from the punctum lachrymale, which may still remain intact at the extremity of the cartilage. (a.) Where the cartilacjinous border of the lid has been cid., the edges of the wound become slightly drawn apart, and an unsightl}^ notch is formed. If the wound has been a clean incised one, the divided ends of the cartilage should be very accurately' fitted together and fastened in situ b}^ a pin and twisted suture. The pin should be a very fine one, such as is used by entomologists for pinning the smaller insects. It should be made to pass through the cartilage of the lid, so close to its free edge, that the silk, when twisted on the pin, will slightly overlay the tarsal margin. I>y attending to these details, accurate union will be probably eff"ected, without leaving any notch or irregularity of the border of the lid. When, howeA'^er, the edges of the wound of the cartilage are jagged or ir- regular, as frequently happens when the lid has been torn by some semi-blunt instrument, it is best first to pare them smooth with a sharp scalpel before bringing them together with a pin and twisted suture. If after a wound of the cartilaginous border of the lid, no treatment has been adopted, the edges of the gap are apt to become more widely separated, and occasionally a certain amount of eversion is also produced. The extent of the deformit}' will necessarily depend ver}' much on the depth of the wound. (;?.) When the canaUculua has been torn through and de- tached from the punctum, a search should be first made for the divided end of the tear duct. It is of course im- possible so to adjust the torn parts that the punctum and the canaliculus can again be made to communicate with each other. If therefore the open end of the divided ca- 32 374 INJURIES OF THE EYELIDS. naliculus can be detected, a small director (Fig. 34, page 335) should be passed up it, and with a cataract knife it should be slit into the lachrymal sac. The closed tube will thus be converted into an open canal, along which the tears will afterwards flow into their proper channel. The torn parts are then to be brought into their normal position, and fastened in situ with one or two fine silk sutures. RESULTS OF INJURIES AND ULCERATIONS OF THE EYELIDS. Anchyloblepharon is the union of the margins of the e3'elids to each other. They may be either partiall}' or completely united. It is, however, seldom that the ad- hesion extends throughout the entire length of the lids. The inner third of the two lids is more frequently joined than the outer or middle portion. In nearly all cases of anchyloblepharon, whether partial or complete, a fistu- lous opening is left at the inner canthus, through which some of the tears find their way on to the face. The iinion between the lids may be either direct, the two edges being completely adherent, or they may be united by membranous bands passing from the one to the other. The causes of anchyloblepharon are lacerated wounds, or any accident which produces an abrasion of the cor- responding surfaces of the tarsal edges of the eyelids. Treatment.- — When the union between the lids is direct, and a fistula exists at the inner canthus, a small director should be passed behind the adherent margins, and out at the fistulous orifice, and upon it the adhesions may be severed with a pair of scissors ; or if this cannot be readily accomplished, the lids may be dissected apart with a shai'p scalpel. If a membranous band is the bond of union between the two lids, it should be divided on a director passed SYMBLEPIIARON. 375 beneath it, and the projecting portions cut oflT close to the margins of the lids. The chance of success following either of the operations depends very much on the daily dressing of the wound : special care should be taken to keep the lids from reuniting during the process of cicatri- zation. This may be generally accomplished by daily sepa- rating them, and anointing the granulating surfaces with a little sweet oil. Symblepharon is an adhesion of the lids to the globe. It is usuall}' produced by an injury which has caused either a destruction or an ulceration of the opposed con- junctival surfaces of the lid and globe, and their subse- quent union b}" granulation. Lime, mortar, and burns from hot metals, or scalds from hot fluids, are the most fre- quent causes of s3'mblepharon, but it may be produced by any agent which either destro^'s or abrades the corre- sponding parts of the lids and globe. Most of the very severe cases of symblepharon which have come under my notice have been due to lime. If the injur}' it has in- flicted is severe, it is absolutely impossible to prevent the union of the lids to the globe. All endeavors to keep the opposed granulating surfaces apart will fail. The con- traction which goes on during the process of cicatrization draws the lid and globe into close apposition, and direct union will ensue in spite of all eflbrts to stop it. Symblepharon is said to be complete wdien the entire inner surface of one lid is adherent to the. globe, and jwrtial when the adliesion is limited to only a part of the opposed surfaces. Both eyelids may be often seen par- tially' attached to the globe, or the lower lid maj' be com- pletely united to it ; but it is exceptional to meet with complete symblepharon of both the upper and loAver lids 376 INJURIES OF THE EYELIDS. of the same eye. The lower eyelid is much more fre- (pieiith' att'ected hy symLlepharon than the ujjper. Two forms of symblepharon may be recognized : 1. Membranous bands or frena passing between the lids and the globe. 2. Direct and close adhesions between the opposed sur- faces of the eye and lids. 1. Membranous Bands heticeen the Lids and Globe. — This is the simplest and most remediable kind of symble- pharon. It is due to a less extensive and more super- ficial injur}^ than that which produces the second form ; generally to some limited ulceration or abrasion of the corresponding parts of the eye and lids. During the hea^ling process the granulations of the opposed surfaces become united, but the constant pull which is exerted ujDOU them by the movements of the globe will often so stretch the adhesions that they will become elongated into membranous bands. 2. Direct and close Adhesions between the oj^posed Sur- faces of the Eye and Lids. — These are caused by an ab- solute destruction of corresponding portions of the con- junctiva of the eye and lid. Deep ulceration or slough- ing follows the injury, and opposed granulating surfaces are left, which ultimately become firmly adherent and blended with each other. During the cicatrization, the contraction of the surrounding conjunctiva draws the lid and globe into such close contact, that the movements of the eye cannot stretch the bond of union, and the lid and globe remain forever afterwards lirndj' bound together. Treatment. — All oi)erations for the cure of symblepha- ron are as a rule very unsatisfactory : in the severe cases « they generally fail to effect any good ; and in the milder ones, the relief which is afforded is comparative. It is only in the slight cases that jwsitive good will be found to follow surgical treatment, — those in which small mem- SYMBLEPHARON. 377 branons Lands ov tags of adhesion pass between the e_ye- lids and the globe. When these are insnhited, so that a l)robe can be passed beneath them, and the oculo-i)al- pebral fohl of conjunctiva still exists entire, much benefit will be derived from an operation. There are tAvo wa^'s in which these narrow mem])ranous bands may be treated. 'X. They may be simply divided by a scalpel or a pair of fine scissors ; and b^' daily passing the end of a probe dipped in a little sweet oil between their cut ends, re- union may generally be prevented. This mode of treat- ment is, however, only applicable to the very mild cases, where a simple tag of adhesion ties the lid to the globe. /?. If the bands are small, they may be first cut off close to the globe, and the edges of the wound which is thus made in the conjunctiva maybe drawn together and united b}' one or two fine stitches. The other extremities of the bands are then to be severed from their attachment to the lid. As in the first operation, careful daily dressing will be required to prevent a rej unction of the cut sur- faces, for unless the wound in the conjunctiva closes by immediate union, which it may fail to do, the tendency to a return of the symblepharon is very great. In those cases of symblepharon where there are direct and clone adhesions bettveen the eye and the lids, many different plans of treatment have been tried, but most of them without much success. It is onl}^ where the extent of the conjunctival surfaces involved is small, that even amelioration can be hoped for. The lid may be generally easily separated from its union with the globe by a care- ful dissection, but we have no means at our command by which we can prevent their again uniting. Plates of metal and glass shields have been interposed between the gran- ulating surfaces, but with very indifferent success. The}' '.V2* 378 INJURIES OF THE EYELIDS. have been generally extrnded dui'ing the contraction which accompanies cicatrization. Mr. T. Pridgin Teale, of Leeds, has suggested a plastic operation in cases of sj'inblepharon, which he speaks of very favorably. He first described it in the Koyal Lon- don Oplithahnic Hospital Reports, vol. iii, p. 253, in which he has cited cases which have been materiall}' benefited b}' it. In a short note which he has kindly given me, he thns describes the oj^eration : •' The adherent lid having been dissected off" the eyeball so as to leave the globe per- fectly free in its movements, one, or, if possible, two flaps of conjunctiva are dissected from the sound part of the e^-eball, and transplanted into the gap. If an}- portion of the adherent lid is united to the cornea, the separation of the lid is commenced at the margin of the cornea, leav- ing the apex of the lid still in situ as an opaque spot on the cornea." There are, however, very many cases of s^'mblepharon where no operation should be attempted. The extent of the adhesions may be so great that it would be worse than useless to endeavor to divide them. Anchylohlepharon and symhlepharon are often asso- ciated ; indeed, Avith the nnion of the margins of the lids it is very general to find also some adhesion between the conjunctival surfaces of the lid and globe. It is, however, rare to find in one eye a complete union of the globe to the lids, and of the lids to each other. ABSCESS OF THE ORBIT. 379 CHAPTER XL DISEASES OP THE ORBIT. Abscess of the Orbit may be caused by blows on the e3'e, by penetrating wounds of the orbit, or by any vio- lence producing fracture of its bony walls, by the lodge- ment of a foreign bod}' in the orbital cellular tissue, or occasionally by the extension backwards of a suppurative inflammation of the lids, or of the tissues in immediate contiguity with the eye, no matter how induced. Inflam- mation of the cellular tissue of the orbit (orbital cellu- litis), brought on from any cause, may terminate in ab- scess of the orbit. Caries, necrosis, or orbital periostitis may likewise lead to orbital abscess. Abscess of the orbit may be either acute or chronic. In the former the inflammatory symptoms generally rapidly follow the injury ; they are sharp and quick in their pro- gress, pus is soon formed, and independently of the his- tory of the case, iinmistakable evidence of its presence is artbrded by the pain, heat, redness, and swelling. Occa- sionall^y, however, there is a variable interval of a week or more of perfect quiet and freedom from pain after the in- jury before an}' premonitory symptoms show themselves, but when once started their course is equally acute and rapid. Symjotoms of Acute Abscess of the Orbit. — Deep-seated pain in the orbit extending around the brow, worse at one time, better at another, but never absent, and steadily in- creasing in severity. Any pressure on the eye, or even moving it, aggravates the pain. The ej^elids become red, 380 DISEASES OF THE ORBIT. shining, and rrdematons ; and tlie conjnnctiva of the lids and glol)e vascular, swollen, and chcmosed. The eye is now observed to protrude slight!}' be3ond the level of the other, and this protrusion increases as the disease ad- vances and the pus makes its wa}' to the surface. The dis[)lacemeut is usually not directl}' forwards, hut more or less downwards and outwards, as it is dependent on the situation of the abscess within the orbit and the part of the eye on which it presses. AVith the increasing pro- trusion of the globe, the sight becomes more or less im- paired from the strain which is being exerted on the optic nerve. The orbital fold of skin above the lid becomes obliterated, and the upper lid so swollen and stretched iu front of the bulging eye that it cannot be raised b}' the patient. Over the most prominent j^art of the swelling a careful examination with the fingers will detect fluctua- tion. The most usual spot for the matter to point is rather to the inner side of the interval between the supra- orbital ridge of the orbit and the upper border of the globe. Occasionally the suppuration may be more or less confined to one or other side of the orbit, and this will in a great measure determine the site at which the pus will endeavor to make its exit ; either the inner, outer, or lower side of the eye may })e the part selected. When the abscess is a small and limited one, there may be little or no displacement of the eye. "NN'ith all these local symptoms there is always consider- able constitutional disturbance. The skin is hot and dr^' , the patient has occasional rigors, he is restless, and his sleep is broken from pain. In chronic abscess of the orbit the symptoms are often masked by the yery slowness with which they develop themselves, and by the absence of funy severe pain. It frequently happens that the patient does not even seek advice until an increasing protrusion of the eye and ABSCESS OF THE ORBIT. 381 a somewhat corresponding diminution in vision excite alarm. Clironic abscess of the orbit is often most difficult to diagnose, and may easily be confounded with a medullary, or recurrent fibroid, or some soft orbital tumor, the elas- ticity of which closely resembles fluctuation. The exciting cause of the abscess may have been an injury inflicted at some distant period, which has been forgotten, and from which the patient thought he had completely recovered; or the slow progress of the disease, and the comparative and in many cases complete absence of pain during its early stages, may make it difficult, if not impossible, for the patient to give a correct account of how or when it commenced. When doubt exists as to the true nature of the case, an exploratory incision should be made into the tumor, and the surgeon should be prepared to act at once on the information it will aflbrd him. If it is an abscess, the incision should be enlarged sufficiently to give a free exit to the pus ; but if, on the other hand, it should prove an orbital tumor, it should, if practicable, be re- moved without any further delay. Treatment of Al)scess of the Orbit. — As soon as it is clear that pus has formed, and that the protrusion of the eye, if there is an}-, is due to its presence in the orbit, a free opening should be made for its escape. The site for making the incision should be that spot where there is the most distinct swelling and fluctuation, and where the pus has a tendency to point. After a free vent has been given to the pus within the orbit, a warm linseed-meal poultice should be applied, and care should be taken that the wound is kept open by examining it dail}', and, if necessary, by passing a probe along the course of the in- cision to prevent the cut edges from uniting. It not nn- frequentl}' happens, after an abscess of the orbit, that the wound from the incision only partially closes, and a long 382 DISEASES OF THE ORBIT. sinus remains from which a slight pnvulent diseliarge continues to drain. When this is tlie case, and when no fragment of necrosed bone can be detected by a probe to account for it, the use of a stimulating injection, such as zinci sulphat. gr. 2 ad aqute 5 1, thrown into the sinus with a glass S3'ringe twice a day, will often prove of great benefit. If, however, a portion of dead bone is felt with the probe, time must be given to allow of its becoming detached, or at least partially loosened from the living structure ; and then, after enlarging the orifice of the sinus, it may be removed with a pair of sequestrum for- ceps, first using, if necessar}^, a gouge, or an elevator, or a pair of fine-cutting bone forceps, to separate an}^ por- tion of bone which may be holding it. Fractures of the Bones of the Orbit may be caused by blows on the head, or by the impaction within its cavity of a large foreign bod}^, one extremit}^ of which has passed through the orbital walls into the antrum or the posterior nares. When the fracture extends into the frontal or ethmoidal cells, there is generally emphysema of the cellular tissue of the lids and the surrounding parts. This arises from the patient forcibh' driving the air through the broken cells when he blows his nose. Fracture of the orbit is often associated with fracture of other portions of the skull, and in such cases it frequentl}^ happens that the contusion or laceration of the brain produced b}' the blow is sufficient to cause death, inde- pendently of the injury which the cranial bones have sus- tained. There is, however, one form of fracture Avhich is con- fined to the Avails of the orbit, and which is very fatal. It is*caused by direct violence, and is commonly produced b}" a forcible tlu-ust in the e^-e with a shar}) or semi- blunt pointed instrument, such as the points of a pair of FRACTURES OF THE ORBIT. 383 scissors, the end of an umbrella or a foil, or b3' the stem of a long tobacco-pipe. The orbit is penetrated, and the end of the stick, or whatever it may be, is thrust against its roof or the upper part of its inner wall, which it in some cases fractures, whilst in others it breaks its vfa.y through the bone and penetrates the substance of the brain. From such an injury the patient seldom recovers : even when the bones are broken, but not penetrated, the sharp splinters usually create such irritation of the brain and its membranes that a fatal result ensues. One peculiarity of this accident is, that its severe nature is apt to be often overlooked ; the exteiuial wound ma}" be small, the imme- diate symptoms may be trifling, and the patient, if a me- chanic, may be able to continue his work some hours, or it ma}' be for two or three days, before his condition obliges him to desist. Symptoms of inflammation and sup- puration may then come on, coupled Avitli those of cerebral or meningeal irritation ; the patient may pass rapidl}- from slight delirium to complete coma, and die in a period varying from a few days to two or three weeks. Treatment of Fractures of the Orbit Fracture of the orbit requires the same treatment as fracture of any other portion of the bones of the skull, with the exception that even if there is reason to believe that a fragment of one of the orbital bones may be pressing injuriouslj^ on the brain, no operation can be attempted to dislodge it. Ab- solute rest, both mental and bodily, should be enjoined in all cases where a fracture of the orbit is suspected. The patient should be kept in bed, and cold water dressings, or an india-rubber bag of ice should be laid over the eye and brow of the injured side; and the bowels should be freelj' acted on by a brisk purgative. All stimulants should be forbidden, and a limited diet should be ordered. If there is much pain in the head, six or eight leeches should be applied to the temple, and these may be re- 384 DISEASES OF THE ORBIT. peated iu twenty-lbiir hours if the symptoms become more urgent. Foreign Bodies in the Okbit, — The lodgement of a foreign body within the orbit is one of the most danger- ous accidents which can be met witli in ophthahnic prac- tice, as it not onl}^ always involves a serious risk to the eye, but it places even the life of the patient in consider- able jeopardy, and in some instances has caused death. It may prove hurtful to the patient both b}' the immediate and secondarj^ effects it is liable to produce. The immediate effects which may arise from the lodge- ment of a foreign body in the orbit are : 1. In its passage into the orl)it, it may either injure the parts within the e^'e, or rupture its external coats. 2. Although the eye itself may escape injury, the optic nerve may be wounded, and absolute blindness follow. 3. It may injure the walls of the orbit, either by pene- trating them or by causing fracture. The secondary effects which a foreign bod}' within the orbit may excite are : a. If a foreign body has escaped observation, and has been allowed to remain buried in the orbit, it ma}' excite orbital cellulitis and abscess. This may lead on to a general inflammation of the globe, which maj' end iu great impairment of vision, or in complete destruction of the e^-e from suppuration. /3. As a consequence of the orbital inflammation, a por- tion of the bones of the orbit may become necrosed. y. The inflammation ma}^ extend backwards along the periosteum lining the orbital walls to the membranes of the brain, and destroy the patient by meningitis, tetanic convulsions, or abscess of the brain. Treatment. — Whenever it can be clearly established that a foreign body is impacted iu the orbit, the treat- FOREIGN BODIES IN THE ORBIT. 385 meiit is to endeavor to remove it as soon as possible. To this rule, however, there are exceptions ; and these are, when the foreign body is a small sliot, or a fine scale of metal which may have flown off from a rivet and passed into the orbit without injury to the eye. The almost im- possibility of finding a small object in a mass of cellular tissue forbids the attempt to hunt after it. If it can be easil}^ felt with a probe introduced through the wound, it should be removed, but no lengthened exploratory opera- tion should be attempted with the view of seeking for it. Such a proceeding would probably excite more irritation than would arise from the presence of a small metallic bod}^ in the orbit. It should also be remembered that small masses of metal may be often imbedded in the cel- lular tissue of any part of the body without producing a symptom of irritation, and that they may remain there for many years without causing any disturbance. Having ascertained by a careful investigation tl'at a foreign bod}^ is in all probability imbedded in the orbit, the following operation for its removal may be performed. The outer canthus should be freely divided, either by a pair of scissors or with a scalpel, to allow of the upper lid being completely turned up, or the lower one drawn down, according to the locality in which the foreign body is lodged. If it has entered the orbit above the globe, the upper lid is to be I'aised, and the reflection of conjunctiva between the lid and the e3'e is to be divided over the spot where the foreign body is suspected to be lying. A probe or the little finger may then be passed through the wound into the orbit by the side of the e^-e, and having felt the object, it may be seized and drawn out with a pair of sequestrum forceps. When tlie foreign body has entered the orbit below the globe, the lower lid must be drawn down, and the lower oculo-palpebral fold of conjunctiva 33 386 DISEASES OF THE ORBIT. must be divided, but tlie remaining steps of tlie operation are the same as tliose already described. If tlie foreign body has become entangled with one of the recti muscles, or from any other cause one of them should interfere with its eas}^ withdrawal from the orbit, it is better at once to divide the muscle with a pair of scissors as close as possible to the globe, rather than to use any force to overcome the resistance it may be causing. Penetrating Wounds of the Orbit are alwa3-s serious. The exact injury which has been inflicted can often be only surmised, and time is required for the manifestation of s^'mptoms, before either a correct diagnosis or prog- nosis of the case can be formed. The instrument which has caused the accident should be examined, to see if any fragment of it has been broken off and left behind in the orbital cellular tissue, and the direction in which it pene- trated the orbit should be noted. The patient should be kept under careful supervision for some days, so as to enable the surgeon to treat from the onset any unfavor- able s^'mptoms that may arise. Even when no injury has been inflicted to the bones of the orbit, orbital cellulitis and abscess are very apt to ensue. Periostitis of the Orbit is usually chronic, but small portions of the orbital periosteum are occasionally acutely inflamed. Acute diffuse periostitis rarely if ever affects the orbit. Chronic periostitis of the orbit is nearly alwa.ys syphi- litic. It iisually leads to the formation of nodes, or the effusion of l^mph beneath the periosteum. The most fre- quent position of the nodes, for which the ophthalmic surgeon is consulted, is on the frontal bone just over the brow; but they sometimes occur within the orbit and give PERIOSTITIS OF THE ORBIT. 387 rise to grave symptoms. The nodes of the flat bones usu- ally dirter in their progress from those which are so com- monly seen on the tibia and other long bones ; for whereas in the latter they frequently ossify and form bony projec- tions; in the former (the flat bones), and especially in those of the skull, the effused 13'mph often softens, and pus is formed beneath the periosteum, and a portion of the subjacent bone eitlier exfoliates or becomes carious. Si/mpfoins. — Dull aching pain, which is worse at nights, when it is usually sufficiently severe to prevent sleep ; swelling of the part, evident to the sight and the touch when it occurs over the superciliary ridge : but when the periostitis is within the orbit, the swelling is indicated by the impaired motions of the eyeball ; or b^' paral^'sis of one or more of its muscles, if the node is in a locality where the ocular nerves can be affected by it ; and if the swelling is large, there is some protrusion or displace- ment of the e3'e. If the node within the orbit should soften, and pus be formed, all the symptoms which char- acterize orbital abscess will gradually develop themselves ; and after the matter has been evacuated, a chronic dis- charge will probably continue until some portion of the orbital bones has exfoliated. Treatment In chronic orbital periostitis there is gen- eralh' a past history of syphilis, possibly dated back many 3'ears ; but when this cannot be obtained, the surgeon must use his own judgment as to the patient's veracitj', and treat the case accordingly. The most useful medi- cine is the iodide of potassium, which should be given in the first instance, in doses of from gr. 3 to gr. 5 three times a day ; but if these fail to do good, they may be in- creased up to gr. 8 or gr. 10. To relieve pain and favor the absorj:)tion of the effused lymph, the unguent, hydrarg. cum belladonna (F. 90) may be rubbed into the brow, and left on during the day. When the paiu is very severe, a 388 DISEASES OF THE ORBIT. subcutaneous injection of gr. ^ to gr. ^ of the acetate of morphia (F. 24), or gr. 5 of the pil. saponis cum opio, may be given at night. If these remedies fail, a mixture with iodide of potassium and perchloride of mercury (F. 78) may be ordered. If the node witliin the orbit soften, and pus be formed, an opening should be made to give vent to it; and if a chronic discharge continue, and this be found dependent on a portion of dead bone not yet exfoliated, the sinus should be syringed out twice a day with a little tepid water, or with a very weak solu- tion of carbolic acid, about tijj 3 ad aquae ^ 1. As soon as the probe detects that the bone is loosened, the sinus should be enlarged, and the exfoliated piece be removed with a pair of forceps. Acute Perioatitis of the Orbit is an acute inflammation of a portion of the orbital periosteum which may have been detached from the bone or otherwise injured by some penetrating wound of the orbit, or may have be- come secondarily affected during an attack of orbital cellulitis. It is accompanied by severe pain and by the formation of pus, which will give rise to all the symp- toms described in the section Abscess of the Orbit. The piece of bone which is subjacent to the inflamed peri- osteum usually perishes, and a discharge of fetid pus con- tinues to drain through the external wound by which the matter was first evacuated, until the dead bone is detached from the living and removed from the orbit. Acute Diffuse Periostitis rarely, if ever, attacks the orbit ; indeed, I do not remember having seen such a case, if, b}' the name, is meant a diffuse inflammation analogous to that which occasionally^ affects the perios- teum of long bones. A good account of this aflection is given in Holmes's " System of Surger}-," in the article " Diseases of Bones," vol. iii, page (124, written b3' him- self. He says : " The pathology of the disease appears NECROSIS AND CARIES OF THE ORBIT. 389 to consist in the partial separation of tlie periosteum from the bone, by efTusion on the surface of the latter of l3'mph or other products, soon giving place to a copious formation of pus, which spreads along the whole bone, and dissects away the periosteum from it, often from one end of the bone to the other." And further on he states that " the whole diaphysis usually perishes, leaving the articular ends unaffected, and, tlierefore, not involving the neighboring joint." The disease is generally ascribed to an injur}' ; it is very rapid in its progress, and often terminates in death by pyaemia. The patients usually af- fected, are the joung and strumous. I have seen several examples of this formidable disease in the long bones, general!}' the femur ; but it has never occurred to me to see anything approaching to it in the orbit. Treatment of Acute Periostitis of the Orbit. — When it is traumatic, or is due to orbital cellulitis, the application of linseed-meal poultices and warm fomentations give the most relief during the acute suppurative period. As soon as there is reasonable evidence that pus has formed, an incision should be made into the orbit to give exit to it. For the chronic discharge kept up by the presence of dis- eased bone, see Treatment op Chronic Periostitis of Orbit, page 387. The patient should be ordered tonics, stimulants, and a lilteral diet. The disease is ver}' de- pressing, and it is not specific ; iodide of potassium and mercurials are, therefore, contraindicated. Necrosis and Caries of the Orbit. — Xccrosis of a portion of one or more of the orbital bones generall}' arises from periostitis induced by an injury, or, by an acute orbital abscess ; whereas, caries is usually produced b}' some constitutional taint, such as syphilis or struma. In the two preceding sections, it is shown that both caries and necrosis may follow inllammation of the periosteum 33* 390 DISEASES OF THE ORBIT. of the orbit. Caries of the malar bone is, however, more frequent than caries of the orbit, and it is a form of the disease which the ophthalmic surgeon is frequently called upon to treat, as it is the cause of a very troublesome ectropion. Treatment. — For necrosis, no permanent cure can be effected until the piece of dead bone has been remoA'ed. Time should be given to allow of its being loosened from the living structures, and then guided by a probe passed through the sinus, by which the discharge escapes, an incision should be made down to the necrosed bone, which should be removed with a pair of fine bone forceps. For caries the treatment is different. True caries is strictl}" ulceration of bone, or, in other words, a degener- ation of the bone particles, which are thrown off, and may often be detected in the discharge. As in ulcers of the skin, the object of the treatment is to restore health}^ ac- tion, and thus produce cicatrization. This ma}' be aimed at by constitutional and local ti'catment. Where there is a S3'philitic taint, the iodide of potassium with iron (F. 73), or the iodide and bromide of potassium combined (F. 77), or other anti-syphilitic remedies may be given ; but when the disease maj^ be attributed to a strumous diathesis, cod-liver oil, the s^^rup of the iodide or hypophosphite of iron will generally do good, and especiall}^ if at the same time the patient can obtain sea air and a nutritious diet, of which milk and eggs form a part. The best local ai)plications are the lotio rubra (F. 51), a lotion of carbolic acid (F. 45), or of chloride of zinc, gr. 1 ad aquae % 1. They should be injected up the sinus b}' a glass S3'ringe twice a day ; and if one lotion causes too much irritation, another should be substituted. If, however, all these remedies fail, a cure may be often ac- complished 1>3' making an incision down to the carious bone, and gouging away the soft and diseased structure. ANEURISM OF THE ORBIT. 391 ANEURISMS OF THE ORBIT. There are three forms of aueurism which may be met with in tlie orbit : 1. The true and the false aneurism. 2. The diffuse or consecutive aneurism. 3. Aneurism by anastomosis. 1. The T7'ue and False Aneurism. — By the term true is understood a simple circumscribed dilatation of the three coats of the arter^^; whilst the iiilQ fahe is improp- Qvly applied to the n^ost usual form of aneurism, in which the middle and internal coats have given way, and the sac is composed of the external or cellular coat. The artery within the orbit which is affected by aneurism is the oph- thalmic, or in exceptional cases one of its branches. Si/mpfoms of Aneurism of the Ophthalmic Artery. — Protrusion of the eye, but if the vessel has not burst, the exophthalmos is not extreme ; pulsation of the globe, some- times visible, but nearlj^ always to be felt with the fingers on the eye ; and, lastly', the sense of pulsation and whir- ring noise which is experienced by the patient, and may be generalljr detected by the medical attendant by placing a stethoscope over the eye, or on the side of the temple. There is often an absence of pain, and the disease may pass for a long time unnoticed, until from some hidden or accidental causes the vessel gives way, and then the suffering becomes extreme, and the symptoms exagger- ated. A case is recorded by the late Mr. Guthrie of aneurism of the ophthalmic artery of both sides. The disease was diagnosed during life and verified after death, when " an aneurism of the ophthalmic artery was discovered on each side, of about the size of a large nut." . . . . " The dis- 392 DISEASES OF THE ORBIT. ease existing on both sides prevented nn operation on the carotid being attempted, to -svliicli indeed the patient wouki not have submitted."* ]Mr. Nunneley has also reported the post-mortem exam- ination of a patient whose right common carotid he tied for the relief of orbital aneurism. The operation was per- formed in August, 1859, and the woman died of serous apoplexy on February 27, 1864. "On the right side of the sella turcica was found a circumscribed aneurism of the ophthalmic artery, just at its origin, as large as a hazel- nut, which was filled witli a dense, solid, red clot."f Cases have been recorded of aneurism of the central arter}' of the retina. In a patient under Dr. G. Sous, of Bordeaux, the disease Avas diagnosed during life b}' the ophthalmoscope, the distended vessel appearing as an ovoid tumor on the left optic disc.| 2. The Diffuse or Consecutive Aneurism is when an artery has been ruptured either from injur}- or disease, and a sac has been formed for the extravasated blood bj^ a condensation of the surrounding tissues, with which sac the artery communicates. This is the most frequent form of orbital aneurism. It may arise from an injur}', such as a blow on the side of the head ; or it may come on from the accidental bursting of a true or false aneurism of the ophthalmic arterj', or from the sudden giving way of one of the vessels in an aneurism by anastomosis. The symptoms which indicate the lesion of an artery within the orbit are sudden severe pain, followed by red- ness and swelling of the lids, oedema of the conjunctiva, and protrusion of the globe, with limitation of its move- ments. There is usualh", in addition, noise in the head, * Lectures on the Operative Surgery of the Eye, p. 158. f Medico-Chirurgical Transactions, vol. xlviii, 18G5. J Annales d'Ociilistique, 1805. ANEURISM OF THE OllCIT. 393 compared I\y one patient to the whirring sound of a steam-engine or threshing machine, and by another to the blowing of a pair of bellows. This thrill is audible to a bystander through a stethoscope placed over the eye or on the side of the temple. A slight pressure of the fingers on the eye will detect pulsations sjnchronous with those at the wrist. In some cases a distinct pulsating tmnor may be felt in the upper region of the orbit ; but in others there is a marked absence of anything like a circumscribed swelling. Stooping or bending the head downwards aggravates all the symptoms. Pressure on the common carotid at once arrests pulsations and causes a diminution of the proptosis. The suddenness of the first symptoms is well illustrated in the following extracts from three of the reported cases. Mr. Travers,* in the account of the patient whose carotid he tied successfully, says, " she felt a sudden snap on the left side of her forehead which was attended with pain." Mr. Dahymple in citing the history of the case in which he ligatured the carotid for aneurism of the orbit, uses the patient's own words : " The attack was sudden — instan- taneous" . . . . " hearing a noise as of the cracking of a whip, and feeling at the same moment an extraordinary kind of pain in the globe of the left eye, she awoke in great alarm and leapt out of bed. "f Lastly, in the report of one of Mr. Nunneley's cases, in w'hich he tied the carotid, it is stated that " as she stooped down to take ofi" her shoe, she suddenly felt something give wa}- in the left eye, as the crack of a gun."| The poor woman died on the sixteenth day after the operation, and on making a post-mortem examination there was found " a small circumscribed aneurism of the carotid * Medico-Cliirurgical Trunsactioiis, vol. ii, 1811. t Ibid. vol. vii, 1815. J Ibid. vol. xlii, 18G9. 394 DISEASES OF THE ORBIT. artery, jnst as the ophthalinie Itranch is given o(T, -which at its origin was partly surrounded by the coaguliun which had escaped from tlie vessel. This also pressed upon the cavernous sinus ; hence, probabl}', the intense congestion and protrusion of all the structures within the orbit."* In each of these three cases, a series of distressing symptoms followed immediately on the first indication that some vessel within the orbit had ruptured. T7'eatment of True^ Fahe, and Diffuse Anetd'i^ms within the Orbit. — There are only two methods of dealing with such cases : (1.) By digital compression of the carotid artery; and (2.) By ligature of the vessel. In all cases where it is practicable digital compression should be first tried. In July, 1856, a female patient with aneurism of the ophthalmic artery, under Professor Gioppi, of Padua, was successfully treated in this manner. " A second case, in which a formidable aneurism of the ophthalmic arteiy, in a patient the subject of aortic and cardiac disease, was cured by digital compression, was published in 1858 by Prs. Yanzetti and Scaramuzza."f It is not necessary that the compression should be continuous — it may be intermittent, being applied only five or ten minutes at a time, according as the patient can bear it. If this treat- ment fails to effect a cure, the carotid should be tied. It is an oi)eration which has been frequently performed and with good success. 3. Aneurism by Anastomosis is usually congenital, al- though it may not be detected until by its increased growth it has made itself manifest by extending beyond the orbit. It consists of a morbidly develo[)ed network * Tnmsactions of the Putliological Society, vol. xi, p. 8. f Holmes's System of Surgery, vol. iii,. pp. 423, 424. ANEURISM OF THE ORBIT. 395 of capillaries in the subcutaneous cellular tissue, forming a prominence beneath the skin, ^vhich increases in size, and is rendered turgid bj' laughing or crying. To the touch it has a tough doughy feeling, quite distinct from fluctuation. Treatment. — When the vascular gro^\th is of limited extent, and is only a short distance within the orbit, it may be surrounded subcutaneously with a ligature and tied. The same proceeding may be adopted to a portion of a growth of a larger size which extends beyond the orbit. There are, however, cases to which this plan of treatment is inapplicable, as when the growth pulsates, is of great dimensions, bulges the eye, and is rapidly in- creasing. For such tumors the effect of temi)orary pres- sure with the finger on the carotid should be tried, and if this succeeds in arresting the pulsations and in reducing the fulness of the growth, the artery should be ligatured. Mr. llaynes Walton succeeded in this manner in curing a large aneurism b}^ anastomosis in a child four months and three weeks old. After the operation, the protrusion of the e^-eball was sensibly diminished, and the child re- covered without a bad symptom.* Dr. Althaus speaks highly of the success he has obtained from the electrol3'tic treatment of vascular growths. f Although 4u his book on this subject he has not related an}' cases of large aneurism by anastomosis in which he has used electrol}- sis, 3'et it is a remedy which fairly commends itself for trial before resorting to liga- ture of the carotid. The plan of injecting the tumor with coagulating fluids, such as a solution of tannin or of perchloride of iron, is fraught with danger, and should not be attempted. * Haynes Walton on the Surgical Diseases of the Eye, 2d edition, p 230. f On the Electrolytic Treatment of Tumors. 396 DISEASES OF THE ORBIT. EXOPHTHALMIC GOITRE — GRAVES S DISEASE. The three sj'iiiptoms which characterize this extraorcli- nary aftection are : exophthahnos of both eyes, enlarge- ment of the thyroid gland, and palpitation of the heart. To these niav be added anaemia, derangement of the fnnc- tions of one or more of the visceral organs, and a peculiar capriciousness of temper ; bnt these signs are not diag- nostic, as the}' are common to other diseases. Exoph- thalmic goitre is more frequent amongst women, thus, '' of fifty cases of this complaint collected by Withuisen, only eight occurred in males."* I shall first briefly de- scribe the gronp of symptoms which mark the disease, and then refer to each in detail. Symjjfoms. — The first sj'mptom is usually palpitation of the heart, which steadil}^ increases, and is aggravated by mental emotion or exercise. The e^'es seem to grow large, and the friends notice that they begin to protrude, and the thj-roid gland expands. The patient suffers fi'om paroxysms of dyspnoea, with violent palpitations, and a sense of fulness of the ej'es and throbbing of the carotids. Associated with these s^Tuptoms there is usually anaemia, irregular action of the bowels, an uncertain appetite, and, if the patient be a female, amenorrhea. Trousseau lays emphasis on the change of temper, which, from being even, becomes capricious and irrital)le, and is often the first indication of there being some constitutional malady. The Exophthalmos^ or protrusion of the eyes, is the symi^tom for which the ophthalmic surgeon is most fre- quently consulted, and it is the one which often causes the greatest amount of anxiety to the patient. As the disease advances, the bulging increases, sometimes to such an extent as to prevent the lids from closing over * Trousseau's Clinical Medicine, Syd. Soc. ed., vol. i, p. 0-32. EXOPHTHALMIC GOITRE. 397 the globes. When this happens, the eyes suffer from ex- posure, and become liable to frequent attacks of inflam- mation. In a poor girl, ait. 18, who was under my care at the hospital, the eyes continued to protrude more and more, until at last, having lost much of the protection of the lids, both eyes became acutely inflamed, and both corneae suppurated. I frequently see this patient, and so prominent are the shrunken globes, that although both are contracted to at least one-third of their original size, the lids, when shut, cannot cover them. Notwithstand- ing the prominence of the ej^es, the sight is generall}' but little affected. In the case which I have just referred to, the girl could see to read and write well before her e^'cs became inflamed. Hypei'trophy of the Tliijroid. — The whole gland is usu- ally enlarged, but, according to Graves, Stokes, and Trousseau, the right lobe is the more affected of the two. In three out of the four cases of exophthalmic goitre re- lated by Morell Mackenzie,* the right lobe was the larger, and, in the fourth, both lobes were equal. The increase in the size of the thyroid is at first almost imperceptible, but, after it has attained certain dimensions, it is pro- ductive of distressing s^'mptoms from interfering with respiration when the patient is in the recumbent position. With the h^^pertrophy of the gland tissue there is dila- tation of the vessels of the gland, and this can be easily recognized in severe cases, by placing the hand over the thyroid, when it will be felt to expand synchronously with the pulsations of the carotids. Palpitation of the Heart. — This is a very constant symptom, and usually the one which first attracts the patient's attention. Trousseau saj's: "The valvular sounds are exaggerated, and are generally' accompanied * Transactions of tlie Clinical Society, vol. i, p. 9. .34 398 DISEASES OF THE 0RI5IT. b}^ a soft systolic Lellows-murnmr, aiu]i])k' in the lartie ai'teries also. The carotids pulsate more forcibly than natural, and they, as well as the jugular veins, have a share in the production of the sounds heard over the en- larged thj-roid."* The palpitations appear, in the early stages of the disease, to be due to functional derange- ment, but in the latter there is frequentl}- dilatation of the cavities of the heart. Derangement of the Visceral Organs. — The appetite is variable — at one time good, at another almost wanting. The bowels are irregular in their action, one patient suf- fering from repeated attacks of diaiTho?a,-»whilst another is troubled with flatus and constipation. In females there is very frequently amenorrhoea. Trousseau remarks: "In the beginning, menstruation is only disturbed, but it is after a time completely' suppressed, and hopes of a favor- able issue are not to be entertained until this function is perfectly re-established. "f Ansemia generally attends this disease, but it is by no means an essential condition, as exophthalmic goitre may exist in robust and florid-looking patients. Treatment. — Dr. Trousseau says : " I can, from expe- rience recommend j'ou to have recourse, in this singular afl'ection, to bleeding, digitalis, and hydropathy."! ^^^^ first and last of these remedies I have not tried, but digi- talis I have frequently ordered, and always with benefit. The iodide of potassium geuerall}' fails to do good in these cases; it depresses too much, and frequentl}' in- duces iodism. From the usualh' anaemic state of the patient, iron Avould naturally be suggested, but with the rapid pulse which mostly accompanies this disease, the drug is badly borne, and aggravates the s^'mptoms. * Trousseau's Clinicul iNledicine, Syd. Soc ed., vol. i, p. 54(). t Ibid., p. 550. X Ibid., j). 588. TUMORS OF THE ORBIT. 399 During the paroxysms of dyspnoea, ice should be ap- plied over the thyroid and over the praecordial region, in an india-rubber ice-bag, and the tincture of digitalis TT)j 10 to "K 15 prescribed every two or three hours, keep- ing a careful watch over the patient during its adminis- tration. In the intervals between the paroxysms, small doses of the tincture of digitalis, combined either with the mineral acids or with an alkali, according to the special indications of the case, will be found of service. If there is habitual constipation, the bitter waters of PuUna, Friedrichshall, or Kissingen, may be also pre- scribed. In female patients, when there is scanty men- struation or amenorrha^a, means should be taken to re- store the uterine functions. In cases which have resisted medicinal remedies, I would certainly try a course of hy- dropathy, witli the hope that by acting freely on the skin the patient may gain that relief which other treatment had failed to attbrd. TUMORS or THE ORBIT. Tumors of the Orbit ma}' be divided into three classes : 1. Those which originate within the orbit. 2. Those which commence within the eye, and after- wards extend to the orbit; or reappear in the orbit after the eye has been excised. 3. Those which have their origin at some site beyond the eye or the orbit, but have extended into the orbital cavity. It would be out of place to discuss in this manual the nature and progress of all the varieties of tumors which ma}' affect the orbit, as nearly every form of tumor which may grow elsewhere, may spring u[) also in this localit3\ I shall therefore allude only to those growths which have 400 DISEASES OF THE ORBIT. some special bearing on the treatment to be pursued for their removal. 1. Tumors which originate within the orbit soon manifest their presence by the pressure thej' exert on the eye. As the growth advances, the globe is protruded in one or other direction, according to the position the tu- mor occupies in the orbit. All sight may be destroyed by the pressure on the optic nerve ; or by the stretching and extension of the nerve from the protrusion of the eye ; or, if the exophthalmos is great, the lids may fail to cover the globe, and the cornea may ulcerate and slough from exposure. It is, however, often astonishing to what an extent the eye may be projected and the optic nerve consequently stretched, without producing any great im- pairment of vision ; and also how the lost sight will be regained after the eye has been restored to its proper position within the orbit by the removal of the morbid growth. The tumors which originate within the orbit may be benign, recurrent, or cancerous ; and may be ex- tirpated with more favorable prospects of success than those which first show themselves within the eye. Of the hcnign growths We have the fibrous, bonv, and cartilaginous tumors and cj^sts. Fibrous tumors usually grow from the periosteum of the orbit, to which they are attached bj- either a broad or a pedunculated base. They are often situated near the edge of the orbit, from which, with care, they ma}^ be re- moved without injury to the eye. Tliese tumors, when carefully dissected out with the portion of the periosteum from which they have sprung, do not reappear. Bony and Cartilaginous Tumors. — The exact nature of these growths can only be ascertained by an exploratory incision, when, if they are attached l»y a short pedicle, they ma}^ be removed. Occasionally, however, their base TUMORS OF THE ORBIT. 401 is SO extensive, and their structure so dense, that it is im- possible to take them away. For the excision of these tumors the operator should be proA'ided with small bone forceps, a gouge, and an elevator, as even when the pedi- cle is small, it may be impossible to detach it without the use of some bone instruments. Cysts of the orbit are of various kinds. The most fre- quent are the atheromatous and the steatomatous, but serous, hydatid, and other forms of cysts are also met with in this locality. The most satisfactory method of dealing with cysts is to dissect them out, but this is often extremely' difficult, and occasionallj' impracticable, without sacrificing the e^'e. The}' sometimes so entwine themselves amongst the orbital muscles that it is hard to follow them ; and their Avails are frequently' so thin that the3^ either give way or are punctured during the opera- tion, and their contents having escaped it becomes almost impossible to identify them from the structures in which they are buried. Unless the cyst is completely excised, it is liable to grow again. If the cyst is large, and on making an exploratory incision into it its contents are found to be fluid, one or two strips of lint may be intro- duced into its cavit}', after it has emptied itself, with the object of exciting sufficient inflammatory action to cause obliteration of the sac. Occasionallj' an orbital cyst will be found to contain hydatids, which may be either echi- nococci or cysticerci. Of the recurrent grotrfhs^ the most frequent is the fijroid recurrent {the spindle-celled sarcoma). This tumor usually grows from the greater part of the periosteum lining the orbit, and can onl}' be eradicated b}' completely extirpating it, and then destroying the whole of the sur- face from which it springs. This is best done by using the chloride of zinc after the tumor has been excised in the manner described at page 405, in the section on 34* 402 DISEASES OF THE ORBIT. Treatment of Orbital Tumors. These recurrent growths differ from the cancerous tumors in that thej'^ do not invade the 13'niphatics or affect neighboring organs. There is another form of fibroid tumor which is recur- rent, but in a different sense to the one just alluded to. It grows from onl}' a limited area of the lining membrane of the orbit, it has a delicate investing capsule, and may be pedunculated. When fairly excised with the portion of the periosteum to which it is attached, it does not re- turn in the same locality', but it reappears in other por- tions of the bod}', generally' selecting for itself some fibrous expansion from which to sprout. I have had one such case under ni}^ care, and as it is an example of a rather rare form of disease, I will brieflj^ quote it. In May, 1866, I removed from the left orbit of a lady a fibroid tumor of six 3 ears' growth. It was pedunculated, inclosed in a delicate capsule, and attached to a small portion of the periosteum of the outer wall of the orbit, which I also excised with the tumor. From this opera- tion she rapidly recovered, and the eye, M'hich had been considerably displaced and impaired in vision, was re- stored to its normal position, and soon regained much of its lost sight. In March, 1867, the patient returned to me on account of a tumor which occupied the whole of the hard and a portion of the soft palate of the left side. It was irregular in outline, but perfectly smooth and very elastic. It was first noticed about four or five months previously as a small swelling in the upi)er part of the left hard palate. For the complete removal of the disease I excised the whole of the left side of the hard palate, and as much of the soft palate as was involved in the disease. From this operation also the patient made a good recovery. In October of the same 3'ear she again came to me. The disease had recurred on the hard jialate of the right side. There was also a fibroid tumor in the parotid region on TUMORS OF THE ORBIT. 403 the same side of the face, which had existed some years, and had now begnn to increase in size. I accordingly removed with the gouge the tumor in tlie palate, scoop- ing away the periosteum and the corresponding portion of bone to which the growth was attached, and excised the parotid tumor. From this operation the patient soon recovered, and up to the present time, June, 1869, she has continued without a recurrence of the disease. Of the cancerous growths which may originate within the orbit, we have the scirrhous, medullary, and melanotic cancers. The two last, however, more frequently first ap- pear in the 636, and afterwards extend to the orbit. For the treatment, see section below. 2, The Tumors wniicn first commence within the Eye, and afterwards extend to the Orbit ; or re- appear IN THE Orbit after the Eye has been ex- cised, are the medullar}^ and melanotic cancers, and the retinal glioma. See articles Medullary' Cancer, page 230, and Glioma of the Retina, page 214. Children are more liable to cancerous affections of the eye and orbit than adults ; Leber* has found that, in one-third of the cases the patients were under ten years of age. For treatment, see section below. 3. Tumors which have their origin at some site beyond the Eye or the Orbit, but have extended into the Orbital Cavity. — Such growths may spring from the antrum, the frontal sinuses, the lachrymal ca- nals, or from some of the bones which help to form the base of the skull, as the pterygoid processes, or the body of the sphenoid. In all cases they should, if practicable, be removed, and at as early a period as possible. Ex- * Soelberg Wells on the Eye, p. 648. -404 DISEASES OF THE ORBIT. ami)les of remarkiible displacement of the e^-e from such growths encroaching on the orbit, will be found in Heath's valuable book on "Injuries and Diseases of the Jaws," pages 238 and 247. TreatmeiU of Orbital Tumor's. — In all cases which ad- mit of a reasonable hope of success, the morbid growth should be excised, and the eye, if possible, saved. When the tumor is cancerous and occupies the greater part of the cavity of the orbit, the eye must be first enucleated, even though it still retain some sight, in order to afford suflicient space for the complete removal of the growth. The small fibrous, or bony and cartilaginous tumors, or even cysts, ma}' often be taken from the orbit without in- jury to the eye. The morbid growth may be frequently removed b}^ an incision through the conjunctiva, and es- pecially- if the globe has been already excised ; but, when more room is required, the external cantlius must be freely divided, so that the lids may be turned either up- wards or downwards, and thus the outer boundary' of the orbit be completely exposed. Whenever there is any doubt as to the nature of the tumor, the surgeon should make an incision down to it, but be prepared to act at once upon the information which he thus gains. In bony tumors the base is sometimes found to be so large, and the structure so hard, that it is more prudent to close the wound than to proceed with the operation. This caution is speciall}' applicable to the broad-based ivor}^ exostoses Avhich are occasionally met with in the orbit. For all the malignant and recurrent growths, the mere excision of the disease is not suflicient, even though the whole mass be apparently taken away, as some germs will cer- tainly be left, which will, in all probability, cause the tumor to grow again. Having excised as much of the tumor as can witli safety be removed with cutting instru- ments, the actual cautery should be freel}^ applied to TUMOES OF THE ORBIT. 405 those parts of it which still remain, and to all the bleed- ing points. When all hemorrhage has been arrested, the chloride of zinc i)aste (F. 7) spread on small pieces of lint, shonld be laid evenl}'^ over the whole surface from which the growth has sprung. A small pledget of cot- ton-wool should then be placed in the orbit, and over this a fold of dried lint, which is to be held in situ b}^ a band- age tied firndy around the head. Before the patient awakes from the chloroform, one-third of a grain of the acetate of morphia (F. 24), should be injected subcuta- neously into the arm, and repeated in two hours if the pain be severe. The pain, a er this operation, is usu- ally great, but it is much lessened if the strips of lint with the chloride of zinc are so packed in the orbit that the skin of the lids is not acted upon by the caustic ; but this, in many cases, is quite unavoidable, as the tumor often grows from the periosteum close up to the margin of the orbit, and some of the chloride of zinc is then almost certain to run into the surrounding tissues, and cause a slough of a portion of the lids. On the day following the operation, the bandage may be removed, and, if there is much tension of the lids from the stuffing within the orbit, some of the cotton-wool may be gently drawn out, and a piece of clean lint being laid over the parts, another bandage should be lightly applied. The remainder of the cotton-wool shonld be taken away on the second day, and a little more laid loosely within the orbit to alisorb the discharge as soon as suppuration commences. This dressing may be repeated daily, but the pieces of lint on which the chloride of zinc has been applied should not be removed until suppuration has quite loosened them from the surface against which they were placed. After about ten or twelve days the sloughs will separate fr( m the orbit, and, if any suspicious-looking granulations spring up, they should be touched with the 406 DISEASES OF THE ORBIT. solid chloride of zinc, or with the potassa cum calce. On three occasions I have seen epileptic convulsions follow within thirty-six hours after the operation, but they have in each instance ceased shortly after the removal of the cotton-wool and the chloride of zinc from the orbit. The fits did not recur, and the patients perfectly' recovered. The success of this mode of treatment has been well proved, and two striking instances of its efficac}^ have been recorded in the " Pathological Transactions." The first was in a patient under Mr. De Morgan, who removed a large encephaloid tumor from the orbit. "It projected nearly four inches forward from the cheek on the outside, and about two inches and three-quarters from the nasal side." * The man died, one year and nine months after the operation, from paraplegia, but there was no return of the disease in the orbit. The account of the post- mortem examination will be found in the "Pathological Transactions," vol. xviii, page 220. The second case was a patient under ra^' care in the Middlesex Hospital, from whom I i-emoved a scirrhous tumor of the orbit.f The whole of the bones of the orbit wei-e detached in one piece, and are to be seen in the museum of that institution. It is now three years and five months since the operation, and the patient con- tinues quite well, and free from an}" recurrence of the disease. Acute Inflammatory Exudation into the Orbit. — A case of this nature was under the joint care of Dr. Goodfellow and myself at the Middlesex Hospital. It presented all the symptoms of a rapidly increasing can- cerous tumor; but after I had enucleated the e^'c, and * Pathological Transactions, vol. xvii, pp. 265-271. f Ibid., vol. xviii, pp. 233-2o-j. INFLAMMATORY EXUDATION. 407 excised the solid growth Avhith filled the orbit, it proved on a microscopical examination to be perfectly structnre- less, and was probabl}' the product of acute inflammation, most likel}^ specific. The man continued in the hospital until his death, five months afterwards, when a post- mortem examination explained most of the symptoms observed during life. A short account of the case was given in the "Lancet,"* from which I have abstracted the following notes : The patient was under the care of Dr. Goodfellow in one of the medical wards; after suffering much pain, the e^'e within twent3-four hours was found to bulge consid- erably. There was paralysis of all the ocular muscles, great impairment of sight, and Q?dema of the lids, with slight chemosis of the conjunctiva. I was asked to see the man, and believing from the rapidity of the symptoms, that they were due to some kind of inflammatory exuda- tion, I thrust a bistoury into the orbit through the upper lid. Onlj'^ a little serum escaped. The bulging of the eye steadily increased, and with it the swelling of the lids and chemosis of the conjunctiva. The pain in the head and orbit at times was very considerable, and twice it was relieved b}' some leeches to the temple. Iodide of potassium was administered in large doses, but without affording any relief. The urgent symptoms continued, the eye became quite blind and immovable, and began to suppurate. As the eye was now lost, and the man's sutferings were extreme, I excised the globe, and then came down upon a hard conical-shaped mass, which ex- actly filled the whole of the orbit. The periorbital mem- l)rane was in situ with the bone, and the tumor corre- sponded with the cone which is formed l\y the muscles and vessels as they pass from the apex of the orbit to the * See Lancet, April 18, 18G8. 408 DISEASES OF THE ORBIT. e3'e. I removed as mneh of this solid material as I was able, leaving- onl}" a small portion at the veiy apex of the orbit, which I felt it would be unsafe to meddle with. Examined with the microscope b}' Messrs. De Morgan, Hulke, and Ca3'ley, the conclusion was, that this solid mass was only inflammatory exudation ; it was perfectly structureless. The following day the man had three epi- lejjtic fits, but from these he recovered, and, so far as the orbit was concerned, he afterwards did perfectl}^ well. There was very free suppuration, which was followed by complete cicatrization. For the first fortnight after the operation, the man seemed decidedly relieved, but the pain in the head then returned ; and on awaking one morning he found the left half of his face paralyzed. He was then transferred to the physicians' wards, where he graduall}' became hemiplegic, in which condition he remained until he died. Post-mortem examination ten hours after death. Rigor mortis strongly marked. Body much wasted ; nodes on the right tibia. On removing the scalp, the outer table of the skull presented a curious worm-eaten appearance, and the bone was adherent at points to an irregularly thickened dura mater. In the substance of the left cere- bral hemisphere, near the front of the upper surface, was a nodule of firm gra^'ish syphilitic deposit, the size of a filbert. At the surface of the corresponding part on the right side, where the pia mater adhered to the brain, there was a circumscribed abscess. There was also an- other abscess, of the size of a hazel-nut, in the substance of the left cerebellar hemisphere. There was necrosis of the petrous portion of the left temporal bone, with an abscess above it leading into the left inferior petrosal and left lateral sinuses, both of which were filled with pus. Cases of acute inflammatory exudation into the orbit are no doubt rare, but 1 suspect that they are more fre- DISTENSION OF THE FRONTAL SINUS. 409 quent than the hospital records would lead us to antici- pate. It is onl}' on this supposition that I can account for the occasional instances which one meets with in practice of the gradual subsidence, without operative treatment, of firm orbital tumors, which had considerably displaced the eye, and had been readily felt with the finger in the orbit. In October, 18GG, I saw in consul- tation with Dr. Stallard a patient, vet. 20, whose right eye was protruded rather more than half an inch from the orbit by a firm growth, the margin of which could be distinctly felt with the tip of the finger pressed within the orbit. The eye began to bulge suddenly in the pre- vious May, after a considerable swelling of the face, for which he had a tooth removed ; and from that date up to the time I saw him, the proptosis had continued to in- crease. Thinking, from the history of the case, that the symptoms might be due to some inflammatory exuda- tion, I thrust a bistoury through the upper lid in two places into the orbit, but only a little blood escaped. He was then ordered a mixture with iodide of potassium, and since then he has steadily improved. The tumor within the orbit has so far subsided, and the e3'e has resumed so nearly its normal position, that an ordinary observer would fail to notice any dift'erence in the prominence of the two eyes. DISTENSION or THE FRONTAL SINUS. The frontal sinus may be distended with pent-up secre- tion, or pus, and the tumor thus formed may so closely resemble a growth from within the orbit, as to render it difficult to arrive at a correct diagnosis without making an exploratory incision. In order to rightly estimate the displacement of the globe which an expanded frontal sinus may produce, it will be necessary to refer briefly to the anatomy of the dry skull. 35 410 DISEASES OF THE ORBIT. The frontal sinuses are two bony cavities placed between the inner and outer tables of the vertical portion of the frontal bone, conipletel}' separated from each other by a bon}' septum. Each of these spaces is subdivided into cells b}' delicate lamellte of bone. These cells extend up- wards about one inch, gradually becoming narrower as they ascend, until the opposed plates of the frontal bone come almost into contact, a thin layer of diplo'e only in- tervening. Forwards and outwards the frontal cells are prolonged between the layers of bone which form the roof of the orbit as far as the mesial line of that cavity, at which part they cease, from the opposed laminae of bone falling together. The half-cells which are seen in the dry frontal bone at the nasal notch, are completed b}' corre- sponding half cells on each side of the cribriform plate of the ethmoid bone. The frontal cells communicate with the middle meatus of the nose by means of the infundi- bulum, which is a long and tortuous bony canal, connect- ing the anterior ethmoidal cells with the frontal sinus above, and with the meatus of the nose below. The situation of the frontal sinuses is indicated on the exterior of the frontal bone b}' two prominences over the root of the nose, more or less strongl}' marked in all people, and called the nasal eminences. Such being the disposition of the frontal cells, it is eas}' to conceive in what direction a new growth, or an accu- mulation of fluid, would cause them to distend. Of their boundar}' walls the weakest is that towards the orbit, where the bony plate which separates that cavity from the frontal sinus is exceedingly thin, and often in the dry skull semi-transparent; so delicate indeed in structure is the iipper and inner part of the orbit, that the linger, in many of the drj- preparations, may be easily pushetl through it. Causes. — In most cases, distension of the frontal sinus DISTENSION OF THE FRONTAL SINUS. 411 is due to iiii iiymy at some remote period, frequently at a date so far from the s^'iiiptoms which first attracted the patient's notice, tliat it seems at first diflicult to fairly attribute the disease as the result of an accident. The extent, however, to which the sinus is often found dilated, and the time which must necessarily be consumed to effect this distension of a bon}^ cavity, together with the oft-told tale of a blow or a fall years ago, can only lead to the con- clusion that an injury is the most frequent exciting cause of these accumulations. The explanation is probably to be found in the supposition, that at the time of the acci- dent a fracture of some of the anterior ethmoidal or frontal cells produced a closure of the infundibulum, the canal by which the mucus from the frontal sinus escapes into the nose. This channel being closed, there was at once a retention of all mucous secretion, wdiich from that time began to slowly accumulate and gradually expand the sinus. In a patient, set. 58, under my care, with an enormous distension of the left frontal sinus, the disease was clearly traceable to a kick he received on the left eye- brow from a horse fifty-four years previously, when four 3'ears of age. There was a depression of the bone over the left eyebrow, and a scar at the side of the nose. A case also is recorded by Mr. Hulke, of a girl, set. lY, with great expansion of the right frontal sinus, which was evidently caused by an accident when she was five years of age. " She fell from a window and received a cut over the right eyebrow^ Her forehead was much bruised and swollen, and she had concussion of the brain."* There are, however, cases of distended frontal sinus, in which no history of an injury can be traced. The only conclusion which can then be drawn is, that from some ac- cidental cause which we cannot detect, the communica- * Koyal London Ophthuhiiic Hospital Eeports, vol. iii, p. 153. 412 DISEASES OF THE ORBIT. tion between the frontal cells and the nose throngh the in- fundibulum has been closed, possibh' from some inflam- mation of the lining mucons membrane. This hypothesis seems probable, as in the case of a yonng girl, a?t. 21, who was under my care, the disease Avas dated from an attack of erysipelas of the head and face when she was six years old, dnring which there was a thick discharge from the nares. Si/mjjtoms — Distension of the frontal sinns ma}' be acute or chronic. When the distension is acitfe it is dne to inflammation of the mucons membrane of the sinus, which leads to the formation of pus. There is generally a dull aching pain over the brow and root of the nose, accompanied by con- siderable constitutional disturbance. The pus gradually accumulates in the frontal sinus, and ultimately dis- charges itself either by bursting into the nose, or by making an exit for itself through the upper and inner part of the orbit. When the latter site is selected there is usually some bulging of the distended sinus into the orbit, and a slight displacement of the eye downwards and outwards. The upper lid becomes red and swollen, and the tumor examined with the finger is tender, and will, if sufficient thinning of the bone has taken place, impart a sense of fluctuation. In most cases the distension of the frontal sinus is chro7iic, and the collection of fluid within its walls is the pent-up secretion of many j^ears. Sealed within a bou}^ cavit}', no decomposition ensues, and increasing year b}' 3'ear in quantity it distends the sinus and displaces the eye. There is frequently no pain, not even a sense of weight over the brow. The only symptoms which are manifest to the patient are, the gradual formation of a tumor at the upper and inner portion of the orbit, and a slow but steadily increasing protrusion of the eye down- DISTENSION OF THE niONTAr^ SINUS. 413 Avaids, outwards, and forwards. In one patient under m}^ care the displacement was so extreme that the upper mar- gin of the cornea of the left Qye, was below the level of the right lower lid. Occasionally the early symptoms are chronic, whilst the later ones are subacute, and produc- tive of a feeling of constant heaviness and aching across the forehead. The disease is usually confined to the frontal sinus of one side, but a case occurred under Mr. llulke of a man in whom both frontal sinuses were af- fected. Treatment of Distension of the Fi-ontal Sinus — The objects to be attained are, first, to evacuate the pent-up fluid, and then to establish a free communication between the frontal sinus and the nose, through which the secre- tion may continue to drain as fast as it is secreted. By these means the cavit}^ of the sinus will gradually collapse, and the eye will be restored in a great measure to its nor- mal position. The ends to be desired will be accomplished by the following operation : A single curved incision parallel with the fold above the lid is to be made over the most prominent part of the tumor, and having by a little dissection exposed Its sur- face, the scalpel should be plunged into it, and an opening made to the extent of the incision. The index finger of the right hand is now to be pushed into the sinus through the wound to ascertain the size of the cavity and if there is any necrosed or carious bone. Whilst thus exploring the sinus, the little finger of the left hand should be passed up the corresponding nostril and an endeavor made to find out the spot at which the tip of the finger in the sinus will approximate most closely the end of the one in the nose. After a little search it will be found that at one part the fingers will almost meet, there being only a thin plate of bone between them. Having gained this information, the finger in the frontal sinus is to be withdrawn, but that in 35* 414 DISEASES OF THE ORBIT. the nostril is to be retained in situ to act as a gnide to the gonge or elevator, which is to be passed into the sinus and made to force a passage into the nose through the lamina of bone on which the tijD of the little finger is rest- ing. A communication between the frontal sinus and the nose having been thus established, an india-rubber drain- age tube with holes cut at short distances is to be intro- duced, one extremit}^ of Avhich is to be afterwards fastened on the forehead, whilst the other end protrudes slightly from the nostril. The easiest wa^y of introducing the drainage tube is to pass a probe with an eye up the nostril and out of the wound, and having fastened the tube to it by means of a piece of string, to draw it back again through the nose. The object of the drainage tube is to keep the channel between the two cavities from closing, and to enable the attendant to wash out the frontal sinus at least twice a da}' with some astringent and disinfectant solution. For the latter purpose the lotio alum, cum zinc, sulph., or the lotio acid, carbolic. (F. 40, 45), may be injected wdth a glass S3'ringe through one of the openings at the upper extremit}' of the tube. The drainage tube should be worn for five or six months, or until all discharge from the nose has ceased. The results of these cases when thus treated are usuall}' most satisfactory. FORMULARY. 1. Liebreich's Eye Bandage. Tlie bandage consists of a linen or a knitted cotton band, ^,from 10 to 10^ inches in length, and 2^ inches in width; at either end of which are attached tapes to keep it in position on the head. Tlie tapes should be one ingh in width. One tape, B, \\^ to 12 inches in lengtli, extends across the top of the head from ear to ear and terminates in a loop, through which the second tape, CD, passes, as in the wood-cut. To apjjly the bandage : The patient having been told to gently close the lids of both eyes, a small square of linen is laid over each, upon which are placed small pads of eotton-wool or charpie. The bandage, which had been previously fitted to the head, is now drawn acros.s the eyes and fastened on the temple, opposite to the eye which has undergone the operation. 2. The Compress Bandage. "This bandage should be about If yards in length, and 1^ inches in width; the outer two-thirds should consist of tine and very elastic flannel, the central third of knitted cotton. The eye hav- ing been padded, the bandage is to be adjusted in the following manner : — One end is to be ap- plied to the forehead just above the affected eye, and is then to be passed to the opposite side of the forehead, above the ear, to the back of the head : the knitted portion is then to be carried on below the ear, and brouglit up- 416 FORMULARY. wards over the compress, the bandage being passed across the forehead, and ils end liinily pinned. The opposite eye ma\' be closed with sticking piiister, or if it also requires a compress, a separate bandage is to be ap- plied to it "* In the place of the flannel and knitted cotton bandage iibove described, a fine linen one will answer equally well. 3. Mercurial Vapor Bath. The following is Mr. Henry Lee's description of his mercu- rial vapor bath. " It consists of a kind of tin case, containing a spirit lamp. In the centre, im- mediately over the wick of the lamp, is a small circular tin plate, upon which the mercurial pow- der is placed. Around this is a circular depression, which is half filled with boiling water. The patient places this on theground, and sits over it, or near it, on a small cane stool. He is then en- veloped, lamp and all, in a cir- cular cloak, made expressly- for this purpose by Messrs. Savigny. "When a cloak cannot be pro- cured, a double blanket answers the purpose very well. At the expiration of a quarter of an hour or twenty minutes, the * " Observations on Compressive Band- ages," by Prof. Von Graefe, abridgei) | and translated by Soel berg Wells, /f. Z<. O. U. Rip., vol. iv, p. 206. I calomel which is placed upon the lamp, the water, and the spirit will have disappeared, and the patient may then get into bed. During the time the pa- tient is taking the bath, he may inhale the vapor for half a min- ute or a minute, on two or three ditt'erent occasions, with advan- tage; and after the bath is over he must contrive not to wipe otf the calomel deposited on his skin. Patients are generally n-- commended to sit over the bath for two or three minutes after the lamp has gone out."* The lamp maj' be obtained of Messrs. Weiss, Savigny, Mat- thews, or any of the London surgical instrument makers. 4. Lapis Divinus. Sulphate of Copper, iS'itrate of Potash, and Alum, of each equal parts, in powder, fused in a glazed earthen crucible, pow- dered Camphor, to the extent of Jq part of the whole, being added near the end of the process. When cold, break in pieces and keep in a closelj'-stoppered bot- tle.f 5. Diluted Nitrate of Silver Points. These are made by fusing Ni- trate of Potash in various pro- portions with Nitrate of Silvi^r; thus:| No. 1 consists of 1 Nitrate of Silver and 2 of Nitrate of Potash. * Article "Syphilis," Holmes's Sys- tem of Surgery, by Henry Lee, vol. i. p. i-21. t Squire's Comp. to Brit. Pharmacnp., 5th edit., p. 96. X Ibid., p. 40. FORMULAEY. 417 No. 2 consists of 1 Nitrate of Silver and 8 of Nitrate of Potash. No. 3 consists of 1 Nitrate of Silver and 3| of Nitrate of Potash. No. 4 consists of 1 Nitrate of Silver and Potash. 4 of Nitrate of 6. Pulvis Caustica. R. Zinci Chloridi ) Partes Zinei Oxydi, j aHiiiales. Jlix them intimately with pes- tle and mortar. Preserve in a well-stoppered bottle. 7. Pasta Caustica. R. Zinei Chloridi, . . gr. 480 Farinaj, . gr. 120, vel q. s. Liquoris Opii Sedativi vel Aquie, . . . 11. oz 1 Misce. 8. Fotus Belladonnse. Extract. BeUadonnie, . gr. 60 To be dissolved in one pint of boiling water, and used as a fo- mentation. 9. Fotus Papaveris. R. Capsiil. Papav. contus., oz. 1 Aquse destillat., . fl oz. 20 Mix, and boil for a quarter of an hour; then strain through muslin. 10. Gargarisma Acidi Hy- drochlorici. R. Acid. Hydrochlorici, diluti., . . . . fl. dr. 2 Decoct. Querciis, . fl. oz. 20 JVlisce. 11. Gargarisma Aluminis. R. Aluminis, . . . gr. 120 Tinct. Myrrhaj, . fl. dr. 4 Aqu;e destillat., ad fl. oz. 20 Misce. 12. Gargarisma Sodse Chlo- ratae. R. Liq. Soda? Chlorata\ fl. dr. 4 Aquie destillat., ad fl. oz. 8 Misce. 13. Guttse Atropiae Sulpha- tis. R. Atropiie Sulphatis, gr. 1 ad gr. 2 Aqufe destillat., . fl. oz. 1 Misce. 14. Guttae Atropiae Sulphatis Fortiores. R. Atropi;p Sulphatis, . gr. 4 Aqua) destillat., . fl. oz. 1 Misce. 15. Guttae Physostigmatis Fabae (Calabar Bean). Extracti Physostigmatis Fa has, . . . gr. 1 ad gr. 4 Aquie destillat., . . fl. dr. 1 Misce. 16. Guttae Argenti Nitratis. R. Argenti Nitratis, . . gr. 1 Aquie destillat., . fl. oz. 1 Misce. 17. Guttae Argenti Nitratis Fortiores. R. Argenti Nitratis, . . gr. 2 Aquiv destillat., . fl. oz. 1 Misce. 18. Guttae Potassii lodidi. R. Potassi lodidi, . . . gr. 3 Aquffi destillat., . fl. oz. 1 Misce. 19. Guttae Zinci Chloridi. R. Zinci Chloridi, gr. 1 ad gr. 2 Aqua' destillat., . fl. oz. 1 Misce. 418 FORMULARY, 20. GuttsB Zinci Sulphatis. U- Zinci Sulphiitis, gr. 1 nd gr. 2 Aqiiie destillut., . fl. oz. 1 Misce. 21. Guttse Cupri Sulphatis. R. Cn]iri Siilpliatis, . . gr. 2 Aqiiie destillat., . fl. oz. 1 Misce. 22. Guttse Opii. R. Vini Opii, . . . fl. dr. 2 Aqune destilhit., . fl. dr. 6 Misce. 23. Guttae Terebinthinae. R. 01. Tercbinthiiue, . fl. dr. 1 01. Olivje, . . . fl. dr. 7 Misce. 24. Injectio Morphiae. R. Morphiae Acetjitis, . gr. 80 Aquse destillat., . fl. oz. 1 Eub the Morphia gradually with the water, and add a few drops of dilute Acetic Acid, if necessary for perfect solution. Min. 6 contain gr. 1 of Acetate of Morjihia. 25. Liniment. Aconiti. R. Linimenti Aconiti, fl. dr. 4 Linimenti Saponis, fl. dr. 6 Misce. 26. Liniment. Ammoniae. R. Liq. Ammonite, . fl. dr. 4 Ol. OlivEe, . . . fl. dr. 4 Misce. 27. Linimentum Belladonnse cum Glycerino. R. Extracti Belladonnfe, Glycerini, . . fia fl. oz. 1 Misce. 28. Linimentum Chloro- formi. R. Chloroform!, Ol. Olivse, . Misce. fl. dr. 4 fl. dr. 4 29. Linimentum Calcis cum Creta. R. Olei Lini, Liquoris Calcis, afi fl. oz. 4 Cretse preparataj, . . uz. 2 Misce. . oz. 1 . gr. 25 fl.-dr. 6 fl. dr. 2 min. 30 30. Linctus. R Theriacse, . . . Pulv. Tragacanthffi, Svrupi Paiiiiveris, . Tiiict. Scillte, . . Acid Suiph. dilut. , Aqua^, fl. oz. 2 Misce. Dose, from a half to two tea- spoonfuls. 31. Lotio Atropiae. R. Atropiffi Sulphatis, . gr. 1 Aqua3 Sambuci, . fl. oz. 2 Aquae destillat., ad fl. oz. 8 Misce. 32. Lotio Belladonnae. R. Extracti Belladonna}, gr. 40 Aqu:e destillat., . fl. oz. 8 Misce. 33. Lotio Belladonnae cum Alumine. R. Extracti Belladonnie, gr. 30 Aluminis, .... gr. 24 AquK Sambuci, . fl. oz. 2 Aquffi destillat., ad fl. oz. 8 Misce. 34. Lotio Stramonii. R. Extracti Stramonii, . gr. 4 Aquas Lauro-Cerasi, fl. dr. 4 Acpue destillat., ad fl. oz. 8 Misce. FORMULARY. 410 35. Lotio Opii. R. Extract! Opii liquidi, gr. 30 Aquas Lauro-Cerasi, fl. dr. 4 Aquae destillat., ad fl. oz. 8 36. Lotio Conii cum Opio. R. Extract! Conii, . . gr. 30 Extracti Opii liquidi, min. 30 Aquie ferventis, . fl. oz. 8 Misce. 37. Lotio Acidi Hydrocy- anici. R. Acidi Hydrocyanici dilut., fl. dr. 1 AquffiElor. Aurantii, fl. oz. 2 AquiB destillat., ad fl. oz. 8 Misce. 38. Lotio Aluminis. R. Aluminis, . . . . gr. 6 Aquae destillat., . fl. oz. 1 Misce. 39. Lotio Aluminis Mit. R. Aluminis, .... cr. 4 Aqu;e destillat., Misce. 1. oz 1 40. Lotio Alum, cum Zinci Sulph. R Aluminis, .... gr. 3 Zinci Sulpliat., . . . gr. 1 Aqua3 destillat., . fl. oz. 1 Misce. 41. Lotio Evaporans. R. Sp. ^theris nitros., fl. dr. Aceti aromatici, . min. Aquaj destillat., ad fl. oz. Misce. 42. Lotio Plumbi. R. Plumbi Acetatis, . . Acidi Acetici dilut. Aquae destillat., Misce. min. 2 fl. oz. 1 43. Lotio Zinci Oxydi. R. Zinci Oxydi, . . . gr. 90 Glycerini, . . . fl. dr. 4 Aquu3 Sambuci, . fl. oz. 2 Aquas destillat., ad fl. oz. 8 Misce. 44 Lotio Glycerini. R. Glycerini, . . . fl. oz. 1 Aquae Flor. Aurantii, fl. oz. 2 Aquae destillat., ad fl. oz. 8 Misce. 45. Lotio Acid. Carbolic. R. Acid. Carbolic, pur., min. 4 to min. 8 Aquae destillat., . fl. oz. 1 Misce. 46. Lotio Hydrarg. Perchlo- ridi. R. Hydrarg. Perchloridi, gr. \ Aquae destillat., . fl. oz. 1 Misce. 47. Lotio Acidi Tannici. R. Acidi Tannici, . . . gr. 30 Sp. Vini rectificati, fl. dr. 4 Aquae llosae, . . . fl. oz. 2 Aqu£e destillat., ad fl. oz. 8 Misce. 48. Lotio Boracis cum Gly- cerino. R. Boracis, .... gr. 120 Glycerini, . . . fl. oz. \ Aquae Sambuci, . fl. oz. 2 Aquae destillat., ad fl. oz. 8 Misce. Very useful in eczema of the face and eyelids. 49. Lotio Arnicae. R. Tincture Arnic;e, min. 30 Aquie destillat., . fl. oz. 1 Misce. 420 FORMULARY. 50. Lotio Nigra. R. Calomelanos, . . . gr. 60 Mucilag. Acacite, . fl. dr. 4 Liquor. Calcis, . ad fl. oz. 6 ilisce. 51. Lotio Rubra. rr. 1 55. Mistura Salinae. R. Pota.^sai Bicarb., . . gr. 10 Spirit. jEtheris nitrosi, fl.dr. J Liq. Ammoniae Acetatis, fl. dr. 1 Aquae destillat., ad fl. oz. I Misce. R. Zinci Sulphati>, . Sp. Rosmarini, Tiiict. Lavandulae comp. aa min. 15 Aquae destillat., . fl. oz. 1 Misce. 52. Mistura Antimonii Tar- tarati. R. Yin. Antimonialis, fl. dr. i Liq. Ammon. Acetati-s, fl. dr. 1 Tinct. Hyoscyami, min. 20 Aquae destillat., ad fl. oz. 1 56. Mistura Cinnamomi. R. Tinct. Cinnamomi, fl. dr. 1 Aquae destillat., Misce. oz. 1 53. Mistura Potassae Citratis. R. Potassae Bicarb., . . gr. 20 Sp. Ammon. Aromat. fl. dr. J Tinct. Aurantii, . fl. dr. h AquiB destillat., . fl. oz. li To be taken in effervescence •with Acid. Citric, gr. 14 dissolved in one tablespoonful of water. The Sp. Ammon. Aromat. may be omitted if desired. 54. Mistura Chloroformi cum Ammonia. R. Ammoniw Carb., . ". gr. 3 Sp. Chloroformi, . min. 15 Tinct. Aurantii, . fl. dr. ^ Aquaj destillat., . fl. oz. 1 Misce. 57. Mistura Cinnamomi cum Acido. R. Tinct. Cinnamomi, fl. dr. ^ Acid. Nitro-Muriatic. dilut., .... min. 10 Aquae destillat., . A- oz. 1 Misce. 58. Mistura Boracis. R. Boracis, gr. 60 Sp. ^theris nitrosi, fl. dr. 4 Syrup. Aurantii, . fl. dr. 4 Aquae destillat., ad fl. oz. 8 Misce. — Dose, 1 ounce. 59. Mistura Nucis Vomicae. R. Tinct. Nucis Vomica?, min. 15 Infus. Gentian, comp., fl. oz. 1 Misce. 60. Mistura Acidi cum Tinct. Nucis Vomicae. R. Acidi Nitro-Muriatici dilut., .... min. 10 Tinct. Nucis Vomicje, min. 15 Tinct. Chirataj, . min. 15 Aqua? destillat., . fl. oz. 1 Misce. FORMULARY. 421 61. Mistura Acidi cum Cin- chona. R. Acidi Nitro-Muriatici dilut., .... min. 10 Tinct. Cinchonas, . fl. dr. ^ Decoct. Cinchona?, fl. oz. 1 Misce. 62. Mistura Cinchonae cum Opio. R. Extract. Cinchonre Flav. liquid., .... min. 15 Acidi Nitrici dilut., min. 10 Tinct Opii, . min. 5 to 10 Aqufe destillat., . fl. oz. 1 Misce. 63. Mistura Cinchoniae. R. Cinchoni;e Di.«ul[)hatis, gr. 3 Acidi Sulphuric! dilut., min. 10 Aqupe destillat., . fl. oz. 1 Misce. 64. Mistura Quiniae. R. Quinitfi Sulphatis, . . gr. 1 Acid. Sulphuric, dilut., min. 10 Tinct. Aurantii, . fl. dr. J , Aquae destillat., . fl. oz. 1 j Misce. I 65. Mistura Quiniae cum Ferro. R. Quiniffi Sulphatis, Ferri Sulphatis, . aa gr. 1 Acidi Sulphurici diluti, min. 5 Aquae destillat., . fl. oz 1 Misce. 66. Mistura Ferri Perchlo- ridi cum Q,uinia. R. Quinite Sulphatis, . . gr. 1 Tinct. Ferri Perchlorid., min. 5 Acidi Nitrici diluti, min. 5 Aqua3 destillat., ad fl. oz. 1 Misce. 67. Mistura Ferri Sulphatis. R. Ferri Sulphatis, . . gr. 1 Acidi Sulphurici diluti, min. 10 Aqua; destillat., . fl. oz. IJ Misce. 68. Mistura Ferri Perchlo- ridi. R. Tinct. Ferri Perchloridi, min. 10 Aquc-e destillat., . fl. oz. 1 Misce. 69. Mistura Ferri Perchlo- ridi cum Acido. R. Tinct. Ferri Perchloridi, min. 10 Acid. Hydrochloric, dilut., min. 10 Aquas destillat., . fl. oz. 1^ Misce. 70. Mistura Ferri Perchlo- rid. cum Strychnia. R. Tinct. Ferri Perchloridi, min. 10 Liquor. Strychnine, min. 5 Aqufe destillat., . fl. oz. 1 Misce. 71. Mistura Ferri cum Tinct. Digitalis. R. Tinct. Ferri Perchloridi, min. 10 Tinct. Digitalis, . min. 5 Infus. Quassiie, ad fl. oz. 1 Misce. 72. Mistura Ferri cum Ergota. R. Tinct. Ferri Perchloridi, min. 10 Tinct. Ergota?, . . min. 15 Aquffi destillat., . fl. oz. 1 Misce. sn 422 FORMULARY, 73. Mistura Potassii lodidi cum Ferro. R. Potassii lodidi, . . gr. 3 Potassiu BiciU'b., . . gr. 5 Ferri ct Ammoiiiic Citrutis, gr. 5 Aquffi destillat., . fl. oz. 1 Misce. 74. Mistura Potassii lodidi. U. Pota.?sii lodidi, . . gr. 3 Potass. Bicarbonat. , . gr. 5 Infusi Quassiffi, . fl. oz. 1 Misce. 75. Mistura Potass. lodidi cum Ammonia. R. Potassii lodidi., . . gr. 3 Potassse Bicarb , . . gr. 5 Ammon. Carbonat., gr. 3 Tinct. Calumbae, . fl. dr. J Aqiuo destillat., ad fl. oz. 1 Misce. 76. Mistura Potassii lodidi cum Colchico. R. Potassii lodidi, . . gr. 2 Potassae Bicarb., . . gr. 10 Tinct. Colchici, . min. 10 Aqiise destillat., . fl. oz. 1 Misce. 77. Mistura Potassii lodidi et Bromidi. R. Potass. lodidi, . . . gr. 3 Potass. Bromidi, . . gr. 5 Potass. Bicarb., . . gr. 5 Tinct. Calumbae, . fl. dr. i Aqua3 destillat., ad fl. oz. 1 78. Mistura Potassii lodidi cum Hydrarg. Perchloridi. R. Hydrarg. Perchloridi, gr. 1 Potassii lodidi, . . gr. GO Tinct. Calumb;c, . fl. oz. 2 Aqua3 destillat., ad fl. oz. 6 Misce. Dose, two teaspoonfuls in a glass of water two or three times a day. 79. Mistura Potassii Bro- midi. R. Potass. Bromidi, gr. 5 to gr. 10 Potass. Bicarb., . . gr. 5 Tinct. Calumbae, . fl. dr. ^ Infus. Calumbie, . fl. oz. 1 Misce. 80. Mistura Hydrarg. Per- chloridi. R. Liquor. Hydrarg. Per- chloridi, . . . fl. dr. 1 Tinct. Cinchonae, . fl. dr. ^ Aquae destillat., . fl. oz. 1 Misce. 81. Mistura Terebinthinae. R. Olei Terebinthinre, min. 15 Mucilaginis Acaciie, fl. dr. 1 Aqua3 Pimentiu. ad fl. oz. IJ Misce. 82. Mistura Magnesiae Com- posita. R. Magnesiae Carbonatis pond., gr. 10 Magnesiie Sulphatis, . gr. (JO Aquaj Menthte Piperitic, fl. oz. 1^ Misce. 83. Mistura Rhei Comp. R. Khei Pulveris, . . . gr. 15 Magnesiae Carbonatis, gr. 10 Sp. Ammon. Aromat., fl dr .} Tinct. Ehei., . . fl. dr. 1 Aqute destillat., ad fl. oz. 1^ Misce. 84. Pilula Aloes cum Ferro. R. Extracti Aloiis Socotrina^, Ferri Sulpiiatis, Pulv. Zingiberis, . :'ia gr. 1 Theriaca^, .... q. s. Misce. FORMULARY, 423 *85. Pilula Aloes cum Nuce Vomica. R Extracti Niicis Vomioppjgr. ^ Extracti Aloes Socotrinse, gr. 1 Extracti Hyoscyami, gr. 2 Misee. 86. Pilula Cinchoninse cum Ferro. R. Cinchoniriie Sulphatis, Ferri Sulplnitis, . aa gr. 1 Confectionis liosse Caninaj, gr, 3 Mi see. 87. Pilula Colocynthidis cum Hyoscyamo. R. Extrae'ti Colocynthidis compositi, .... gr. 3 Extracti Hyoscyami, gr. 2 Misee. — Dose, 1 or 2. 88. Pilula Colocynthidis cum Hydrargyro- R. Pilula; Hydrargyri, Es:tracti Colocynthidis compositi, . . . aa gr. 2 Extracti Hyoscyami, gr. 1 Misee. 89. Pilula Colocynthidis cum Rheo. R. Pilulffi Colocynthidis com p., gr. 3 PiiuliTe Ehei comp., . gr. 3 Extracti Hyoscyami, gr. 2 Mix and divide into two pills. Dose 1 or 2. 90. Pilula Calomelanos cum Colocynthide. R. Hvdrargvri Subchloridi, gr. 1 Extracti Colocynthidis compositi, . . . gr. 3 Ipecacuanha} Pulveris, gr. ^ Misee. — Dose, 1 or 2. 91. Pilula Elaterii Com- posita. R. Elaterii, . '. . . . gr. ^ Extract. Aloes Socotrinte, Extracti Hyoscyami, gr. 3 Misee. 92. Pilula Colchici Comp. Extract. Colchici Acetici, gr. 1 Pulv. Ipecacuanha comp., gr. 4 Extracti Hyoscyami, gr. 1 Misee. 93. Pil. Cannabis Comp. R. Extract. Cannabis Indicie, Extract. Belladonnas, gr. ]( Extract. Aconiti, . . gr. ^ Misee. One pill at night or when in great pain. 94. Pil. Calomel, cum Opio. R. Hydrarg. Subchloridi, gr. 1 ad gr. 2 Pulv. Opii, . gr. I ad gr. ^ Confect. Rosa3 Caninae, q. s. Misee. 95. Pil. Hydrarg. cum Opio. R. Pil. Hydrarg., . . . gr. 4 Pulv. Upii, . . . . gr. i Misee. 96. Pil. Hydrarg. lodidi Virid. R. Hydrarg. lodidi Virid., gr. 1 Extracti Lactucae, . gr. 2 Misee. 97. Unguentum Belladonnse. R. Extracti Belladonna', o/.. ^ Clyceriiii, . . . li. dr. 1 Adipis, vz. I Misee. ; 424 FORMULARY. 98. Unguent. Belladonnae Comp. R. Hydrarg. Ainmoniati, gr. 5 Extract. Belladonnae, gr. 10 Adipis, oz. 1 Misce. To be rubbed on the forehead and temple. The surface may be then covered with a piece of tissue paper to prevent the hair getting into it. 99. Unguent. Hydrarg. cum Belladonna. R. Extract. Belladonnae, gr. 60 Unguent. Hjdrarg., gr. 420 Misce. To be rubbed into the temple and around the brow. 100. Unguentum Hydrar- gyri cum Opio. R.Opii, gr. 60 Unguenti Hydrargyri, gr. 4-0 Misce. 101. Unguentum Opii. R. Opii, gr. 60 Adipis, .... gr. 420 Misce. 102. Unguent. Hydrarg. Nitratis Dilut. R. Unguent. Hydrarg. Nitratis, .... gr. 20 Unguent. Cetacei, gr. 120 Misce. 103. Unguent. Hydrarg. Nitric-Oxyd. Dilut. R. Unguent. Hydrarg. Ni- tric-0.\yd., . . . gr. 40 Unguent. Cetacei, gr. 240 Misce. 104. Unguent. Plumbi cum Balsam. Peru. R. 01. Lini, . . . . fl. dr. 4 Emplast. Plumbi, . gr. 240 Bal.-am. Peru, . . min. 30 Recommended by Pagen- stecher in severe cases of Tinea Tarsi. It is to be spread on lint and applied to the lids at bedtime. 105. Unguent. Hydrarg. Biniodid. R. Hydrarg. Biniodid., gr. 5 to gr. 10 Unguent. Cetacei, . . oz. 1 Misce. A mercurial counter-irritant. In applying this ointment the fingers should be covered with a glove. 106. Unguentum Stramonii. {Middlesex Hospital.) R. Foliorum Stramonii re- centium, . . . . lb. ^ Adipis, lb. 2 Mix the bruised leaves with fat and expose to a mild heat until the leaves become friable, then strain through lint. FORMULARY. 42; FORMULARY FOR CHILDREN. 107, Mistura Salina. R. Liquor. Ammoniie Citra- tis, fl. dr. 4 Sp. ^Etheris nitrosi, fl. dr. 3 Syrup. Tolutjini, . fl. dr. 4 Aquffi destillut., ad fl. oz. 4 Misce. — Dose, one dessert- spoonful every four hours. 108. Mistura Antimonii Tar- tarati. R. Vini antimonialis, fl. dr. 2 Liq. Amnionic Citratis, fl. dr. 4 Syrup. Althaese, . fl. dr. 3 Aquae destillat., ad fl. oz. 4 Misce. — Dose, one dessert- spoonful between 2 and 4 years of age ; one tablespoonful be- tween 4 and 8. 109. Mistura Potassae Chlo- ratis. R. Potassaj Chloratis, . gr. 24 Acid. Hydrochloric, dilut., min. 24 Syrupi Aurantii, . fl. dr. 4 Aquje destillat., . fl. oz. 4 Misce. — One tablespoonful three times a day. 110. Mistura Cinchonae cum Acido. R. Extract. Cinchonae flav. liquid., .... min. 40 Acidi Nitrici diluti, min. 40 Syrupi Aurantii, . fl. dr. 3 Aquic destillat., ad fl. oz. 4 Misce. — Dose, one table- spoonful. 111. Mistura Cinchonae cum Infus. Rosae. Extract. Cinchona; flav. liquid., . . . . fl. dr. 1 Syrup. Aurantii, . fl. dr. 4 Infusi Eosaj comp., ad fl. oz. G Misce. — One tablespoonful twice a day. 112. Mistura Cinchonae cum Tinct. Belladonnae. R. Extract. Cinchon;e flav. liquid., . . . min. 5 Acid. Nitric, dilut., min. 3 Tinct. Belladonna}, min. 3 Aquaa, .... ad fl. oz. J Misce. — For a child from 4 to 7 years of age. 113. Mistura Potassii Brom. cum Tinct. Belladonnae. R. Potassii Bromid., . . gr. 2 Tinct. Belladonnje, min. 3 Aqua3 destillat., . fl. oz. J For a child between 4 and 7 years of age. Misce. 114. Mistura Ferri lodidi. R. Syrup. Forri lodidi, Glycerini, Aqua3 destillat., Misce. in. 10 to 20 . fl. dr. I ad fl. oz. A 115. Mistura Potassii lodidi cum Ferro. R. Potassi lodidi, . . gr. 8 Ferri et Ammoniae Citra- tis, gr. 24 Sacchari albi, . . . gr. 60 Aquas, . . . ad fl. oz. 4 Misce. — Onedessert-spoon- ful for a dose. 36* 426 FORMULARY. 116. Mistura Ferri Citratis. R. Ferri et Ammoniae Citratis, . . . . gr. 30 Sacchari albi, . . . gr. 60 Aqua} destillat. , . fl. oz. 4 Misce. — One dessert to a table- spoonful twice a day. 117. Mistura Ferri Hypo- phosphitis. R. Syrup. Ferri Hypophos- 'pliitis, . . min. 15 to 3^" Aqute destillat., . fl. oz. ^ Misce. 118. Pulvis Cinchonae cum Soda. R. Pulvoris Cinchonae flavie, Sodaj Bicarbonatis, partes sequales. Misce. — Dose, gr. 5 to gr. 10. 119. Pulv. Ferri Carbonat. cum, Saccharo. {P. B.) Dose, gr. 3 to gr. 6, once or twice a day. 120. Pulvis Ipecac. Comp. cum Potass. Nitrat. R. Pulvis Ipecac, corup., gr. 1 Potassffi Nitratis, . . gr. 2 Misce. 121. Pulvis. Hydrarg. cum Creta cum Saccharo. R. Pulvis Hydrarg. cum Creta, gr. 1 Pulvis Sacchari albi, . gr. 2 Misce. 122. Pulvis Alterativus. R. Hydrarg. cum Creta, gr. 1 Sodje Bicarbonatis, . gr. 2 Pulvis Khei, . . . gr. 3 Misce. — Dose, gr. 6 to gr. 12. 123. Pulv. Hydrarg. cum Creta cum Rheo. R. Hvdrargvri cum Cretii, gr. 1 Pulv. liliei, . . . . gr. 2 Misce. — Dose, gr. 3 to gr. 8. 124. Pulvis Scammonii cum Jalapa. R. Pulv. Scammonii, . gr. 1 Pulv. Jalapie, . . . gr. 3 Misce. — Dose, gr. 3 to s^r. 8. 125. Pulvis Calomel, cum Rheo. R. Pulv. Khei, . . . . gr. 4 Hydrargyri Subchloridi, Pulv. Cretae Aromaticae. aa gr. 1 Misce. — Dose, gr. 3 to gr. 8. 126. Pulvis Calomel, cum Jalapa. R. Pulv. Jalapa^, . . . gr. 4 Hydrargyri Subchloridi, Zingiberis, . . . aa gr. 1 Misce. Dose, gr. 3 to gr. 6. 127. Pulvis Calomel, cum Scammonio. R. Pulv. Scammonii, . gr. 4 Hydrarg. Subchloridi, Sacchari puriticati, aa gr. 1 Misce. — Dose, gr. 3 to gr. 6. 128. Pulvis Calomel, et Scammon. cum Jalapa. R. Hydrargyri Subchloridi, gr. Scammonii, .... gr. Pulv. Jalapae, . . . gr, Mi.sce. — Dose, gr. 3 to gr. 7. TEST-TYPES FOR ASTIGMATISM. By Dr. Orestes M. Pray. ^ liliiiii »^^ 5m A»w\V Xs X \AVV w JJ 1 INDEX. Abscess of cornea, 51 eyelid, 372 orbit, 379 Abscission of the eye, 79 Accommodation, diseases of, 260 Acute inflammatory glaucoma, 134 Alternating strabismus, 283 Amaurosis, 238 causes of, 243 from disease of cerebrum, 243 cerebellum, 244 spinal cord, 244 loss of blood, 246 reflex irritation, 246 uterine derangements, 245 monocular, 247 signification of, 238 Amblyopia, 247 signification of, 247 Anatomy of fourth nerve, 309 frontal sinus, 409 sixth nerve, 309 third nerve, 305 Anchyloblepharon, 374 Aneurism of orbit, 391 by anastomosis of orbit, 394 difi'use or consecutive, 392 true and false, 391 treatment of, 395 Anomalies of refraction. 260 Anterior chamber, dislocation of lens into, 187 staphyloma of the sclerotic, 80 Arlt, Dr., operation for entropion, 351 Artificial pupil, 112 with a broad needle and Tyr- rell's hook, 113 by iridodesis, 1 14 incision of iris, 115 excision of iris, 116 Artificial eyes, 325 Asthenopia, 280 from hypermetropia. 280 insufficiency of the internal recti, 281 Astigmatism, 275 compound. 277, 278 irregular, 276 mixed, 278 regular, 277 simple, 277 to ascertain the presence of, 278 treatment of, 278 Atrophy of optic nerve, 236 from tobacco, 238 Atropic cup of optic nerve, 237 Black cataracts, 157 Blennorrhcea, 328 Blepharospasm, 362 Bone on the choroid, 224 Bowman, Mr., operation for arti- ficial pupil, 1 16 on capsulo-lenticular cataract, 176 ectropion, 356 spoon for traction operation. 164 Broad needle, 155 Burns and scalds of eye, 317 Canaliculus, to slit up the, 335 Canular forceps, 186 Capsular cataract, 149 opacities, 181 varieties of, 181, 182 treatment of. 183 Capsule, opaque, needle operation for, 183 430 INDEX. Capsule, opaque, operation with two needles for, 1S5 canular forceps for, 186 Capsulo-lenticular cataract, 149, 176 Caries of orbit, 389 Cataract, 149 black, 157 capsular, 149, 175 cnpsulo-lenticular, 149, 175 congenitnl or infantile, 150 operations for, 152-155 cortical, 150 diabetic, 149, 176 fluid, 177 hard, 149, 156 treatment of, 157 operations for, 158-175 cnsualties after an operation for. 170 treatment after extraction of, 168 lamellar, 150 nuclear, 157 pj'ramidal, 176 secondary, 181 senile, 149, 157 soft, 149 striated, 157 traumatic, 178 treatment by flap extraction, 158 Graefe's modified linear ex- traction, 164 Jacob, Short sight. Sre Myopia Simple glaucoma, 138 Sixth nerve, paralysis of, 310 anatomy of, 310 Small shot, injuries from, 322 Snow-blindness, 250 Soft cataract, 149 operations for, 152-156 Sparkling synchysis, 146 Spasm of ciliary muscle, 297 Speculum, spring-stop, 113 Spoons for traction operation for cataract, 164-166 Spud for removal of foreign bodies, 85 Squint. See Strabismus Staphyloma, anterior, of sclerotic, 80 posterior, of sclerotic, 220 ciliary, 80 of cornea, 76 operations for, 78-80 Stilling's knife, 330 Strabismus, 282 alternating or binocular, 283 causes of, 284 concomitant, 285 convergent or internal, 286 Critchett's operation for diver- gent, 294 divergent or external, 287 following divisions of inter- nal recti, 293 Graefe's operation for, 291 hooks used in operation for, 290-291 Liebreich's operation for. 292 Moorfields operation for, 290 paralytic, 303 periodic, 283 primary deviation in, 285 secondary deviation in, 285 436 INDEX. Strabismus, to note the extent of the, 284 treatment of, 288 Streatfeild's operation for entropion, 350 Striated cataract, 156 Stricture of nasal duct, 329 Strong acids, injuries from, 318 Strumous corneitis, 46 Suction operation for cataract, 155 Suppurative corneitis, 50 choroiditis, 221 iritis, 101 • Symblepharon, 375 Sympathetic irritation, 126 ophthalmia, 126-127 Synchysis, 146 scintillans, 146 Syndectomy, 36 Syphilitic iritis, 97 ulcers of eyelid, 364 Taylor, Mr., spoon for traction ope- ration, 166 Teale, Mr. T. P., operation for sym- blepharon, 378 suction operation, 155 Tension of globe, to ascertain, 140 Third nerve, paralysis of, 306 anatomy of, 306 Tinea tarsi, 342 Trachoma, 28 Traction operation for cataract, 162 Traumatic cataract, 178 treatment of, 179 iritis, 102 treatment of, 103 Tremulous iris, 141 Trichiasis, 345 Tumors of choroid, 229 conjunctiva, 41 cornea and sclerotic, 40 eyelids, 367 Tumors of frontal sinus, 410 iris, 106 orbit, 399 retina, 214 sebaceous or dermoid, near orbit, 369 Tyrrell's hook, 114 Test-types, 427 Ulcers of eyelid, 364 epithelial, 365 rodent, 365 syphilitic, 364 of cornea, 58 chronic vascular, 64 superficial, 58 nebulous, 59 transparent, 59 deep, 60 crescentic or chiselled, 62 sloughing, 61 Vinegar, injuries from, 319 Vitreous humor, diseases of, 142 dislocation of lens into, 189 fluidity of, 146 foreign bodies in, 147 hemorrhage into, 148, 228 inflammation of, 142 opacities of, 143, 145 Warts on conjunctiva, 41 Weak acids, injuries from, 319 Weber's conical sound, 329 Wecker's canaliculus knife, 335 White atrophy of optic nerve, 236 Wounds of eyelids, 372 Zehender's ophthalmoscope, 255 HANDBOOKS AND MANUALS BUSY PRACTITIONEK AND STUDENT. 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