b's \n\n\n\nHOMEOPATHIC MEDICAL PRACTICE: \n\n\n\nSYSTEMATIC TREATISE \n\n\n\nDISEASES OF THE BRAIN AND EYE; \n\n\n\nFOR THE USE OF \n\n\n\nGENERAL PRACTITIONERS AND STUDENTS. \n\n\n\n\n\n\n\n\n\nBy C. P. HART, M.D. \n\n\n\nFORMERLY SURGEON-IN-CHARGE OF THE SURGICAL WARDS, CHIEF SURGEON TO THE EYE \n\nDEPARTMENT, AND PRESIDENT OF THE BOARD OF MEDICAL EXAMINERS OF BROWN \n\nGENERAL HOSPITAL, LOUISVILLE, KY.J ASSISTANT EDITOR OF THE \n\nAMERICAN HOMOEOPATHIC OBSERVER J AUTHOR OF \n\nREPERTORY TO NEW REMEDIES, \n\nETC., ETC. \n\n\n\n0, \n\nWITH NUMEROUS TABLES AND ILLUSTRATIONS. \n\n\n\n\n\n\nDETROIT: \n\nPUBLISHED BY EDWTN ALBERT LODGE, \n\nAMERICAN OBSERVER OFFICE. \n\n1878. \n\nft \n\n\n\n\nItftf \n\n\n\nut* \n\n\n\nEntered according to Act of Congress, in the year 1877, \n\nBy EDWIN ALBERT LODGE, \n\nIn the Office of the Librarian of Congress, at Washington, D. C. \n\n\n\nALL RIGHT RESERVED. \n\n\n\nWm. A. Scripps, Printer, \n\nArcade Building, 46 Larned St. West, \n\nDetroit, Mich. \n\n\n\nPREFACE. \n\n\n\nThe present work, consisting of brief treatises on Diseases \nof the Brain and Eye, was originally designed to form the \ninitial portion of a more general work on the Homoeopathic \nPractice of Medicine. But as the Author\'s time is now so fully \noccupied by professional duties as to prevent its speedy com- \npletion, and as the parts are complete in themselves, and will \nmake a convenient Manual on Diseases of the Brain and Eye, \nthe publisher has decided to issue them as a distinct work. \nThe portion relating to Ophthalmology having been published \nseparately, the following remarks, taken from the Preface to \nthat volume, will be equally applicable to this : \n\nUnfortunately, the science of which we treat is still regarded \nby many as too abstruse, and the practice of it too difficult, \nfor the general profession, and hence it has been relegated, \nfor the most part, to a comparatively small number of prac- \ntitioners. We say unfortunately, because the vast majority of \nophthalmic diseases are still treated, and of necessity always \nwill be treated, by the ordinary medical attendant. The \nimportant question, then, is, not whether diseases of the eye \n\n\n\n4 PREFACE. \n\nshould be turned over to the specialist for more scientific \ninvestigation and treatment \xe2\x80\x94 the propriety of which, in many- \ncases, no one who has any regard for the welfare of the patient \nwill deny \xe2\x80\x94 but whether the general practitioner, who, nine \ntimes out of ten, is expected to treat these cases, shall be \nproperly qualified to discharge a duty which, whether qualified \nor not, he is required to perform. Besides, even if it were \npossible for the majority of such cases to be referred to experts, \nthe general practitioner would still need to be as fully informed \non this as on other branches of medical learning, in order to \nenable him to give proper and timely advice to his patients, \nand to secure to himself the advantages, too numerous to \nmention, resulting only from a well-rounded medical education. \nLet us not be misunderstood. We are not calling in \nquestion the propriety of referring all complicated and difficult \ncases to specialists, but, as nine-tenths of all diseases of the \neye are either inflammatory or functional, and as only a small \nproportion of eye difficulties, except such as require manual \ndexterity in operating, will be sent to ripe specialists \xe2\x80\x94 of which \nthere indeed but very few\xe2\x80\x94 we are simply emphasizing the \nneed of greater competency on the part of those who are daily \ncalled upon to diagnose and treat this important class of cases. \nAnd we opine that the chief reason the general profession is, \nas a body, so lamentably ignorant of Ophthalmology, is not in \nconsequence of the abstruseness of the science, for this is no \ngreater than that of any other department of medicine and \nsurgery ; more especially since the discovery of the ophthal- \nmoscope \xe2\x80\x94 the use of which has greatly simplified the subject, \n\n\n\nPREFACE. 5 \n\nand rendered many parts of it much more definite and easy of \ncomprehension. But we are of the opinion that the reason of \nthis acknowledged incompetency lies chiefly in the paucity of \nsuitable Manuals. Not that the profession is wholly without \nvaluable aids of this character, but that those already published \nare, for the most part, too concise to serve as guide-books to \nthe student and general practitioner, or else savor too much of \nprolixity, in consequence of the introduction of unnecessary \ndetails, or of matter which belongs rather to the province of \nstrictly theoretical treatises. \n\nWhether this volume will meet the requirements above \nsuggested, is not for the author to affirm. He can, however, \ntruly say, that he has labored conscientiously and assiduously \nto bring it up to the standard of what he conceives to be \nrequisite in a text-book of this character ; and he will feel \namply compensated for his labors if the work shall be found \nfree from any serious defects, and, at the same time, not \nwanting a reasonable degree of the only merit within the scope \nof his design, namely, that of furnishing a clear and concise \ndescription of ophthalmic diseases and their appropriate treat- \nment, together with a correct and intelligible account of the \nfacts, principles and discoveries furnished by the ablest of the \nAmerican, English and German authorities. \n\nWe have not deemed it necessary, nor even desirable, to \ncite the authority for every important statement made in the \ntext. To have done so would have greatly encumbered our \npages, and increased the size and expense of the work. We \nhave, however, in most cases, given due credit for any fact or \n\n\n\n6 PREFACE. \n\ndiscovery the authorship of which it is important the reader \nshould know ; and would refer those who desire to con- \nsult any of the original sources of information to the admirable \ntreatise of Stellwag, whose bibliography of every department \nof the literature of Ophthalmology, is sufficiently ample to \nsatisfy the most exacting. \n\nC. P. HART. \nWyoming, Ohio, October, 1877. \n\n\n\nERRATA. \n\n\n\nOwing chiefly to the fact that some of the proof-sheets failed to \nreach the Author in time for revision, a number or typographical \nerrors remain uncorrected. Fortunately, most of them are of such a \ncharacter as to be readily understood by the reader, and will not, \ntherefore, need to be pointed out. In order, however, to avoid any \nambiguity, the reader will please insert, the pronoun their between \n"require" and "separate," on page 102, fifth line ; omit the period \nafter the word characteristic, on page 254, second paragraph; and \nsubstitute edgeiox "eye" in note on page 122 ; epichondral for " epis- \ncleral" on page 136, twenty-first line; it for them in the tenth and \ntwelfth lines on page 188; T for " Tn" in parenthesis on page 213 ; \nand Aurum for " Arum " on page 254. \n\n\n\nPRACTICE OF MEDICINE. 9 \n\nGENERAL OBSERVATIONS. \n\nAlthough this department, as its title indicates, is intended to be \ndevoted strictly to the practice of medicine, yet, owing to the erro- \nneous notions still prevalent concerning the system of practice \nherein inculcated, its principles are often misunderstood, perverted \nand misapplied. It will, therefore, not only not be out of place, so \nfar as may be consistent with our general plan, to endeavor at the \noutset to correct such erroneous views, by a few preliminary obser- \nvations on the true principles of our system ; but we may reasonably \nhope, by so doing, to make their practical application by the inex- \nperienced more intelligible and easy, as well as to prevent, to some \ndegree, those perversions of them which arise altogether from igno- \nrance. Still, as Hahnemann himself observes, (Organon, \xc2\xa7i,) "the \nfirst and sole&vXy of the physician is, to restore health to the sick," and \nnot to spend his time in constructing and explaining, much less in \ncontending about mere theories, whether true or false. \n\nIn pursuance of this plan, we shall first lay down a few of the \nmore important definitions and homoeopathic aphorisms, after \nwhich we shall treat briefly of symptoms, both pathogenetic and \nmorbid,* and then of the homoeopathic medicines, their doses, du- \nration of action, and repetition. \n\nDEFINITIONS AND APHORISMS. \n\nDisease is a departure from health \\ and is either local, as affecting \nonly a part of the animal sytem or functions, or constitutional^ as \nembracing, to a greater or less extent, the whole system. \n\nDiseases are either acute or chronic, the former term being applied \nto such derangements of the health as are speedily overcome, and \nproduce no permanent organic changes ; and the latter to those \ndiseases which are either slow in their development and progress, or \nwhich, from wrong treatment or otherwise, are extended far beyond \nthe natural term of their duration. \n\nThey are also divided into primary, and secondary or consecutive, \nthe former term being applied to the original disease, or first series \n\n* Strictly speaking, all symptoms are morbid, since they are the result of \ndiseased action ; but we shall use the term in its ordinary sense, to denote \nonly those symptoms which belong to natural diseases, in contradistinction to \nthose which are artificially excited, namely, the pathogenetic, or medicinal. \n2 \n\n\n\n10 HOMOEOPATHIC \n\nof derangements ; and the latter to the subsequent morbid phenom- \nena, particularly when they grow out of, or are in any way dependent \nupon, or referable to, the primary disease. \n\nThe causes of disease may be either external or internal, mechan- \nical, chemical, pathogenetic, or toxical. \n\nAmong the most prolific internal causes of disease, is a depraved \nstate of the blood, or taint of the system, affecting to a greater or less \nextent nearly the whole human family \xe2\x80\x94 the resultant of former dis- \neases on the human system, which, variously modified, have come \ndown to us from our ancestors \xe2\x80\x94 and called by Hahnemann, psora. \nWhatever opinion we may entertain concerning Hahnemann\'s theory \non this subject, or however unfortunate he may have been \xe2\x80\x94 if, in- \ndeed, he was unfortunate \xe2\x80\x94 in the selection of a term by which to \ndesignate this peculiar condition, the fact itself cannot be ignored, \neven by those who attempt to throw ridicule upon it. The condition \ndoes exist, and not only acts as a prolific cause of disease, but greatly \nmodifies diseases originating from other causes. Ordinarily it exists \nin a dormant or latent state, producing a chronically depraved state of \nhealth, usually termed dyscrasia; but when it becomes active, as it \ndoes when other causes have disturbed the comparatively healthy \nbalance which the vital force, aided by time, has served to produce, \nor when thrown into activity by the effects of remedial agents, then \nits presence becomes so pronounced that the most prejudiced can- \nnot fail to see it. What matters it, then, so we clearly recognize the \ncondition itself, whether we call it psora, dyscrasia, chronic blood \ndisease, or any thing else? As long as no better name is found \nfor it, we have no hesitation in calling it psora, and psora it shall be ! \n" Multa non sunt sicut multis videntur /" \n\nDiseases can properly be said to be cured, only when the affected \nparts and functions are restored to their original state ; that is to say, \nwhen the disease is thoroughly eradicated, and its effects entirely \nremoved from the system. On the other hand, when diseases, either \nthrough treatment or otherwise, simply disappear, or become latent, \nwithout being thoroughly eradicated, they are said to be suppressed. \nIt is this suppression of disease, the ordinary result of allopathic \ntreatment, which constitutes true psora, as above defined, and is the \nchief cause of nearly every chronic disease. Whenever it becomes \nactive, there is generally an effort, so to speak, on the part of nature \n\n\n\nPRACTICE OF MEDICINE. II \n\nto eliminate it from the system by throwing it to the surface, consti- \ntuting the various forms of tetter, and other itchy eruptions, whence \nthe name by which Hahnemann designated the affection, namely, \npsora, a term derived originally from the Greek, and signifying to rub. \n\nFrom the foregoing, it is evident that the psora, properly so \ncalled, is a very different affection, ordinarily, from that single vulgar \nform of it commonly called the itch, to which allopathists would fain \nconfine it. The latter is the least significant, as it is the most super- \nficial, of all its multiplied forms and manifestations, and generally \ndepends upon some local cause of irritation; while the former is a \nprofound, peculiar, compound morbific element, whose impress is so \nclearly stamped upon almost every form of disease, as greatly to modify \nits character, duration, history and treatment. It is, in fact, as before \nstated, the expression of the difference between the cure and the \nsuppression of disease, which has resulted from the general non- \nobservance in treatment, from time immemorial, of the true and only \nlaw of cure, the homoeopathic, which we will now explain. \n\nIt was a discovery of the immortal Hahnemann, that diseases can . \nonly be cured by remedies which are capable of producing similar \ndiseases in healthy persons. This irrefutable law of nature is ex- \npressed by the formula, " similia similibus curantur," or like is cured \nby like, a law as simple and beautiful in its expression, as it is \nuniversal in its application ; and which is destined to revolutionize \nthe whole art and science of medical practice. \n\nThis great natural law of cure had suggested itself to several \nearly physicians, especially Stahl, whose words are as follows : " The \nreceived method in medicine, of treating diseases by opposite \nremedies \xe2\x80\x94 that is to say, by medicines which are opposed to the \neffects they produce, (contraria contrariis) \xe2\x80\x94 is completely false and \nabsurd. I am convinced, on the contrary, that diseases are subdued \nby agents which produce a similar affection." (Similia Similibus.) \n\xe2\x80\x94 See Introduction to Hahnemann \'s Organon. But it was not until \nthe brilliant genius of Hahnemann set it forth disclosed in all its \nbeauty and perfection, with irrefutable reasoning and the most ample \nillustration, that it began to be generally recognized by the learned \nas the true, unerring, a?id universal law of nature ; while now, it may \nbe truly said, there are but few so ignorant and undiscerning, as not \nin some way " to do it homage." \n\n\n\n12 HOMCEOPATHIC \n\nExperience shows that, agreeably to this law, those medicines \nwhich, taken in large quantities, produce in healthy organisms symp- \ntoms similar to those of the disease, are the therapeutical agents \nthat, in small and convenient doses, cure it in the most prompt, \ncertain, and permanent manner. Hence it follows, that homoeopathic \nremedies annihilate disease, by exciting in the system a certain \nartificial malady, which so closely resembles the natural one, as to \ndestroy the symptoms of the disease to which such relation is \nsustained. \n\nIn order, therefore, to effect a satisfactory cure of any particular \ndisease, we have, in the first place, to select from all others that \nmedicine whose effects, symptoms, or manner of action, upon the \nhealthy organism, most nearly resembles the symptoms of the disease \nwhich we aim to cure ; and, secondly, to administer it in such form \nand manner, and with such frequency, as experience shows to be \nbest adapted to the end in view. The first of these prerequisites we \nshall consider under the head of \n\nSYMPTOMATOLOGY. \n\nSymptoms are of two kinds or classes, namely : those belonging \nto natural diseases, called morbid, and those developed by medicinal \nagents, acting upon healthy organisms, termed pathogenetic. Their \ncharacter is essentially the same, and they differ only in degree and \nmanner of production. The former are the expression, or represen- \ntation, so to speak, of natural diseases, or maladies ; the latter of \nanalogous artificial diseases. The former are arranged in particular \ngroups, more or less variable, according to the age, sex, temperament, \nand general constitution of the patient ; the latter in certain other \ngroups, more or less similar, according to the nature of the medicine \nproducing them, their mode of preparation and administration, and \nthe condition and susceptibility of the provers, or those upon whom \nthey are made to act. While there are no known medicines capable \nof producing groups of symptoms precisely the same as those of \nnatural diseases, many of them furnish groups of striking similarity, \nwhereby we are enabled to select, agreeably to the law of " similia" \nsuch as prove curative in natural diseases. These, when rightly \nselected and administered, never fail of effecting perfect cures ; such \nmedicines are therefore called specifics. Hence a thorough knowl- \nedge of the Materia Medica, and especially of the pathogenetic \n\n\n\nPRACTICE OF MEDICINE. 1 3 \n\nsymptoms peculiar to the several remedies, and which are termed \ncharacteristics, is essentially necessary to success in homoeopathic \npractice. Such knowledge can only be acquired by studying and \ncarefully noting the effect of medicines on the healthy subject. \nHappily, so far as the production of a true Materia Medica is \nconcerned, this work in the vast realm of pathogenetic investigation, \nhas already been performed by numerous observers and provers, \nupon whose veracity and accuracy we can implicitly rely. Of these, \nHahnemann justly stands at the head ; while the names of Stapf, \nHartlaub, Hering, Franz, Nenning, and a host of others, furnish a \nconstellation whose light pales only before that of the illustrious \nfounder of the homoeopathic system. \n\nNotwithstanding all this, it is not to be denied that our Materia \nMedica has already become encumbered with many indefinite and \nunreliable "symptoms " whose presence in our works renders it \nextremely difficult, in many cases, to make a proper selection. \nHence it becomes necessary in searching for a specific, to carefully \nsift, compare, and weigh the several symptoms, both of the remedy \nand the disease, selecting that which furnishes the most striking and \nperfect resemblance between them, at the same time having regard \nto the following principles : \n\ni. Symptoms have a relative value only ; that is to say, the patho- \ngenetic characteristics of a medicine are of greater or less value, \nonly as compared with those which have or have not the same char- \nacteristics ; so that those symptoms, which at one time, or in one \nseries of comparisons, have no particular value, may at another \ntime be of the greatest importance. Hence no pathogenetic or \nmedicinal symptom should be disregarded, or lightly esteemed, be- \ncause common to other remedies, any more than we should be \njustified in neglecting similar symptoms in the treatment of disease. \n\n2. The totality of the symptoms is the only true indication in the \nselection of the remedy. For although, as before remarked, there \nare no well-recognized pathogenetic groups of symptoms precisely \nthe same as those of natural diseases, there are those which bear \nsuch a striking resemblance to them, as plainly to indicate their reme- \ndial virtues under the law of " sitnilia." But since they are often \nassociated with others of a diverse character, it is necessary always \nto have regard to the totality of the symptoms, otherwise the law \ncould not justly be said to apply. \n\n\n\n14 HOMCEOPATHIC \n\n3. A remedy to be perfectly homoeopathic, must be capable of \nproducing all those symptoms which are peculiar \', extraordinary and \ncharacteristic in the natural disease. When this resemblance exists, \nthe disease will generally yield to a single dose of the medicine, \nprovided the remedy be properly administered, and due attention \ngiven to hygienic influences. \n\n4. If a remedy is chosen which is not strictly homoeopathic to \nthe disease, that is, to the totality of the symptoms, it will, especially \nin appreciable doses, give rise to symptoms not properly belonging \nto the disease, and therefore referable only to the remedy ; or it will \nhave the effect of increasing the morbid symptoms, producing what \nis called homoeopathic aggravation. If, in these cases, the pathogenetic \nsymptoms are sufficiently similar to those of the disease, to give the \nremedy a decidedly homoeopathic effect, the disease will, as in the \nformer case, generally yield to a single dose of the medicine, pro- \nvided sufficient time be allowed for the homoeopathic aggravation to \nsubside. \n\nTHE HOMOEOPATHIC MATERIA MEDICA. \n\nThe homoeopathic materia medica, in its complete form, contains \nsuch a vast number of symptoms, natural, morbid and pathogenetic, \nthat the student is apt to be overwhelmed by their multiplicity and \nunscientific arrangement. I have therefore made a selection, under \nthe head of " Characteristic Materia Medica" embracing only such \npathogenetic symptoms as are peculiar to the several remedies, or \nhave been confirmed by clinical experience. Of course, this is not \nintended in any sense as a substitute for our more elaborate works on \nthe subject, but simply as an aid to the student in acquiring an easy \nand at the same time definite knowledge of the characteristic symp- \ntoms of our principal medicines. A thorough knowledge of these \nsymptoms, together with the analytical system of diseases and their \nremedies, will enable any competent person to select, without diffi- \nculty, the true specific for any group of symptoms which may present \nthemselves in the course of any disease, either acute or chronic. \nThese tables the student will do well to memorize, especially those \npertaining to the more common and special forms of disease, as well \nas the characteristic indications of the remedies employed. This \namount of familiarity with the homoeopathic materia medica, and the \npathogenesis of medicines, is necessary in order to give the required \ncoup d\'ozil of the symptoms, so that the relation of the remedy to \n\n\n\nPractice of medicine. 15 \n\nthe disease may be readily and clearly recognized, and much time \nand suffering, as well as unnecessary labor and research, avoided. \n\nTHE HOMOEOPATHIC DOSE. \n\nOwing to its extreme minuteness, the efficiency of the homoeopathic \ndose, whether the medicine be exhibited in the first or last attenua- \ntions, has often excited the astonishment of the inexperienced. \nMany ingenious attempts have been made to explain its efficiency ; \nsome referring it solely to a dynamic power developed in its prepa- \nration, and others attributing it simply to dilution. Doubtless, both \nexplanations are, to a certain extent, correct ; that is to say, that a \ndirect and absolute increase of medicinal energy is produced by \nsimple attenuation, while at the same time their peculiar virtues \nare exalted by atomic separation. For, on the one hand, it \ncannot be denied that within certain extreme and indefinite \nlimits, bounded only by atomic separation, medicinal substances \nare free to act upon the living organism, only in proportion \nas their ultimate particles, or atoms, are in a condition to be \nbrought into the most intimate connection with the living \ntissues; while, on the other hand, it is equally certain, that true \natomic separation must, from the very nature of the case, set free \nthe peculiar medicinal virtue of the substance, and that in direct \nproportion to the amount of atomic separation. So that, practically, \nit makes but little, if any, difference which explanation is received, \nsince in both cases, the power or virtue of the medicine, whether \ndynamic or otherwise, is proportionate to the amount of dilution, \nattenuation, or atomization, to which the medicine is subject in its \npreparation. \n\nFor these reasons, we would, as a general rule, recommend the \nemployment of the higher attenuations, except when used as blood \naliments, as antidotes to toxic symptoms, and in specific blood diseases, \nwhen the size of the dose, or degree of attenuation, should be regu- \nlated by the object in view, and by the exigencies of the case. (See \nthe remarks on doses and attenuations under the head of Diphtheria.) \nSome, on the other hand, prefer the high attenuations only in chronic \ndiseases, and employ low ones in the acute. But, if the above rea- \nsoning be correct \xe2\x80\x94 and we can testify that it has been amply verified \nin our own experience \xe2\x80\x94 the practitioner has only to repeat the dose \nat sufficiently short intervals, to extinguish promptly and satisfactorily \n\n\n\n1 6 HOMOEOPATHIC \n\nthe most acute symptoms. Cases, it is true, sometimes occur, in \nwhich the lower preparations seem to yield the best results ; but we \nare satisfied, both by experience and observation, that in the vast \nmajority of cases, if sufficient care and judgment be exercised in the \nselection and administration of the remedy, the greatest benefit will \nbe derived from the exclusive use of the higher potencies, in nearly \nevery simple or non-specific form of disease.* c. p. hart. \n\n* The student will naturally desire some definite rule or principle by \nwhich to regulate the potency, or size of dose, in particular cases. In lieu of \nsuch information, which can only be acquired by long practice and observation, \nthe suggestions contained in the following extract from an article of ours, \nentitled " Observations on the Homoeopathic Dose." published in the " Cincinnati \nMedical Advance" for November, 1873, may be of value : \n\n" But a still more important consideration, affecting the question of dose, \nis the precise pathological condition of the patient. The symptoms, so far as \ncasual observation goes, may be the same, and yet different cases, or the same \ncase at different times, require either different remedies, or different attenua- \ntions of the same remedy. This is a matter of every day observation, and yet \nit is not sufficiently recognized in our therapeutics. To illustrate : A patient \nis threatened with congestion of the bowels. This presupposes a congested \nstate of the portal system. The latter, more particularly, will determine the \nremedy. The former, including, of course, all the minuter elements of \nthe case which go to make up the tout ensemble, and especially the matter of \nsusceptibility, time and degree, will cceteris paribus, determine the potency or \ndegree of attenuation. Thus, the state of greatest congestion short of actual \neffusion, necessarily calls for the higher attenuations, since the lower ones \nwill be quite certain to precipitate the condition we wish to avoid. On the \nother hand, slight congestions, contrary to what, at first glance, we might sup- \npose would be the case, generally require the lower potencies, though the higher \nmay answer the purpose ; but the latter will require, of course, to be pushed to \nthe point of successful reaction to be effective. The great difficulty in such \ncases, is, to determine the exact pathological condition in question. If the \ntension, so to speak, of the function, or diseased action of the part, is as great \nas nature will bear without a decided change of condition, then the higher \npotencies will be most effective in subduing the symptoms for which they \nare given. On the other hand, using the same term as before, if the tension \nis light or weak, and the diseased function or action of the part is capable of \na much greater strain, without any essential change in its pathological condi- \ntion other than one of degree, or range of action, then experience shows that \nlow attenuations are equally, and in many cases, even more effective than the \nhigh. In short, the whole question seems to turn upon the facility with \nwhich, in any given case, reaction is capable of being excited. \n\nOf course, there are some conditions which stand outside of this law, such \nas chemical, chemico-vital and toxical conditions, which it would be absurd \nin the highest degree to attempt to bring under it; such for example as \nanozmia, in which there is a notable deficiency of haematine in the blood. \nHere iron is required as a nutrient, and hence, cceteris \'paribus, the lower the \nform in which we administer it, the better." \n\n\n\nPRACTICE OF MEDICINE. 1 7 \n\nREPETITION OF THE DOSE. \n\nThe repetition, no less than the volume of the dose, is a subject \nupon which great differences of opinion still exist among \nhomceopathists. Some administer the medicine in a single dose, \ngenerally of a low attenuation, and if no perceptible benefit is found \nto result, they fly immediately to some analogous remedy, or alter- \nnate it with others of a supplementary, or supposed corroborative \ncharacter, as though a curative effect were to be obtained by a direct \naction of the medicine. But no principle of our practice is better \nestablished, than that cures, properly so called, are never effected \nby the direct action of medicines, but by the reaction of the vital force \nexcited by them. (Hahnemann, Org., \xc2\xa7\xc2\xa763, 64, 68.) Hence, expe- \nrience shows that, although a single dose of a well-selected remedy \nis often sufficient to produce a healthy reaction, and thus start a \ncure, which, if not interrupted by injudicious interference, mental \nimpressions, or errors of diet, will go on to completion ; yet, if the \ndisease be severe, so that reaction of the vital force is not easily \nexcited, a repetition of doses, at longer or shorter intervals, \naccording to the urgency of the case, the nature of the affection, \nand the age, constitution and temperament of the patient, is neces- \nsary in order to produce a salutary effect. The greatest caution, \nhowever, needs to be observed in the repetition of the dose, as well \non the one hand to avoid aggravations resulting from excessive \nreaction, as on the other to promote it by a steady pathogenetic \ninfluence of the vital power, to the extent of a complete subdual of \nthe morbid symptoms. Nor should we fail to remember, that a too \nsudden, or a too violent assault on the vital power, even to the point \nof successful reaction, is often attended by unpleasant effects, espe- \ncially if low attenuations are employed, so as in a great measure to \nfrustrate the end in view. When, therefore, the vital power rises in \nopposition to the action of the remedy, especially when new symp- \ntoms, and not simply aggravations of the old ones, are developed, \nwe must allow sufficient time for the excitement to subside, and \nthen, if a healthy reaction has taken place, the salutary effect should \nbe allowed to continue uninterrupted to its close ; if not, it should \nbe steadily but gently stimulated by such repetition of the remedy \n3 \n\n\n\n1 8 HOMOEOPATHIC \n\nas may be found necessary to accomplish it* Of course, the frequency \nof such repetitions will necessarily depend, as before stated, upon the \nnature of the disease, the urgency of the case, and the age, constitu- \ntion, temperament and general condition of the patient. \n\nAs a general rule, we have obtained the best results by dissolv- \ning twenty or thirty globules of the thirtieth potency in half a tumbler \nof water, stirring it well, and giving a teaspoonful of the solution \nevery hour, or oftener, in acute cases, and once or twice a day in \nchronic cases. If aggravations occur, either natural or pathogenetic, \nthe medicine should be omitted until they subside, or until it is seen \nwhat effect, if any, the omission has upon the symptoms, when, if a \ncurative action has been fully developed, the medicine already given \nmay be found to suffice ; if not, it should be repeated, agreeably to \nthe rules and principles already suggested. If the disease be a \nviolent one, such as croup or cholera, the medicine should be ad- \nministered every five, ten or fifteen minutes, according to the urgency \nof the case. In all instances, whenever an amelioration of the \nsymptoms takes place, the administration of the medicine should be \nsuspended ; but should they recur, or convalescence cease, the \nsame medicine should be immediately resumed, or another appro- \npriate one given. Should the salutary effects of the remedy be \ninterfered with, or suspended, in consequence of errors of diet, \ncold, or other causes, measures should be adopted to counteract \nthe supposed cause of the interference, and as soon as the interrup- \ntion ceases, the original medicine should be at once resumed, and \nthe disease guided to a favorable issue agreeably to the principles \nalready explained. \n\nALTERNATION OF MEDICINES. \n\nOwing to the great diversity of morbid conditions, and the com- \nparatively limited number of single remedies in every respect \nhomoeopathic to them, it often becomes advisable, especially in \nacute cases, to give two, and sometimes three medicines, in alterna- \ntion, whenever necessary to cover the characteristic symptoms of the \ndisease. In this way, for instance, in Croup, we sometimes find it \nexpedient to give Aconite, Hepar sulph. and Spongia in rapid succes- \n\n\n\n* Jahr, Snelling\'s Hull\'s, to which work we are under great and frequent \nobligation. \n\n\n\nPRACTICE OF MEDICINE. 19 \n\nsion, or alternation ; or, after Aconite, the two latter in alternation ; \nor we may have occasion to give Phosphorus and Bromine, in the \nsame manner, according as the particular forms and stages of the \ndisease seem to require. In the same manner, also, in Erysipelas, \nwe give Aconite and Belladonna, or Belladonna and Rhus, or Rhus \nand Phosphorus, according to the various forms and stages of the \ndisease. \n\nWhenever in acute cases it becomes necessary or expedient to use \ntwo or more medicines in alternation, great care should be taken \nto observe the effect of each remedy upon the symptoms, and one or \nthe other of them should be withdrawn, or another more appropriate \none substituted, as occasion may require. At the same time, equal \ncare should be taken not to make such changes unnecessarily, or too \nfrequently, bearing in mind the fact, that the production of new \nsymptoms, when properly belonging to the disease, or the aggrava- \ntion of old ones, are good signs, and only require that the medicine \nshould be withheld, or given less frequently, to produce the most \nfavorable results. \n\nSome practitioners are opposed to the alternation of remedies, \nparticularly in chronic cases, but in our opinion without good reason. \nWhen the medicines selected are truly homoeopathic to the symp- \ntoms \xe2\x80\x94 and of course no others should ever be used \xe2\x80\x94 we are confi- \ndent that we have in this way often been able to abridge the treat- \nment several weeks, and even months. Thus, in a case of Chronic \nDiarrhoea of over eight months standing, attended by painful \npalpitations of the heart, and which had long resisted single remedies, \nhowever judiciously administered, we prescribed Petroleum and \nCrocus sat. alternately once a day \xe2\x80\x94 Petr. for the diarrhoea, and Croc. \nfor the painful palpitations \xe2\x80\x94 and within a week the diarrhoea and the \npalpitations both ceased, and there was no return of either. In this \ncase China, Ferrum, Calc. c, Petr. Phos., Sulph., and a dozen other \nremedies had been tried singly in vain. \n\nAnother patient, a merchant, had been afflicted for more than \nthree years with non-syphilitic ulcers, boils and carbuncles, associa- \nted with more or less muscular rheumatism, affecting sometimes one \npart of the body, and sometimes another. For this combination of \nsymptoms we prescribed Silicea and Bryonia, in alternation, once a \nday, for about a week, when the rheumatism being relieved, we \n\n\n\n20 HOMOEOPATHIC \n\nwithdrew Bryonia, but continued the Si/icea, until the ulcers showed \nsigns of amendment, when we withdrew the medicine altogether. In \nthe course of a few weeks the ulcerations were entirely healed ; but \nshortly afterwards the rheumatic pains returned with greater violence \nthan at first. We then gave a single dose of Bryonia jo, and rested \nthe case. In a short time the rheumatism disappeared, and the \npatient\'s health was fully restored. \n\nWe desire particularly to caution the prescriber against changing \nthe medicine in chronic cases on the first appearance of aggrava- \ntions, even when they seem to demand it, as should always be done \nin acute diseases, for such aggravations are much more apt to occur \nin chronic cases, especially when medicines are alternated ; but if \nthe medicines given are homoeopathic to the principal symptoms, the \naggravations will shortly subside, so soon as the vital force has \nbecome paramount to the disease. All that is necessary in such \ncases is, to diminish the frequency of the doses until the curative \naction is fully established. \n\nDURATION OF THE ACTION OF MEDICINES. \n\nEvery medicine has a peculiar effect on the living organism, as \nwell with respect to its period of action, as to the medicinal symp- \ntoms it is capable of producing. As a general rule, the duration of \naction of vegetable remedies is much shorter than that of mineral \nmedicines, the former generally lasting only a few hours or days, \nwhilst the latter frequently continues many months, and even years. \nThus, the action of Aco?iite is sometimes limited to a period not \nexceeding half an hour, while, on the other hand, the effects of \nMercury on the system often extend through months and years, and \neven through life. \n\nObservation also establishes the fact, that the pathogenetic \neffects of medicines are subject to precisely the same laws of period- \nicity that control diseased action. This gives rise to what are called \nsecondary symptoms, in which the primary effect of the medicine is \nfrequently followed by one of an exactly opposite character. It also \nproduces those medicinal aggravations which are frequently mistaken \nfor the exacerbation of natural disease. These aggravations are gen- \nerally found to recur, in most chronic affections, every seven or eight \ndays, being more marked on each alternate day or week, until, after \n\n\n\nPRACTICE OF MEDICINE. 21 \n\nthe lapse of six or eight weeks, they commonly subside altogether. \nHence it becomes necessary in many chronic affections, especially \nwhen medicinal exacerbations occur, not to repeat the remedy oftener \nthan once a week, and sometimes not oftener than once in two or \nthree, or even once in six or eight weeks, in order not to interfere \nwith the healthy reaction of the vital force. In fact the same, rule \napplies in chronic cases of this character, as in those which are acute, \nwith this difference, that we measure the interval between the doses \nin the former by weeks instead of hours or days, the period which is \nfound to govern the medicinal aggravations determining the repeti- \ntion of the dose in all cases. \n\nWe have hitherto regarded the medicine employed as having been \nrightly selected ; but if otherwise, one of two things will follow ; \neither the medicine will have no perceptible effect whatever upon \nthe disease, or it will give rise to symptoms which, not being similar \nto those of the disease, will only add to the discomfort of the patient, \nand if long-continued will greatly aggravate the case. In either \nevent, the medicine should be immediately replaced by one whose \nmode of action corresponds more accurately to the ense?nble of the \nmalady, and which will at the same time cover the principal symp- \ntoms produced by the remedy just omitted. The safest and most \npractical rule to follow in these cases is, to watch attentively the \nmoral condition and general aspect of the patient, and if ameliora- \ntion takes place in these particulars, to await the further action of the \nmedicine; if not, the state of the patient becoming progressively \nworse and worse in these respects, no time should be lost in seeking \na more appropriate remedy.* Care should be taken, however, not \nto reject a remedy which has been carefully chosen, whatever may \nbe the momentary or occasional character of the aggravations \ndepending upon it, until sufficient time has elapsed to observe the \nalternations of good and bad symptoms, which, as before stated, \nshould be at least seven or eight days in chronic cases, and from five \nto fifteen or thirty minutes in those which are acute. This rule \nshould be followed in every case in which aggravations or secondary \nsymptoms are observed ; in every other we should follow the general \ndirections already laid down under the head of "repetition of dose." \n\n\n\n* Jahr. \n\n\n\n22 \n\n\n\nHOMCEOPATHIC \n\n\n\n\n\n\n\n\n\n\n\n\n\nTABLE I. - \n\n\n-ANALYSIS \n\n\n\n\n\n\n\n\n\n\nr \n\n\nr Weak, \n\nChina. \n\nAnsemic, \n\n\n\n\n\n\n\n\n\n\n\n\n\n\nFerr. \n\n\n\n\nr \n\n\n\n\n\n\nr \n\n\n\n\n\n\nm \n\no \n\n\n\' Gland. Swell. \nIod. Sil. \n\n\n\n\ni \n\n1 *5 \n\n\nAccelerated, \n\nJ.C071. \n\nRetarded, \n\n\n\n\n\n\nCold, \n\n\n\n\n\n\n13 - \n\n\nTubercle, \n\n\n\n\n13 \n\n\nDigital. \n\n\n\n\n\n\nI>ulc. \n\n\n\n\n\n\n\n\nPhos. \n\n\n\n\nj \n\n\nIrregular, \n\n\n\n\n\n\n\n\n\n\ns \n\n\no \n\n\nTettersUlc\'rs, \n\n\n\n\nb \n\n\n^Lrsen. \n\n\n\n\n\n\n\n\n\n\n%-J \n\n\nGQ \n\n\nArs. Merc. \n\n\n\n\n\n\n\n\n\n\nConcussion, \n\n\n\n\n5 . \n\nDD \n\n\n\n\n\' Anasarca, \n\n\n\n\n.2 \n\n\nQuick, \n\nBryonia. \n\n\n\n\nr \n\n\n\n\n\n\ns \n\no \n\n\n\n\nArsen. \n\n\n\n\nrt \n\n\nSlow, \n\n\n\n\n, \n\n\n\n\n\n\nQ \n\n\ntJ \n\n\nAscites, \n\n\n\n\n"Bh \n\n\nCastor. \n\n\n\n\na \n\n\nExp. to Water \n\n\n\n\n\n\n<x> \n\n\nHell. Merc. \n\n\n\' \n\n\nOQ \n\n\nIrregular, \n\n\n\n\n8) \n\n\nor Damp, \n\n\n\\ \n\n\n\n\n"73 - \n\n\nAdipose, \n\n\n\n\nPS \n\n\nI Opium. \n\n\n\n\n\n\neg \n\n\nRhus. \n\n\n\n\n\n\nGQ \n\n\nCede. c. \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nPregnancy, \n\n\n\n\n. \n\n\nIncreased, \n\n\n\n\n\n\n\n\n\nm \n\n\n\n\n\n\nSepia. \n\n\n\n\n\xe2\x80\xa2*3 \n\n\nCole. c. \n\n\n\n\nJ \xc2\xb0 7 \' \xe2\x80\x9e ^ \n\n\nv \n\n\n\n\n\n\nOB \n\n\nDeficient, \n\n\n, \n\n\nii \n\n\nCb/ea. \n\n\nh \n\n\n\n\nEmaciated, \n\n\nC \n\n\n\n\nNux V. \n\n\n\n\nfl \n\n\n\n\n* \n\n\n\n\nChina, Ars. \n\n\n\n\n\n<: \n\n\nCanine, \n\n\n*a \n\n\nGrief, \n\n\n& \n\n\n\n\n\' Infancy, \n\n\n\n\n\n\n\nChina. \n\n\n< \n\n\nV \n\n\nIgnatia. \n\n\nfe_ \n\n\n\n\nCham. \n\n\nti \n\n\n-g f Excessive, \n\n\nill \n\nM \n\n5 \n\n\nK \n\n\nb. \n\n\n\n\nAdolescence, C. - \n\n\n0" \n\n\n.!: J JLrsew. \n\n\nH. \n\n(H \n\n\n\n\nAnger, \n\nCham. \n\n\n03 \n\n\n\n\xe2\x80\xa2H \n\nIS \n\n\n9? \n\n60 - \n< \n\n\nPuis. Bell. \nCrit, Age, \nLach., Sepia. \nOld Age, \n\n\n\n\n\xe2\x80\xa2H \n\n\np I None, \n. r Sopor, \n\n\nIB \n\n\n\n\nfe \n\n\n\n\nOpium. \n\n\n^ \n\n\no J Opium. \n\n\n\n\nft \n\na \n\n\nJealousy, \nHyoscyamus. \n\n\n\xc2\xa3 \n\n\nf Male, \n\n\n\n\n\n=2 1 Sleeplessness, \nL G#ea. \n\n\n\n\n\n\n\n\noq 1 Female, \n\n\n\n\n-\xe2\x80\xa2 f Amenorrhea, \n\n| 1 Pulsatil. \n\n^ 1 Menorrhagia, \n\nL Ignatia. \n\n\n\n\n\n\nChagrin, \n\nPhos. A. \n\n\n\n\n1 \n\n\nPuis. \nGentle, \n\n\n\n\n\n\n\n\n\n\n\n\n. \n\n\nPuis. \n\n\n\n\n\n\n\n\n\n\nFright, \n\nOpium. \n\n\n\n\nc \n.2 \n\n\xe2\x80\xa2S3 - \no \n\no* \n\n\nIrascible, \n\nNux V. \nMelancholy, \n\n\n\n\nf Diarrhoea, \n\no J ip. Merc. \n-2 ] Constipation, \n00 I Op.Suiph. \n\n\n\n\n\n\n\n\n\n\n00 \n\n\nIgnatia. \n\n\n\n\n\n\n\n\nNostalgia, \nCapsicum. \n\n\n\n\n5 \n\n\nCheerful, \n\nCoffea. \n\n\n\n\n. ( Scanty, \nc J Canthar. \n\n\n\n\n\n\n\n\n\n\n\n\nSanguine, \n\n\n\n\n\'J* 1 Copious, \n\n\n\n\n\n\n\n\n\n\n<u \n\n\nHyos. \n\n\n\n\n\n\n\n\n\n\n\n\ns \n\n\nLymphatic, \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nLach. \n\n\n\n\n\n\n\n\n\n\n\n\ns \n\n0> \n\n\nCholeric, \n\n\n\n\n\n\n\n\n\n\n\n\n\n\nNux V. \n\n\n\n\n\n\n\n\n\nOF \n\n\n\nPRACTICE OF MEDICINE. \nDISEASE. \n\n\n\n23 \n\n\n\nd. <{ \n\n\n\nf I Morning. \n\nTime >- Evening. \n. I J Night. \n\n\xe2\x80\xa22 \n\n"I \xe2\x96\xa0\xc2\xa5\xc2\xbb\xe2\x80\xa2*\xe2\x80\xa2 1 Erect. \n\n> \\ Positlon JEecumbent \n\n- 1 \n\nbC \n\nif ,, .. I Slow. \n\nMotlon }Ea P id. \n\nKest, Diet, etc. \n\n\n\n\' Conditions \n\nsame as above and \n\n\n\nvery numerous. \nSee \n\n\n\nMat. Med. \n\n\n\nEight Side, \n\nLeft Side, \n\nMorning, \n\nEvening, \n\nDay, \n\nNight, \n\nMotion, \n\nEest, \n\n\n\nBell. \n\nAeon. \n\nNux. \n\nPuh. \n\nCalad. \n\nSidph. \n\nBryonia. \n\nRhus tox. \n\n\n\nCongestion, \n\nBell. \n\n\n\nFever, \n\n\n\nAconite. \n\n\n\nPleuritic Pain, \n\nBryonia. \n\n\n\nEmesis, \n\nIpecac. \n\nCephalalgia, \n\nGlonoine. \n\n\n\nCardialgia, \n\nNux Vom. \n\n\n\nVesic. Ervs., \n\nBhus lox. \n\n\n\nPsoric Erup., \n\nSulph. \n\n\n\nAlgidity, \n\nArsen. \n\n\n\nDelirium, \n\nHyoscy. \n\n\n\nTremor, \n\nArnica. \n\n\n\nAnaesthesia, \n\nCarbo veg. \n\n\n\n24 HOMOEOPATHIC \n\nSELECTION OF REMEDIES. \n\nWe have purposely delayed considering the various circumstances \nconnected with the proper selection of remedies, until we had dis- \ncussed the different questions connected with their action, in order \nthat the relations which they severally sustain to each other might be \nmore readily traced and comprehended. For, in order to be able to \nselect the most appropriate remedy in any given case, it is not only \nnecessary to be well acquainted with the pathogenesis of the several \nmedicines, but, as already stated, to keep in view the totality of the \nsymptoms, as well as the exciting cause, and other modifying circum- \nstances. Hence, although much, and sometimes everything, depends \nupon the homoeopathicity of the re??iedy, that is to say, the similarity of \nits symptoms to those of the disease, it is no less important to ascer- \ntain the immediate exciting cause of the malady, and to keep in view \nthe constitution, age, sex, disposition and temperament of the patient ; \nand also the state of the principal bodily functions, such as the \nrespiration and circulation, appetite and thirst, sleep, catamenia, \nstool and urine. In order to obtain a comprehensive view of the \nwhole circle of indications referred to, we will present them in tabular \nform, with illustrative examples under each head. It is scarcely \nnecessary to remark, by way of explanation, that in these instances \nthe examples cited in the table sustain no relation to the other con- \nditions with which they are associated, but simply to the particular \nsymptom or condition under which they are respectively placed; that \nis to say, the selection in this instance not having been made with \nany reference to the general pathogenesis of the several remedies \nmentioned \xe2\x80\x94 as would need to be the case in actual disease \xe2\x80\x94 are \nsimply illustrative of the particular indications with which they stand \nconnected in the tables. \n\nA careful inspection of the foregoing table, will show that some \nof the indications embraced in it should have a much greater in- \nfluence on the selection of the remedy than others. Thus, age, by \nitself, is no criterion for the selection of a remedy, being subordinate \nto every other indication, and is only to be taken into consideration \nwhen the other symptoms correspond. On the other hand, the \nconstitutional condition, as a general rule, is, next to the exciting cause \n\n\n\nPRACTICE OF MEDICINE. 2$ \n\nof the greatest importance, and often exercises a controlling influence \nupon the selection. Of course, the practitioner is not to lose sight \nof the fact, that the medicine must in all cases be homoeopathic to \nthe characteristic symptoms of the disease \\ but when these are few \nin number, or not well pronounced, or when the auxiliary symptoms \nare the most prominent, then the selection is made to depend to a \ngreat extent, and sometimes entirely, upon the latter. Thus, for ex- \nample, a patient is attacked with symptoms suggestive of incipient \nphthisis, such as a slight hacking cough, occasional slight pains in \nthe chest, scanty expectoration of saltish mucus, and suppression of \nthe menses. Here, Pulsatilla, by restoring the catamenia, will \nprobably effect a cure ; and is preferable to Phosphorus, which, were \nit not for the suppression of the menses, (which in this case is prob- \nably the exciting cause of the whole difficulty,) would be the most \nappropriate. Indeed, it may be laid down as a general rule, that \nthe sexual sphere exerts a controlling influence in nearly all the \ndiseases of females, and should therefore never be lost sight of in \ntheir treatment. In these cases, it is true, the selection is made to \ndepend upon a mere function, but it is one the derangement of which \nfrequently makes a profound impression upon the system, giving rise \nto many secondary symptoms, and is therefore entitled to the highest \nconsideration. \n\nSUBSTITUTION OF MEDICINES. \n\nWe have already remarked, that no two medicines produce pre- \ncisely the same pathogenetic effects ; whence it follows, that no rem- \nedy can be a perfect substitute for another. But it frequently hap- \npens in the treatment of disease, that after a medicine has spent its \naction, the symptoms have undergone so little change, as to suggest \nthe continuance of the same remedy. In such cases, the happiest \neffects are sometimes produced by the substitution of another, but \nsimilar medicine. The change in the symptoms, though slight, may \nbe sufficient to point out an analogous remedy more pathogenetic- \nally appropriate ; bur even when this is not the case, the new im- \npression made upon the symptoms by the minor differences in the \naction of the two remedies, will frequently be found to exert a more \nbeneficial effect upon the disease, than would result from the con- \ntinuance or repetition of the original medicine. This is especially \n4 \n\n\n\n26 HOMOEOPATHIC \n\ntrue of chronic maladies, in which, as already stated, care should \nalways be taken to allow sufficient time for the remedy to spend its \nentire force ; after which, though there should be but a mere shade \nof variation produced in the symptoms, there can be no good reason \nfor its continuance. Indeed, we would lay it down as an invariable \nrule in such cases, never to repeat the same remedy. The catalogue \nof medicines of similar pathogenetic action is now sufficiently ex- \ntensive, to enable the practitioner to substitute an analogous remedy \nin all cases of this character. The same care, however, is neces- \nsary in the selection of a substitute, and the same rules apply, \nas in the selection of the original medicine, it being a supreme law \nin the use of all homoeopathic remedies, that they should be capable \nof producing symptoms similar to those for which they are given ; \nand, secondly, that they should always be allowed to complete their \naction before being changed. No medicine, therefore, however \nanalogous it may be, is ever to be substituted for another while the \nformer is still acting, and not then until, by a comparison of all the \nsymptoms, its homoeopathicity is clearly established. \n\nWith due observance of the foregoing directions, substitution, \nagreeably to the order of succession contained in the following table, \nwill, as a general rule, be found to be the best adapted for consecu, \ntive treatment ; the remedies named as being suitable after others \nbeing those to which a preference should be given over other medi- \ncines having analogous properties, but which sustain no such re- \nlation to the previous treatment. While, therefore, on the one hand, \nremedies should always be selected with reference to the totality of \nthe symptoms existing at the time the selection is made, without re- \ngard to any definite order of succession in their administration, the \nsubsequent treatment, on the other hand, should be so conducted \nthat their administration shall correspond, as far as possible, with the \norder of succession here given : \n\n\n\nPRACTICE OF MEDICINE. \nTABLE II.\xe2\x80\x94 SUBSTITUTION. \n\n\n\n27 \n\n\n\nREMEDY. \n\n\nSUITABLE AFTER. \n\n\nSUITABLE BEFORE. \n\n\nAconite. \n\n\nAm. and Sulph. \n\n\nArn., Ars., Bell., Bry., Cann., \nIpec, Spong., Sulph. \n\n\nAlumina. \n\n\nBry., Lach., Sulph. \n\n\nBry. \n\n\nAnt. cr. \n\n\n\n\nPuis, and Mere \n\n\nAnt. tart. \n\n\nBar. c. and Puis. \n\n\nBar. e, Ipec, Puis., Sep.,Sulph. \n\n\nArsenicum. \n\n\nAeon., Arn., Bell., Chin., Ipec., \n\n\nChin., Ipec, Nux vom., Sulph. \n\n\n\n\nLach., Verat. \n\n\nVeratrum. \n\n\nAsa fcet. \n\n\nPuis, and Thuja. \n\n\nCaust. and Puis. \n\n\nAURUM. \n\n\nBell., Chin., Puis. \n\n\nPuis. \n\n\nBelladonn. \n\n\nHep., Lach., Merc, Phosphor., \n\n\nChin., Con., Dulc., Hep., Lach. \n\n\n\n\nNitric Acid. \n\n\nPlat., Bhus., Stram. \n\n\nBryonia. \n\n\nAeon., Nux v., Op., Rhus. \n\n\nAlum, Rhus. \n\n\nCalc. carb. \n\n\nChin., Cupr., Nit. ac, Sulph. \n\n\nLye, Nit. ac, Phos., Sil. \n\n\nCarbo veg. \n\n\nKali, Lach., Nux v., Sep. \n\n\nArs., Kali, Mere, Phos. ac. \n\n\nCausticum. \n\n\nAsa f., Cupr., Lach., Sep. \n\n\nSep., Stan. \n\n\nChina. \n\n\nArn., Ars., Ipec, Merc, Phos. \n\n\nArs., Bell., Carb. v., Pulsatilla, \n\n\n\n\nac, Veratrum. \n\n\nVeratrum. \n\n\nCuprum m. \n\n\nSulph., Verat. \n\n\nCalc, Verat., Sulph. \n\n\nHepar s. \n\n\nBell., Lach., Sil., Spong., Zinc. \n\n\nBell., Merc, Nit. ac, Spong., \n\nSil. \nArn., Ars., Chin., Cocc, Ign., \n\n\nIpecacuan. \n\n\nAeon., Ars., Am., Verat. \n\n\n\n\n\n\nNux vom. \n\n\nKali carb. \n\n\nLye, Nat. m., Nit. ac. \n\n\nCarb.v.,Petro.,Phos.,Khus.,Sul. \n\n\nLachesis. \n\n\nArs., Con., Hep., Lye, Merc, \n\n\nAlum., Ars.,Bell., Carb. v.,Caust. \n\n\n\n\nNit. ac, Nux v. \n\n\nCon., -Dulc, Merc, Nux v., \nPhos. ac. \n\n\nLedum. \n\n\nLycopodium. \n\n\nChina, Sepia. \n\n\nLycopodium \n\n\nCalc, Silicea. \n\n\nGraph., Led., Phos., Puis., Sil. \n\n\nMercurius. \n\n\nAnt. c, Bell., Hep., Lach. \n\n\nBell., Chin., Dulc, Hep., Lach. \nNit. ac, Sep., Sulph. \n\n\nNitric acid. \n\n\nBell., Calc, Hep., Kali., Nat. c \n& m., Pulsat., Sulph., Thuja. \n\n\nCalc, Petrol., Puis., Sulph. \n\n\nNux VOM. \n\n\nArs., Ipec, Lach., Petrol., Phos. \nSulph. \n\n\nBry., Puis., Sulph. \n\n\nOpium. \n\n\n\n\nBry., Calc, Petrol., Puis. \n\n\nPetroleum. \n\n\nNit. ac, Phos. \n\n\nNux vomica. \n\n\nPhosphorus \n\n\nCalc c, Chin., Kali, Kreos., \nLye, Nux v., Rhus., Sil., \nSulph. \n\nLachesis and Rhus. \n\n\nPetrol., Rhus., Sulph. \n\n\nPhos. AC. \n\n\nChina, Fer., Rhus., Verat. \n\n\nPulsatilla. \n\n\nAsa f., Ant., Aur., Chin., Lach., \n\n\nAsafcet., Bry., Nit. ac, Sep., \n\n\n\n\nLycop., Nit. ac, Rhus., Sep., \n\n\nThuja. \n\n\n\n\nSulph., Tart., Thuja. \n\n\n\n\nRhus. tox. \n\n\nArn., Bry., Calc, Con., Phos., \n\n\nBry., Phos., Phos. ac, Pulsat., \n\n\nSepia. \n\n\nPhos. ac, Puis., Sulph. \n\n\nSulph. \n\n\n\n\nCaust., Led., Merc, Puis., Sil., \n\n\nCarb. v., Caust, Puis. \n\n\n\n\nSulph., Sulph ac. \n\n\n\n\nSilicea. \n\n\nCalc, Hep., Lye, Sulph. \n\n\nHep., Lach., Lye, Sep. \n\n\nSpongia. \n\n\nAeon., Hepar-sulph. \n\n\nHepar sulph. \n\n\nSulphur. \n\n\nAeon., Ars., Cupr., Mere, Nit. \n\n\nAeon., Bell.,Cale,Cupr., Mere, \n\n\n\n\nac, Nux v., Puis., Rhus. \n\n\nNit. ac, Nux v., Puis., Khus., \nSep., Sil. \n\n\nThuja. \n\n\nNitric acid. \n\n\nNitr. ac, Puis. \n\n\nVeratrum. \n\n\nArs., Chin., Cupr., Phos. ac \n\n\nArs., Arn., Chin., Cupr., Ipec. \n\n\n\n28 HOMOEOPATHIC \n\nEXTERNAL APPLICATIONS. \n\nGreat difference of opinion still exists among homoeopathists in \nrelation to the extent, propriety and usefulness of external applica- \ntions in the treatment of disease. Hahnemann himself regarded \nthem as extremely prejudicial, both in acute and chronic cases, \neven when the applications were strictly homoeopathic to the disease; \nand for the following reasons : (See Org. \xc2\xa7\xc2\xa7 185 \xe2\x80\x94 206.) \n\n1. They are unnecessary. If the remedy is truly homoeopathic \nto the morbid symptoms, the disease will be cured by its internal use \nalone, if rightly managed. \n\n2. They are deceptive. " For the simultaneous application of a \nremedy internally and externally, in a disease where the principal \nsymptom is a permanent local evil, brings this serious disadvantage \nwith it \xe2\x80\x94 the external affection usually disappears faster than the in- \nternal malady, which gives rise to an erroneous impression that the \ncure is complete, or at least it becomes difficult, and sometimes im- \npossible, to judge whether the entire disease has been destroyed or \nnot by the internal remedy." \n\n3. They are injurious. For if the local symptoms are not sup- \npressed, as they are likely to be by local applications, " they may \nlead to the discovery of the homoeopathic remedy suitable to the en- \ntire malady ; this remedy once discovered, the continued existence \nof the local affection would show the cure was not yet perfected, \nwhile its disappearance would prove that the evil had been extirpa- \nted to its very root, and the cure absolute." \n\nOur own opinion, fortified by experience, is this : \xe2\x80\x94 If the disease \nis highly acute, and the local symptoms very distressing, local rem- \nedies, of a truly homoeopathic character, are always safe and bene, \nficial ; safe, because, being homoeopathic to the symptoms, they can \nonly act in harmony with nature ; and beneficial, because the symp- \ntoms in such cases are always sufficiently well pronounced, to render \nany mistake in the selection of the proper curative agents unneces- \nsary, while they often contribute greatly to the relief and comfort of \nthe patient. \n\nOn the other hand, in the treatment of chronic maladies, local \napplications, as a general rule, are less necessary for the comfort of \n\n\n\nPRACTICE OF MEDICINE. 29 \n\nthe patient, less promotive of recovery, and much more apt to be \nattended by the evil consequences apprehended by Hahnemann. \nHence we seldom make use of them in diseases of long standing, \nwhether general or partial, but depend entirely upon internal treat- \nment, which alone is capable of producing permanent and satisfac- \ntory results. \n\nHOMOEOPATHIC REGIMEN. \n\nUnder this head we propose to point out, in a general way, the \nseveral kinds of food, drink, and external influences, which are and \nwhich are not allowable under homoeopathic treatment. It is evident \nthat as the homoeopathic dose is exceedingly minute, everything \nshould be excluded from the regimen, that is capable of exercising \nany medicinal influence upon the patient, however small. Hence, \ncoffee, green tea, spiced chocolate, beer, wine, rum, gin, punch? \nvinegar and other acids, spices, medicinal roots and herbs, fat meat, \nespecially pork, strongly seasoned viands and sauces, ice-cream and \npastry flavored, old cheese, rancid butter, pickles, ducks, geese, and \nyoung veal, perfumery and other odorous preparations, as they al \nact more or less medicinally, should be entirely prohibited during \ntreatment, and for some time afterwards. On the other hand, all \nordinary articles of diet, both solid and liquid, not included in the \nabove list, and not too highly seasoned, may be used with moderation, \nat proper intervals. \n\nIn addition to the observance of suitable dietetic instructions, the \npractioner should enforce proper hygienic regulations. Among these \nmay be mentioned, the avoidance of long-continued confinement in \nclose rooms, late hours, too much or two little sleep, unchaste habits, \nthe reading of sensational or obscene literature, excessive labor, \neither bodily or mental, insufficient ventilation, sedentary or un- \nhealthy occupations, and, in fine, everything which can act injurious- \nly upon the health or retard the recovery of the patient. \n\nTobacco, in all its forms, not only antidotes homoeopathic medi- \ncines, but, by lowering the tone of all the vital functions, greatly un- \ndermines the health, producing dyspepsia, hemorrhages, cardialgia, \ngastralgia, general debility, and many forms of visceral disease ; at \nthe same time it acts powerfully upon the brain and nerves, derang- \ning their action, and consequently the functions depending upon \n\n\n\n30 H0MCE0PATHIC \n\nthem. Hence, persons addicted to the excessive use of tobacco, \nare almost always subject to palpitations of the heart, vertigo, head- \nache, weakness of the limbs, dimness of vision, loss of appetite, dis- \nturbed sleep, and general nervous prostration. \n\nCoffee and green tea also act in a similar manner, and if used \nimmoderately and in great strength, sometimes give rise to conse- \nquences scarcely less pronounced, or less serious. Both of these \nbeverages contain nitrogen in large quantity, which overstimulates the \nbrain and nerves, producing sur-excitation of the senses, and followed, \nsooner or later, by a corresponding depression of the nervous system, \ngiving rise to a large train of functional disturbances, and greatly \nimpairing the general health. Black tea, on the contrary, if pure, \nis not injurious to homoeopathic preparations, and being far less \nstimulating than the green, may be used in moderation, in most \ncases, without injury ; but even this should be denied if it excites the \nnerves of the patient, as it does of some very sensitive organizations, \nespecially when not accustomed to its use. \n\nInstead of coffee and tea, water and fresh milk, or cocoa and \nmilk, may be used ; and in cases demanding increased nourishment, \nclear milk, warm from the cow, is a beverage of the most wholesome \ncharacter, alike suited to children and to adults. Cocoa shells, also, \nas well as pure chocolate, furnish a pleasant and refreshing beverage. \n\nIt follows that spirituous and malt liquors, as well as the \nso-called galenical preparations of the apothecary, are exceedingly \npernicious, and should never be resorted to except in extreme cases; \nand even then, none but the purest wine or brandy should be used, \ngreatly diluted, and in quantities so small as not to be followed by \nany marked reaction. In cases demanding it, a teaspoonful or two \nof sherry wine, or half that quantity of pure brandy, may be given in \nbroken doses, properly diluted, but its effects upon the system will \nneed to be carefully watched, and undue stimulation avoided. \n\nThe habitual use of spirituous liquors, even in moderate quanti- \nties, congests and inflames the lining membrane of the stomach, \nweakens digestion, and impairs, to a greater or less extent, the vital \nfunctions. Hence it sometimes becomes necessary in such cases, to \nraise somewhat the general tone of the system before the beneficial \neffects of medicines can be obtained. This can generally be best \n\n\n\nPRACTICE OF MEDICINE. 31 \n\naffected, by giving wine or brandy in small quantities, largely diluted, \nbeing careful to observe the precautions above-mentioned. Persons \nenfeebled by old age, also, sometimes require similar treatment, be- \nfore the system will respond satisfactorily to the action of medicines. \nThis careful and judicious use of pure liquors, for medicinal pur- \nposes, is a very different thing from the indiscriminate and almost \nunlimited use of it under allopathic treatment, and still more, the \nfearful abuse of it as a general beverage, which such practice has \ntended to confirm. \n\nAs to malt liquors, though of undeniable benefit at first, in some \ncases of emaciation and debility, especially during convalescence from \nexhausting diseases, they are apt to derange the stomach, particu- \nlarly if the digestive organs are enfeebled, and, by congesting the \nportal system, to increase the derangements and the weakness foi \nwhich they are prescribed. They should, therefore, be used with \nthe greatest caution, and always tentatively, bearing in mind their \nstimulating qualities, and their tendency to produce hepatic en- \ngorgement. Nevertheless, to persons accustomed to their use, es- \npecially industrious laborers, we should not hesitate to allow a single \nglass of pure beer, whenever such an amount of stimulation is not \notherwise contra-indicated. \n\nSoda-water, when properly made and flavored, is a pleasant and \ncooling beverage, acceptable to the stomach, and wholesome to the \nsystem. Fresh sweet cider and lemonade are also pleasant drinks, \nand not injurious during the heat of summer, if used in moderation ; \nbut, owing to their acid qualities, they should be strictly forbidden \nwhile the patient is under homoeopathic treatment. \n\nWe have already indicated, in a general way, the various kinds \nof solid food which may properly be allowed to convalescents, and \nto a limited extent while under treatment; but preference should \nalways be given to such as are the most nourishing and easy of \ndigestion. \n\nFresh oysters are very easy of digestion, and so is wild game, \nsuch as squirrels, quails, rail birds, rabbits and venison. Partridges, \nwild ducks and common fowls, if not too old and tough, or too young, \nare of comparatively easy digestion, but do not suit all stomachs. \nYoung and tender beef is always very digestible and nourishing, and \n\n\n\n32 HOMOEOPATHIC \n\nstands at the head of every kind of animal food. Mutton is not \nquite so easy of digestion as beef, but is very wholesome, and es- \npecially useful whenever there is any tendency to dysentery or \nchronic diarrhoea. Veal is less easy of digestion than mutton, es- \npecially if very young, besides having a tendency to cause diarrhoea; \nit should therefore be used very sparingly, particularly in the \nsummer season. Pork, from the fineness and closeness of its grain \nand the amount of fat associated with it, is the most difficult of \ndigestion of all the meats, besides being more stimulating and less \nnutritious. Its use should be totally interdicted to all but laborers ; \nand the health of the people would be greatly benefited if it were \nentirely banished from civilized life. \n\nScale fish, such as trout, perch, haddock, shad, bass, flounders, \nwhitefish, carp, blackfish, pike and codfish, when fresh, are easy of \ndigestion, and being rich in phosphorus, are well suited to consump- \ntives, and persons suffering from nervous weakness. Eggs, also, are \nvery nutritious, and when properly cooked, are of easy digestion. \nThey should either be soft-boiled, poached, or scrambled. \n\nVegetable food, from the absence of nitrogen, is less stimulating \nthan animal food, and therefore better suited to the summer season, \nhot climates, and plethoric persons. It is also better adapted to the \nearlier stages of acute diseases, and, indeed, is the only kind of diet \nthat is generally admissable at such times. From its favoring a \ngentle disposition, it should always be prescribed when the temper \nis irascible and violent. Being less subject to putridity than animal \nfood, it is better suited to a scorbutic condition of the system ; but \non account of its greater tendency to cause acidity, flatulency and \nstomachic weakness, it should be sparingly used in all cases likely to \nbe injuriously affected by such qualities. Graham bread, rye mush> \noat meal pudding, rice pudding, boiled grits, and stewed prunes and \npeaches, are not only nourishing and easy of digestion, but are par- \nticularly adapted to a dry and feverish state of the system, especially \nwhen attended with constipation. Farina, tapioca and sago are ex- \ncellent articles of diet during the earlier stages of acute diseases, being \nless stimulating than most other kinds of food, and better tolerated \nby the stomach. \n\n\n\nPRACTICE OF MEDICINE. 33 \n\nThe following dietetic regulations should be observed at all times, \nwhether in health or sickness : \n\ni. No food is fit to be eaten that is not sound and fresh ; that is, free \nfrom disease and decay. Rotten vegetables and putrid meat are \nprolific sources of disease, and should always be rejected. \n\n2. Food should be properly and sitfficiently cooked; that is, not too \nhighly seasoned, nor simply parboiled or watersoaked, but so cooked \nas to leave it tender, juicy and nutritious. \n\n3. // should always be eaten with deliberation, and well masticated ; \nnot bolted down in large masses, which is a very common cause of \ndyspepsia, and the numerous ills connected with it. \n\n4. Food should be taken into the stomach only at proper intervals. \nThe habit of eating at any and all times is very injurious to health. \nThe stomach needs rest ; and to get it not more than two or three \nmeals a day should be permitted. Invalids and valetudinarians \nsometimes require to partake of food more frequently ; but in such \ncases the quantity should be correspondingly diminished. \n\n5. No one should ei>er eat to the point of satiety or repletion. When \nthe stomach is too much distended, digestion is slow and difficult ; \nand disorder of both the stomach and bowels is not an unusual con- \nsequence of indiscretion. \n\n6. Lastly, and as a general rule, no one should eat exceptitig when \nhe is hungry, and should stop eating as soon as the sense of hunger is \nrelieved. This is a cardinal rule of dietetics, and should be observed \nby every one who is desirous of maintaining the integrity of his \ndigestive organs unimpaired, or who aims to recover their tone and \nefficiency after they have lost them. \n\nMEDICAL NOMENCLATURE. \n\nBesides being divided into acute and chronic, diseases are dis- \ntinguished as either general, partial or local. This classification, \nthough not founded upon any definite and well-grounded pathological \ndistinction, possesses considerable convenience for purposes of refer- \nence, and we shall therefore avail ourselves of it in the description of \ndiseases. \n\nThat the distinction just mentioned is not well-founded, we have \nonly to instance the subject of fever, as treated in allopathic works, \nwhere it is divided into as many different forms as there are types of \nthe disease, predominance of symptoms, or supposed causes for its \nproduction. Thus we have inflammatory, typhous and typhoid fever, \nfever beginning as sthenic or inflammatory, and ending as asthenic or \nadynamic, intermittent, remittent and continued, cerebral, hepatic, \ngastric, or gastro-enteric, hectic, and so on, almost ad infinitum; what \nbetter illustration could we have of the absurdity of the old-school \nmethod of treating diseases by names, instead of recognizing them \nby their true distinctive characters \xe2\x80\x94 the symptoms \xe2\x80\x94 which is in fact \n\n5 \n\n\n\n34 HOMOEOPATHIC. \n\nthe only practical method of distinguishing them, as allopathists \nthemselves are compelled to admit, when they come to the consider- \nation of the special forms of disease. And yet, when we make use \nof the only rational method of treating disease by symptoms, instead of \nnames, they hasten to cry out, absurd. Well may we respond, "O \nconsistency, thou art a jewel/" \n\nWe thus see, in marked contrast, not only the propriety of our \nmethod of practice, but the absolute necessity that exists for studying \nwell the entire group of morbid symptoms in every individual case of \ndisease, and not from a few predominant symptoms that force them- \nselves upon the attention of the most casual observer, adopt the \nconvenient but indefinite and unsatisfactory method of classifying \ndiseases under some of their many appellations, and then treating \nthem in the usual routine manner by name. This is, indeed, a very \nconvenient method for those who are too indifferent or too lazy to \nstudy, and are only anxious, by pandering to the prejudices of the \nmultitude, to cover their ignorance under the cloak of learning. But \nthis course will neither satisfy the conscientious physician, nor will it \nyield creditable results. Nothing short of a careful study and com- \nparison of all the symptoms, will demonstrate the infinite variety of \ndiseased action, or enable the practitioner to adapt his remedies in- \ntelligently to its many forms, in conformity to the great and unerring \nlaw of cure. \n\nIf, therefore, we shall so far yield to the common notions of \ndisease, as to describe some of its principal varieties under the \nnames by which they are generally known, we wish it to be distinctly \nremembered that we do so only for the sake of convenience, and not \nbecause we subscribe to the correctness of the nomenclature. Disease \ncannot be correctly classified by any combination of technical terms. \nIt is correctly written only on the face of nature itself, by the multi- \nplied and ever-varying symptoms which characterize it. Presumptious, \nindeed, must that man be, whatever may be his claims to erudition, \nwho attempts to portray in words the multiform phases of disease, \nand present them to us under the mantle of a learned nosology, as a \nfull and correct delineation of disease. For ourselves, we shall \nattempt nothing of the kind. A few of the more prominent and \ncommon forms will be described, so far as the aid of such lights as \nrecent pathology has shed upon them will permit; but we desire \nemphatically to admonish the student, that a knowledge of disease \ncan by no means be obtained alone from books; and that the \nhighest use to which they can be applied, is to serve as guides to its \nsuccessful study at the bedside of the patient. \n\n\n\nPRACTICE OF MEDICINE. 35 \n\n\n\nCHAPTER I. \n\n\n\nDISEASES OF THE ENCEPHALON. \n\n\n\nPRELIMINARY OBSERVATIONS. \n\nThe cerebral affections which we propose to consider in \nthis chapter are those of a vascular, nervo-vascular, and in- \nflammatory character \xe2\x80\x94 those which consist chiefly in a dis- \nturbance of the mental functions will be reserved for another \nplace. \n\nThe former include anaemia and hyperaemia of the brain \nand its membranes ; conditions the existence of which some \npathologists still regard as absurd and impossible, but which \nwe shall assume have been amply verified by abundant phy- \nsiological, clinical, and necroscopical evidence. \n\nThe question which formerly excited such acrimonious dis- \ncussion, namely, whether the amount of blood in the cranial \ncavity is always the same, has, we think, been satisfactorily \ndetermined in the negative by recent physiological experi- \nments ; so that the existence of both cerebral anaemia and \nhyperaemia is no longer a matter of doubt, but must be re- \ngarded as of frequent occurrence. \n\nBefore entering more fully upon the description of these \nconditions,we shall introduce a couple of analytical tables em- \nbracing the principal cerebral regions and sensations, together \nwith the remedies which, irrespective of other relations, are \nchiefly indicated. \n\n\n\n36 \n\n\n\nTABLE IIL\xe2\x80\x94 CEREBRAL REGIONS. \n\n\n\nAsafoetida \n\nBelladonna \n\nBryonia \n\nCantharis \n\nCausticum \n\nCina. \n\nDigitalis \n\nDrosera \n\nIgnatia \n\nPlumbum \n\nSabina \n\n\n\nAoid. Phos. \n\nAlumina \n\nargentum \n\ncocculus \n\ncolchicum \n\nphosphorus \n\nRH 8 TOX. \n\nSabadilla \nSanguinaria \nSpongia \nSulphur \n\n\n\nAcid. mur. \n\nAconitum \n\nAgaricus \n\nAnacardium \n\nAnt. crudum \n\nArnica \n\nCamphora \n\nChina \n\nCrocus \n\nEuphrasia \n\nGraphites \n\nHepar sulph. \n\nHelleborus \n\nHyoscyamus \n\nKali carb. \n\nLachesis \n\nLycopodium \n\nNatr. carb. \n\nNux vomica \n\nPulsatilla \n\nSilicea \n\nSpigelia \n\nStannum \n\nStaphysagria \n\nThuja \n\n\n\nAcid. nit. \n\nAmbra \n\nArgent. \n\nArnica \n\nAsarum eu. \n\nCapsicum \n\nChina \n\nColocynth \n\nCrocus \n\nDigitalis \n\nEuphorb. \n\nIodium \n\nPlatina \n\nRhododen. \n\nSambucus \n\nSepia \n\nAconite \nAnt. or. \nasafoetida \nCamphora \n\nClCUTA \nClNA \n\nCocculus \nCuprum \nMerc. sol. \nPetroleum \nEhus. tox. \nSec cor. \nSpigelia \nSpongia \nStramonium \n\nAurum \n\nBaryta \n\nBelladonna \n\nBryonia \n\nCalcarea \n\nCannabis \n\nCarb. veg. \n\nDulcamara \n\nDrosera \n\nEuphrasia \n\nFerrum \n\nHelleborus \n\nHyoscyamus \n\nIgnatia \n\nLachesis \n\nNux vom. \n\nPlumbum \n\nPulsatilla \n\nSabina \n\nStaphysagria \n\nSulphur \n\nVerat. alb. \n\n\n\nAconite \n\nAnt. cr. \n\nArnica \n\nArsenicum \n\nAsafoetida \n\nAsarum eu. \n\nBelladonna \n\nBryonia \n\nCamphora \n\nChina \n\nCina \n\nCocculus \n\nColocynth \n\nCrocus \n\nDigitalis \n\nDrosera \n\nDulcamara \n\nGlonoine \n\nHelleborus \n\nHyoscyamus \n\nIgnatia \n\nIpecac. \n\nMercurius \n\nNatr. mur. \n\nNux vom. \n\nPlatina \n\nPlumbum \n\nPulsatilla \n\nRhododend. \n\nSabina \n\nSepia \n\nSilicea \n\nSpigelia \n\nSpongia \n\nStaphysagria \n\nAtomina \n\nargentum \n\nAURUM \n\nBaryta \n\nCapsicum \n\nCicuta \n\nCOFFEA \n\nGelseminum \n\nRhus. tox. \n\nVerat. alb. \n\nAmbra \n\nAnacardium \n\nCalcarea \n\nCannabis \n\nCantharis \n\nCarb. veg. \n\nCausticum \n\nChamomilla \n\nColchicum \n\nConium \n\nCuprum \n\nEuphrasia \n\nFerrum \n\nGraphites \n\nIodium \n\nKali carb. \n\nLycopodium \n\nOpium \n\nPhosphorus \n\nSambucus \n\nStannum \n\nSulphur \n\nZincum \n\n\n\nChina \n\nCimicifuga \n\nColchicum \n\nGlonoine \n\nIgnatia \n\nMoschus \n\nNux vom. \n\nPulsatilla \n\nRhus tox. \n\nSpigelia \n\nSpongia \n\nAconite \n\nArgent um \n\nAsarum eu. \n\nBelladonna \n\nBryonia \n\nCamphora \n\nCannabis \n\nCantharis \n\nCarb. veg. \n\nCicuta \n\nDigitalis \n\nGelseminum \n\nHyoscyamus \n\nLycopodium \n\nMerc sol. \n\nOpium \n\nPetroleum \n\nSanguinaria \n\nSabina \n\nStannum \n\nAcid. phos. \n\nAnacardium \n\nArnica \n\nAsafoetida \n\nAurum \n\nBaryta \n\nCalcarea \n\nCapsicum \n\nCoffea cr. \n\nCrocus \n\nCuprum \n\nDrosera \n\nEuphrasia \n\nHelleborus \n\nIpecacuan. \n\nPlatina \n\nRhododend. \n\nSambucus \n\nStaphysagria \n\nSulphur \n\nThuja \n\nVerat. vir. \n\n\n\ntemples. vertex \n\n\n\nAcid. phos. \nArgentum \nChina \nRhus tox. \n\nAconite \n\nArnica \n\nAsafcetida \n\nAsarum eu. \n\nCannabis \n\nCantharis \n\nCapsicum \n\nChamomilla \n\nCina. \n\nCocculus \n\nCuprum \n\nDigitalis \n\nEuphrasia \n\nHelleborus \n\nHepar sulph. \n\nTgnatia \n\nLachems \n\ntfHEUM \n\nRhododend. \n\nSabina \nSpigelia \nSpongia \nStaphysagria \n\nAcid. nit. \n\nAgaricus \n\nAlumina \n\nAnacardium \n\nAnt. crud. \n\nBelladonna \n\nBryonia \n\nCalcarea \n\nCamphora \n\nConium \n\nOpium \n\nPhosphorus \n\nStannum \n\n\n\nAmbra \n\nChina \n\nCimicifuga \n\nCocculus \n\nCuprum \n\nGlonoine \n\nHelleborus \n\nLachesis \n\nStramonium \n\nThuja \n\nVerat. alb. \n\nAcid. phos. \n\nArnica \n\nCina \n\nGelseminum \n\nIodium \n\nNux VOM. \n\nPhosphorus \n\nSpigelia \n\nAconitum \n\nAnacardium \n\nAnt. crud. \n\nArgentum \n\nAsafoetida \n\nAsarum eu. \n\nAurum \n\nBelladonna \n\nBryonia \n\nCannabis \n\nCantharis \n\nCapsicum \n\nCausticum \n\nCoffea cr. \n\nColocynthia \n\nConium \n\nCrocus \n\nEuphrasia \n\nFerrum \n\nGraphites \n\nIgnatia \n\nIpecacuan. \n\nPlatina \n\nSabina \n\nSambucus \n\nSepia \n\nSilicea \n\nSpongia \n\nStannum \n\nStaphysagria \n\nSulphur \n\n\n\nTABLE IV.\xe2\x80\x94 CEREBRAL SENSATIONS. \n\n\n\n37 \n\n\n\nAconitum \nArnicum \nBelladonna \nBryonia \nCalcarea \nGelsemin- \n\'lonoine \nHelleborus \nIpecacuan \nLycopod \nMerc- sol- \nNux vom- \nPetroleum \nPulsatilla \nRhus tox- \nSilicea \nSulphur \n\nAlumina \n\nCantharis \n\nChina \n\nEuphrasia \n\nIgnatia \n\nSepia \n\nStannum \n\nStramonium \n\nVerat- vir- \n\n\n\nAcid nit. \n\nCamphora \n\nCausticum \n\nCoffea cr. \n\nDigitalis \n\nDrosera \n\nDulcamara \n\nHyoscyamus \n\nNat. mur. \n\nPhosphorus \n\nPlumbum \n\nValeriana \n\n\n\nPAIN.* \n\n\n\nAconitum \n\nAlumina \n\nApis \n\nArnica \n\nBelladonna \n\nBaryta \n\nBryonia \n\nCalcarea \n\nCantharis \n\nChamomil- \n\nChina \n\nCimicifuga \n\nCoffea cr- \n\nColocynth- \n\nConium \n\nGlonoine \n\nHyoscyam \n\nIgnatia \n\nMux vom- \n\nOpium \n\nSilicea \n\nSpigelia \n\n\n\nAcid mur- \n\nAnt- cru. \n\nArsenicum \n\nCocculus \n\nIpecacuan. \n\nLycopodium \n\nNat- carb- \n\nNat- mur. \n\nRhus tox- \n\nStramonium \n\nSulphur \n\n\n\nAcid phos. \n\nCrocus \n\nCuprum \n\nHelleborus \n\nIodium \n\nLachesis \n\nMercurius \n\nPlumbum \n\nSepia \n\nValeriana \n\n\n\nAconitum \n\nBelladonna \n\nBryonia \n\nChamomil. \n\nCicuta \n\nCarb- veg- \n\nConium \n\nDigitalis \n\nDulcamara \n\nFerrum \n\nIpecacuan- \n\nLycopod- \n\nMercurius \n\nNux vom, \n\nPulsatilla \n\nPhosphorus \n\nSabina \n\nSpongia \n\nStaphysag- \n\nSilicea \n\nVerat- alb- \n\n\n\nAcid nit- \nAcid phos- \nAgaricus \nAlumina \nArsenicum \nCactus \nCamphora \nChina \nCimicifuga \nCocculus \nCoffea cr- \nCuprum \nDrosera \nGlonoine \nHelleborus \nHyoscyamus \nIgnatia \nNat mur- \nOpium \nPetroieum \nPlumbum \nSpigelia \nStannum \n\n\n\nArnica \n\nAsai\'cetida \n\nCannabis \n\nCrocus \n\nCalcarea \n\nCausticum \n\nEuphrasia \n\nKali carb. \n\nPlatina \n\nSec. cor. \n\nStramonium \n\nSulphur \n\nThuja \n\n\n\n* Tearing or \n\nStinging. \n\n\n\nPRE88UKB. \n\n\n\nAconitum \n\nArnica \n\nBelladonna \n\nBryonia \n\nCalcarea \n\nCapsicum \n\nChina \n\nCimicifuga \n\nNat- mur- \n\nNux vom- \n\nSpigelia \n\nAcid nit. \n\nAcid phos. \n\nAsafcetida \n\nAsarum eu. \n\nArsenicum \n\nChamomilla \n\nCocculus \n\nIgnatia \n\nIpecacuan \n\nPetroleum \n\nPulsatilla \n\nSulphur \n\nValeriana \n\n\n\nAcid mur, \n\nAmbra \n\nArgentum \n\nAnacardium \n\nAurum \n\nCamphora \n\nCausticum \n\nCarb. veg. \n\nCannabis \n\nCapsicum \n\nCicuta \n\nCina \n\nCoffea cr. \n\nCrocus \n\nDigitalis \n\nHelleborus \n\nHyoscyamus \n\nIodium \n\nLachesis \n\nMercurius \n\nNatr. carb. \n\nPhosphorus \n\nPlatina \n\nRhododendron \n\nSepia \n\nSilicea \n\nStannum \n\nStaphysagrla \n\nZincum \n\n\n\nAconitum \n\nArnica \n\nBelladonna \n\nBryonia \n\nCannabis \n\nConium \n\nGelsemin- \n\nGlonoine \n\nLycopod- \n\nNatrum \n\nNux vom- \n\nPetroleum \n\nPhosphor. \n\nRhus- tox- \n\nSec cor- \n\n\n\nAcid nit. \n\nApis \n\nCactus \n\nCalcarea \n\nCamphora \n\nCarb. veg. \n\nCocculus \n\nDigitalis \n\nGraphites \n\nIpecacuan. \n\nMercurius \n\nMoschus \n\nNat. mur. \n\nOpium \n\nPulsatilla \n\nSpigelia \n\nStaphysagria \n\nStramonium \n\nSulphur \n\nThuja \n\nVerat. alb. \n\n\n\nAmbra \n\nArsenicum \n\nBaryta \n\nCannabis \n\nCantharis \n\nCausticum \n\nChamomilla \n\nChina \n\nCicuta \n\nCoffea cr. \n\nCrocus \n\nCuprum \n\nDrosera \n\nEuphrasia \n\nHelleborus \n\nHepar. sulph. \n\nHyoscyamua \n\nNitrum \n\nPlatina \n\nPlumbum \n\nStannum \n\nZincum \n\n\n\nRUSH OF BLOOD. \n\n\n\nAconitum \n\nBelladonna \n\nBryonia \n\nCactus \n\nCannabis \n\nChina \n\nCalcarea \n\nCarb- veg \n\nColocynthis \n\nFerrum \n\nGelsemin- \n\nGlonoine \n\nGraphites \n\nHyoscyam. \n\nLycopod- \n\nMercurius \n\nNux vom- \n\nOpium \n\nPlumbum \n\nPulsatilla \n\nPhosphorus \n\nRhus tox- \n\nSepia \n\nSilicea \n\nSulphur \n\nSpongia \n\nStramon. \n\nVerat- vir- \n\nAcid. nit. \n\nAgaricus \n\nAlumina \n\nAmbra \n\nApis \n\nArsenicum \n\nCamphora \n\nChina \n\nCocculus \n\nCoffea cr. \n\nCuprum \n\nDrosera \n\nHelleborus \n\nHyoscyamus \n\nIgnatia \n\nLachesis \n\nNat. mur. \n\nOpium \n\nPiumbum \n\nRanunculus \n\nRatanhia \n\nSenega \n\nSenna \n\nTartarus \n\nValeriana \n\nVerat. alb. \n\nZincum \n\nAnt. crud. \n\nArnica \n\nBaryta \n\nCantharis \n\nCausticum \n\nDigitalis \n\nIodium \n\nS^phyMgrl* \n\n\n\n38 DISEASES OF THE ENCEPHALON. \n\nANJEMIA OF THE BRAIN * \n\nCerebral Anaemia is a disease of such comparatively rare \noccurrence, that it would scarcely merit separate considera- \ntion, were it not that the similarity of its symptoms to those \nof cerebral hyperaemia renders it liable to be mistaken for \nthat condition \xe2\x80\x94 an error of very grave importance in diseases \nof the brain, even under homoeopathic treatment. \n\nThe disease consists either in a diminished supply of blood \ncirculating in the brain, {hyposmia vel ancemla stride sic dic- \ntus,) or in the cerebral circulation being deficient in haema- \ntine, (kydrcemia,) or in both, {liypcemia et hydtcemia) The first \nmay be referred to whatever cause impedes the flow of blood \nto the brain, to contraction of the cerebral vessels by spasm \nor otherwise, or by any other condition whereby the inter-cra- \nnial space is lessened ; the second, to the various causes which \nproduce impoverishment of the blood, and give rise to general \nanaemia ; and the last to sanguineous losses, which when con- \nsiderable always produce both paucity and poverty of the \ncirculating fluid. \n\nSYMPTOMS. These vary considerably according as the anae- \nmia is gradually or suddenly produced. When it occurs grad- \nually, the symptoms at first are similar to those of the op- \nposite condition of hyperaemia, namely : great excitement \nof the cerebral functions, headache, flashes of light, confu- \nsion of sight, humming in the ears, vertigo, loss of memory, \nand sometimes convulsions. At a later period, if the disease \ngoes on unchecked, symptoms of paralysis may supervene. \n\nWhen, on the other hand, cerebral anaemia sets in suddenly, \nas in flooding, traumatic haemorrhages, and other rapid losses \nof the sanguineous fluid, the symptoms presented are those of \nsyncope, namely : loss of consciousness, of the senses, and of \nvoluntary motion, accompanied with a retarded pulse and res- \npiration, and frequently with slight convulsions. \n\nDIAGNOSIS. The greatest care is necessary, especially with \nchildren, to distinguish this state from that of cerebral con- \ngestion. When caused by debilitating losses, and especially \n\n* See American Horn. Observer, vol. vii., p. 55. \n\n\n\nANEMIA OF THE BRAIN. 39 \n\nwhen associated with general anaemia, or with an impaired \nstate of the assimilative functions, the history of the case, \ntogether with the fact that the symptoms of cerebral anaemia \ngenerally diminish or disappear in the recumbent position, \nwill serve to distinguish it from hyperaemia of the brain. \n\nHowever induced, cerebral anaemia is always attended with \ngreat danger to life, especially with children, though when \nearly recognized, and promptly and correctly managed, the \ndisease, even in its acute form, will generally yield to the \nfollowing \n\nTREATMENT. In simple syncope,all that is generally requir- \ned in the way of treatment is, to lay the patient in a horizontal \nposition, and thus favor a return of blood to the brain If, \nhowever, the fainting is of frequent recurrence, it will com- \nmonly be found to depend upon some other affection, against \nwhich the treatment will need to be specially directed. \n\nTHERAPEUTIC INDICATIONS. \n\nArsenicum. Violent headache, humming in the ears, ob- \nscuration of sight, particularly on raising the head, vertigo, \nloss of consciousness, pale, chlorotic colored face, great weak- \nness and prostration, impaired memory, syncope. \n\nThis remedy is eminently homoeopathic to cerebral anae- \nmia ; and is well suited to cases which are complicated or ag- \ngravated by the injudicious use of Ferrum. Care should be \ntaken not to use Arsenicum low in this disease. I have gen- \nerally obtained the best results from the 30th potency. \n\nCalcarea carb. Throbbing, hammering headache, accom- \npanied with great physical prostration, paleness of the face, \ncold hands and feet, and mental weakness, vertigo, loss of \nconsciousness, frequent fainting fits, suspension of the senses, \npalpitation of the heart, shortness of breathing, \n\nThis remedy is well suited to general as well as cerebral \nanaemia. \n\nCamphora. Vanishing of the senses, vertigo, violent throb- \nbing headache, embarrassment of the circulation and respir- \nation, pale cold skin, spasms and convulsions. \n\n\n\n40 DISEASES OF THE ENCEPHALON. \n\nHahnemann says of this remedy : "Vertigo, loss of con- \nsciousness, and coldness of the body, appear to be primary \ntreatment of a dose of Camph., and point to a diminished \nafflux of the blood to those parts which are distant from the \nheart ; whereas, the rush of blood to the head, heat in the \nhead, &c, are symptoms denoting a reaction of the vital pow- \ners, just as forcibly as the former symptoms denoted their \ndiminished action." \n\nThe action of this remedy is so evanescent as to require it \nto be given in rapidly repeated doses , it is therefore best \nsuited to those cases of cerebral anaemia which take the form \nof syncope, especially when caused by the loss of blood. \n\nChina. Headache, especially in the morning, mental weak- \nness, vertigo, especially on raising the head, obscuration of \nsight, humming in the ears, fainting fits, pale cold face, cold- \nness of the hands and feet, great debility, with tingling, trem- \nbling or twitching of the muscles and limbs. \n\nThis remedy is best suited to those cases of anaemia caused \nby the excesssive loss of animal fluids. \n\nCina. Violent headache,which increases by reading or men- \ntal effort, dizziness, obscuration of sight, faintness, which is \nrelieved by lying down, paleness of the face, convulsions, par- \nalytic lameness. This remedy is especially suited to chil- \ndren, particularly where there is any suspicion that the symp- \ntoms are caused by verminous irritation. \n\nIpecacuanha. Violent headache, excited and aggravated by \nstooping, vertigo with temporary loss of consciousness, pale \nface, cold hands and feet, nausea, with or without vomiting, \nsweet or bitter taste, convulsive twitchings of the limbs. \n\nThis remedy, also, is well adapted to children, and likewise \nto cases resulting from the loss of animal fluids. \n\nNux Vomica. Headache, especially in the morning, men- \ntal weakness, vertigo, with obscuration of sight and whizzing \nin the ears, loss of consciousness, syncope, sleeplessness, fright- \nful dreams, constipation, coldness of the whole body, spasms \nand convulsions. \n\nThis remedy is best suited to cases attended with constipa- \ntion, and like Arsenicum should always be used high. \n\n\n\nCEREBRAL HYPEREMIA. 4 1 \n\nSecale Cor. Vertigo, headache, loss of consciousness, men- \ntal weakness, hammering and buzzing in the ears, obscuration \nof sight, paleness of the face, diarrhoea, metrorrhagia, spasms \nand convulsions. \n\nThis remedy is particularly applicable to cases of cerebral \nanaemia caused by colliquative alvine evacuations, or by \nflooding. \n\nVeratrum alb. Headache aggravated by movement, espe- \ncially stooping, giddiness, vanishing of the senses, wakeful- \nness, fainting fits, general coldness, violent vomiting and purg- \ning, spasms and convulsions, followed or attended by paralytic \nweakness. \n\nThis remedy is suited to similar conditions to those for \nwhich Secale cor. is indicated, but with this difference, that \nwhile the latter is better adapted to cases of cerebral anaemia \ndepending upon uterine haemorrhage, Veratrum alb. is better \nsuited to such cases as depend on losses occasioned by ex- \ncessive alvine discharges. \n\nFor other remedies employed in this disease, consult Ta- \nbles V. and XII * \n\nDiet and Regimen. The diet, particularly in cases occa- \nsioned by loss of animal fluids, should be light and easily di- \ngestible, liberal in quantity, and nutritious. In most cases the \nmoderate use of malt liquors may be allowed, but strong al- \ncoholic drinks are unnecessary, and should be avoided. \n\nCEREBRAL HYPERJEMIA-CONGESTION OF THE BRAIN.f \n\nHyperaemia of the the brain is either active or passive. \n\nPassive Hyperemia is the result of mechanical or other \ncauses interfering with the return of blood from the brain, \nproducing over-distension of its vessels, and consequent de- \npression of its functions. \n\nSymptoms. Its characteristic symptoms are : coldness, es- \npecially of the head, from enfeebled circulation, impeded res- \npiration, a sense of weight and fullness of the head, produc- \ning more or less stupor or drowsiness, vertigo, impaired vision, \nlividity, or else undue paleness of the lips and face, nausea, \nand sometimes vomiting. \n\n* See American Horn. Observer, vol. vi., p. 556 ; vol. vii., p. 295. \nt See American Horn. Observer, vol. ii., p. 51. \n6 \n\n\n\n42 THERAPEUTIC INDICATIONS. \n\nTreatment. The treatment of passive congestion consists \nin removing, as far as possible, the causes which produce it \nRest, both physical and mental, and the avoidance of every- \nthing calculated to disturb the circulation, such as excess in \neating and drinking, are of special importance in every case, \nand should be carefully observed. \n\nActive Hyperemia of the brain is more common than the \nvariety just described, and is sometimes serious and even fa- \ntal; but it derives its chief importance from being the ordin- \nary precursor of meningitis, hydrocephalus, and cerebral apo- \nplexy. It is generally characterized by one or more of the \nfollowing \n\nSYMPTOMS. High excitement of the cerebral functions, \nvertigo, headache, delirium, morbid vigilance, or its opposite, \nstupor or drowsiness, confusion of mind, loss of memory, feel- \ning of weight and fullness in the head, roaring and buzzing in \nthe ears, confusion of sight, and other evidences of deranged \nvision, nausea and vomiting, and in some cases spasms and \nconvulsions, or the opposite condition of muscular weakness \nand paralysis. \n\nETIOLOGY. The chief predisposing causes of cerebral hy- \nperemia are : overrichness of the blood, or a plethoric condi- \ntion of the system,the sanguineous temperament, the cessation \nof growth, and the change of life. Among the more common \nexciting causes are : exposure to heat and cold, suppressed \neruptions, rheumatism and gout, excess in eating and drink- \ning, determination of blood to the brain, excessive mental la- \nbor, moral emotions, excitement of the passions, and mechan- \nical injuries. \n\nTreatment. As in passive congestion of the brain,the first \nthing to be done is, as far as possible, to remove or lessen the \nexciting cause. This of itself will frequently produce entire re- \nlief. Hence, all excess in eating and drinking, the excitement \nof the passions, mental and bodily labor, and everything cal- \nculated to excite the circulation, or affect the mind, should be \ncarefully avoided. \n\nTHERAPEUTIC INDICATIONS. \n\nAconite. Headache, with fullness and heaviness, as from a \nweight, throbbing and piercing pains in ^the head, forehead \nand temples ; heat and redness of the face and eyes, excess- \n\n\n\nCEREBRAL HYPEREMIA. 43 \n\nive photophobia, flashes of light, roaring in the ears, tempo- \nrary blindness, vertigo, aggravation of pains by movement, \nmore or less relief in the open air. \n\nAconite though generally inferior to Belladonna in cerebral \nhyperaemia, is perhaps the best remedy for that condition when \ncaused by violent emotions, such as anger or fright. \n\nArnica. Heat and burning in the head, with coldness of \nthe body, throbbing headache in the forehead and temples, \nincreased by warmth or exercise, nausea and vomiting, verti- \ngo, delirium, loss of consciousness, tendency to apoplexy. \n\nArnica is always the best remedy for congestion of the \nbrain of a traumatic origin, or when produced by mechanical \nviolence, such as falls, blows, etc. \n\nBelladonna* Sense of weight and heaviness in the head, \nwith painful stitches, vertigo, delirium, loss of consciousness, \nredness of the face and eyes, roaring and humming in the \nears, dilation or contraction of the pupils, morbid vigilance,or \nits opposite, stupor, great sensitiveness to light and noise, \nspasms and convulsions. \n\nThis is by far the best general remedy for cerebral hyperae- \nmia, especially for children. \n\nBryonia. Compressive pain in the head, especially in the \nmorning, pain in both temples, pressing outwards, photopho- \nbia, buzzing in the ears, intolerance of light and noise, pain in \nthe head increased or caused by stooping, bleeding of the \nnose, drowsiness during the day and disturbed and unrefresh- \ning sleep at night, startings in sleep, with twitchings in the \nfacial muscles, skin alternately hot and moist, nausea or vom- \niting, constipation. \n\nThis remedy is especially indicated when the above symp- \ntoms are unrelieved by Aconite or Belladonna. \n\nCoffea cruda. Wakefulness at night; great nervousness and \nexaltation of the senses ; heat in the head and face, flushed \nface and cold feet; bleeding from the nose; buzzing in the ears; \ndiarrhcea. \n\nCoffea is well suited to infantile cases of cerebral conges- \ntion, especially when caused by teething or diarrhcea. \n\nGelseminum sempervirens. \\ Headache,extending from occi- \nput to root of nose,dull,pressive and stupefying; vertigo; dim- \n\n* See Amer^Hom. Observer, vol. ii.Zp.143; also new series ,vol. i., p. 384. \nt See American Horn, Observer, vol. ii., p. 164.J \n\n\n\n44 THERAPEUTIC INDICATIONS. \n\nness of vision; roaring in the ears; diplopia; amaurosis; sensi- \ntiveness to light; depression of spirits alternating with mirth- \nfulness; incoherency of thought, drowsiness, or its opposite, \nmorbid vigilance. \n\nGelseminum is an efficient remedy in cerebral congestion \ncaused by teething, mental excitement, sunstroke and cata- \nmenial suppression. \n\nMercurius. Sensation of great pressure and fullness in the \nhead, as though it would burst ; feeling as though the brain \nwas compressed by an iron band ; great anguish and restless- \nness, especially at night; pains in the head of a boring, tear- \ning, shooting character ; lachrymation and burning of the \neyes ; buzzing in the ears, with hardness of hearing ; vertigo. \n\nMercurius is particularly applicable to rheumatic, arthritic \nand syphilitic cases. \n\nNux Vomica. Cephalalgia, with nausea and vomiting; \nheaviness and confusion of the head ; soporose condition, with \na tendency to apoplexy, or the opposite condition of wake- \nfulness ; burning of the eyes; intolerance of light, especially \nin the morning; altered vision; ringing and roaring in the ears; \nvertiginous intoxication and cloudiness. Symptoms aggra- \nvated by eating, exercising in the open air, and by coffee. \n\nNux vomica is particularly suitable in such cerebral con- \ngestions as are caused by excessive mental labor, by the hab- \nitual use of intoxicating liquors, and by sedentary modes of \nlife. \n\nOpium. Coma, with apoplectic symptoms ; stertorous \nbreathing, confusion of the intellect, and sense of heaviness \nand pressure within the head, or the opposite condition of \nsleeplessness, with delirium, throbbing of the cerebral arte- \nries, redness of the face, scintillations before the eyes, hum- \nming in the ears, spasms, convulsions and paralysis. \n\nOpium is particularly indicated in those cases of cerebral \nhyperemia characterized by symptoms of depression, such as \nstupor, stertorous breathing, slow pulse, slow respiratory \nmovement, and dark, livid redness of the face, with coldness \nand paleness of the rest of the body. It is also particularly \nuseful in congestions caused by fright or debauchery. \n\nPulsatilla. Drowsiness in the daytime, and sleeplessness \nand great restlessness at night; vertigo; confusion of the head; \n\n\n\nCEREBRAL HYPEREMIA. 45 \n\noppressive, beating headache; red, bloated face; fiery circles \nbefore the eyes; diplopia; buzzing in the ears; bitter, bilious \ntaste in the mouth; nausea and vomiting. \n\nPulsatilla is most suitable to cases of cerebral congestion \noccurring in young females, especially when caused by de- \nrangement of the catamenia, It is also well adapted to cases \noccasioned or aggravated by a disordered stomach, or by a bil- \nious condition of the system. \n\nRhus tox. Heavy, reeling headache; shaking or wavering \nsensation in the brain, especially when walking, vertigo when \nlying down; red and burning, or pale and puffy face; drowsi- \nness in the daytime and restlessness at night. \n\nThis remedy is applicable to such cases as arise from, or \nare associated with acute articular rheumatism, and also to \ncases caused by exposure to cold, or to getting wet and \nchilled. \n\nVeratrum viride. * Violent throbbing headache, heat and \nfullness in the head, with throbbing of the cerebral vessels, \nthrobbing of the carotids, vertigo, flushed face, ringing in the \nears, double vision, sensitiveness to light and sound, derange- \nment of the stomach, palpitation of the heart, oppression of \nbreathing, weakness and diminished sensation in the limbs, \nwith spasms and tendency to paralysis. \n\nVeratrum vir. is one of the most powerful and efficient rem- \nedies for cerebral congestion, but nevertheless it requires to be \nused low to be effective. Its sphere of usefulness is similar to \nthat of Belladonna. \n\nDiet and Regimen. The diet should be plain and unstim- \nulating ; hence, every form of animal food, rich, or high-sea- \nsoned dishes, coffee, and other stimulating drinks, should be \ncarefully avoided. Moderation in eating and drinking, with \nregular habits, out-door exercise, bathing, early rising and \ncheerfulness, will facilitate recovery, and, so far as practica- \nble, should be observed in all cases. \n\nFor other remedies which may sometimes be found suita- \nble, see the following table ; also consult the therapeutic indi- \ncations and tables under the head of Cephalalgia. \n\n\n\n* See American Horn. Observer, vol. vii., p. 55. \n\n\n\n46 \n\n\n\nTABLE V. \n\n\n\nd s \n\nn d \nEq Ph \n\n\n\nd .2 \no S \n\nI\xe2\x80\x94 I HH \n\n\n\n\xe2\x80\x94 r-i x \n\n-2 ^H M \n\n\n\n\xc2\xa3 JS "S \n\n\n\nO r3 r-! \n\n\n\na a \n\n\n\na \n\n\nX \n\n\no \n\n\n3 \n\n\nti \n\n\nS \n\n\n\n\n\n\n\n\n\n\nd \n\n\n\n\n\n\nd \n\n\n-d \n\n\n0) \n\na \n\n\n3 \n\n\n\nS <2 \n\n\n\n\xc2\xab S5 \n\n\n\n\nS ? \xc2\xa3 \xc2\xa3 \n\n- _, _ _ \n\n\n\nbo rt bo \n\n\xe2\x80\xa2S \xc2\xa7 .2 \n\nH W H \n\n\n\n\na a> \n\n\n\nd H \xc2\xbb \n\n\n\nMS \n\n\n\ns s \n\n\n\na a \n\n\n\nM Ph W \xc2\xab \n\n\n\n\xc2\xab \xc2\xab Pw Pm \n\n\n\n\xe2\x96\xba \n\n\nO \n\n\nfs \n\n\no \n\n\n\n\n\n\ne3 \n\n\n^3 \nO \n\n\n3 \n\n\n32 \n\n\nH \n\n\nCO \n\n\n\nP-l PL, \n\n\n\n2 2 2 S \n\n\n\nto to o \n\na -2 s \n\ns I a \n\nS * 0) \n\nd m n \n\nPQ Pi P-. \n\n\n\n* g? \n\n\n\nPh <J \n\n\n\ng? I \n\n\n\nto to 3 c\xc2\xb0 \n\nd S3 ^ \n\n\n\nto to \xc2\xa3 \n\nG fl d \n\n>^ 3 2 to \n\n\n\nfl <l <) Pk \xc2\xab \n\n\n\n2 -& ft 2 *C 2 \n\n\xe2\x96\xa1 T: -r-< r\xc2\xab t? "-\xe2\x80\xa2 \n\n\n\nO fi \n\n\n\no -g \n\n6 3 \n\n\n\nP-. p-i \n\n\n\n2 \xc2\xa9 \n\n<J PQ \n\n\n\nPQ O \n\n\n\n\n\n3 \n\nI \n\na \n\n3 \n\n\n52 \n\na \nid \n\n\n\n\nc3 \n\n\n\n\nI \n\nX \n\nd \n\n\na \n\nd \nft \n\n\ng3 \n\n1 \n\n1 \n\n\n02 \n\nd \n\n\nc3 \n\n\n\xe2\x96\xa03 \n\ncc \n\n\n1 \n\n\na \n\n\nft \n\n\nO \n\n\na \n\n\nH \n\n\nB \n\n\no \n\n\nPh \n\n\nPh \n\n\nBQ \n\n\n> \n\n\n\nPRACTICE OF MEDICINE. 47 \n\nVERTIGO-STUPOR-INSOMNIA. \n\nThese morbid phenomena of the brain are frequently mere- \nly isolated symptoms, depending upon cerebral conditions the \npathology of which it is not always easy to settle, yet it is \noften of the greatest importance to do so. We shall endeavor \nin this article to point out the chief diagnostic signs by which \nthe several conditions in question may generally be satisfac- \ntorily determined. \n\ni. Vertigo, or giddiness, like cephalalgia, is generally \nsymptomatic of some affection of the brain or its membranes, \nof which it is sometimes the chief indication ; at other times \nit is associated with disorder of the stomach, or with other \n\nSymptoms, of which the following are the most promi- \nnent : headache, more or less violent, in the temples and fore- \nhead, aggravated by stooping, coughing, and mental exercise; \nbuzzing or roaring in the ears, vanishing of the senses, op- \npression of breathing, nausea, indigestion, constipation, pulsa- \ntion of the vessels of the head and neck, anxious expression \nof the countenance, which is pale and bloated or red and \nturgid, drowsiness during the day, and interrupted and unre- \nfreshing sleep at night. \n\nDIAGNOSIS. Atlantic vertigo generally attacks the patient \nin the morning, is aggravated by exercise, especially in the \nopen air, and is benefited by rest, particularly in the recum- \nbent position, and by food and stimulants. Hypercemic ver- \ntigo, on the other hand, seldom occurs in the morning, is of- \nten ameliorated by persevering exercise and is increased by \nmental labor, stimulating food and drinks, and the recumbent \nposition. \n\nEtiology. * The predisposing causes of anaemic vertigo \nare : mechanical obstructions, contraction or spasm of the \ncerebral vessels and organs, loss of animal fluids, etc. The \nchief predisposing cause of hyperaemic vertigo, on the con- \ntrary, is a plethoric condition of the system, with a redun- \ndancy of blood in the cerebral vessels. The exciting causes \n\n* See American Horn. Observer, vol. viii., p. 284 et seq. \n\n\n\n48 STUPOR \xe2\x80\x94 INSOMNIA. \n\nare : over-indulgence in eating and drinking, the free use of \nspirituous and malt liquors, coffee, and other stimulating bev- \nerages, excessive mental exercise, grief, indulgence of the pas- \nsions, sedentary occupations, etc. \n\nTreatment. This, of course, should correspond with the \npathological condition of the cerebral vessels, and is there- \nfore identical with that for Ancemia and Hypercemia of the \nBrain (which see); consult also Table XII., and the several \ndiseases of which this is a characteristic symptom. \n\nDIET AND Regimen. In anaemic vertigo we should pre- \nscribe a nourishing diet, moderately stimulating drinks, and \nmental and bodily repose ; while in hyperaemic vertigo, the \npatient should rise early, take daily exercise in the open air, \nmake free use of the flesh brush, observe regular habits, live \nsparingly, and carefully abstain from the use of every kind of \nstimulant. \n\n2. Stupor, or morbid drowsiness, is a condition of the \nbrain which closely resembles natural sleep, but differs from \nit in being far less under the control of the patient\'s will. It \nis of every degree of intensity, from slight drowsiness to \ncomplete coma, in which consciousness is entirely lost. Press- \nure upon the cerebral substance always produces it, and hence \nit is generally referred to that cause ; but careful investiga- \ntion shows that, like vertigo, it may depend upon exactly op- \nposite pathological conditions, being found associated with \nboth depression and exaltation of the cerebral functions\xe2\x80\x94 \nthat is to say, with both anaemia and hyperaemia of the brain \nand its membranes ; hence, the diagnosis, etiology and treat- \nment of this condition are similar to those of the affection \njust described. \n\n3. Insomnia, or sleeplessness generally results from irrita- \ntion or over-excitement of the brain, and, as we have seen, is \na prominent symptom of the hyperaemic condition of that \norgan. Certain stimulants, such as coffee and tea, exciting \nnews, joy, hope, etc., are sufficient to produce it in some indi- \nviduals ; while the sudden withdrawal of alcoholic stimulants \nto which the patient has long been accustomed, furnishes a \n\n\n\nCEPHALALGIA\xe2\x80\x94 HEADACHE. 49 \n\nstriking example of its occasional dependence upon the op- \nposite condition of nervous and vascular depression. The \nsame symptom is also frequently observed in cases of great \ngeneral debility, where depression rather than exaltation of \nthe cerebral functions is the apparent cause; Insomnia, there- \nfore, requires similar discrimination in treatment to that re- \nquired for vertigo and stupor ; indeed, there is in these affec- \ntions such a striking resemblance to each other in their path- \nlogical conditions, as well as in their causes and associated \nsymptoms, that notwithstanding the opposite character of the \neffects, the treatment required for each is similar and often \nidentical. * See Cephalalgia, Cerebral A nccmia and Hypere- \nmia, and the corresponding tables. \n\nCEPHALALGIA-HEADACHE. \n\nHeadaoh.9 is seldom an independent affection, but is gen- \nerally symptomatic of some other disease. Sometimes it de- \npends upon derangement of the stomach, constituting what is \ncalled sick headache ; at others it is associated with hepatic \ndisorder, constituting bilious headache ; and at others, it is \nsymptomatic of some intestinal, renal, uterine, cerebral or \nspinal affection. The most opposite conditions of the circu- \nlation produce it, such as active and passive congestion, ana> \nmia,or plethora. So, also, it may depend upon nervous irrita- \ntion, or nervous depression. Sudden cold, suppressed erup- \ntions, severe mental labor, excess in eating and drinking, \nrheumatism and gout, determination of blood to the head, \nand external injuries, are among the more common causes of \nthe affection, and require to be considered in the treatment. \nErrors of diet, also, frequently produce it, as well as the vari- \nous mental emotions, such as anger, grief, fright, anxiety, \nchagrin, and even joy itself. There are also nervous and hys- \nteric headaches, which are frequently symptomatic of uterine \nderangement\'; but these are sometimes dependent only upon \nfunctional disorder of the nervous system. \n\nTreatment. Most headaches may be readily cured by \nthe removal of the cause, and by quietude. Thus, if caused \n\n* See American Horn. Observer, vol. iii., p. 474. \n7 \n\n\n\n50 THERAPEUTIC INDICATIONS. \n\nby watching or by mental labor, simple rest is all that is re- \nquired. If caused by a derangement of the stomach, absti- \nnence from food for a short period will relieve it. So, also, if \ncoffee, beer, wine, or other drink, is the exciting cause, of \ncourse it should be laid aside, or medicine will do but little \ngood. \n\nTHERAPEUTIC INDICATIONS.* \n\nAconite. Compressive and stupefying pains, with a sensa- \ntion of fullness and heaviness in the head ; throbbing and \npiercing pains in the forehead and temples, congestive head- \nache, with heat and redness of the face, ringing in the ears, \nand redness, smarting or burning of the eyes ; vertigo, with \nnausea, especially when stooping, suddenly rising, or moving \nthe head; determination of blood to the head, with throbbing \nof the vessels of the neck, rapid pulse, and burning heat of \nthe face and scalp. Aggravation of the pains from move- \nment ; amelioration in the open air. \n\nAconite is a useful remedy for catarrhal, rheumatic and \nnervous headaches, also for those arising from determination \nof blood to the head. {Cerebral Congestion) \n\nBelladonna. Intense pain in the forehead ; feeling of full- \nness and pressure in the head, as though it would burst; vio- \nlent throbbing and sensation of fluctuation within the head, \nlacerating pains over the eyebrows; undulating shocks, extend- \ning from before backwards, and to either side; heaviness of \nthe head, producing a feeling of intoxication ; rush of blood \nto the head, with beating of the carotids, redness of the eyes, \nand buzzing in the ears; excessive sensibility to light and noise \nor clouded vision, with vertigo. {Congestive Headache) Ag- \ngravation of the symptoms by stooping ; partial relief by ly- \ning down. \n\nBelladonna is particularly applicable to cases of congestive, \ncatarrhal and arthritic headaches, especially when occurring \nin females, and persons of highly sensitive organizations. \n\nBryonia. Burning, beating headache, especially in the \nmorning and after meals; rush of blood to the head, with feel- \n\n* See American Horn. Observer, vol. viii., p. 33, et seq. \n\n\n\nPRACTICE OF MEDICINE. 51 \n\ning of compression, darting pains in the head, especially on \none side ; jerking, shooting and drawing pains through the \nhead, sometimes with nausea or vomiting ; pain in both tem- \nples, with pressure from within outwards ; heat and congestion \nin the head; with soreness of the scalp, aggravation by move- \nment. \n\nBryonia is most useful in those cases in which constipation \nis the principal cause of the headache. \n\nCalcarea carb. Semi-lateral headache, with nausea and \neructations ; throbbing, beating, or pressing pains in one side \nof the head, or in the forehead ; drawing, cramp-like pain in \nthe top of the head, with coldness of the forehead, headache \nevery morning ; aggravation by study, spirits, exercise, and \nmental emotion. \n\nEspecially suited to scrofulous subjects. \n\nChamomilla. Oppressive, drawing headache in one side, \nwith redness of one cheek and paleness of the other ; dull, \nheavy, throbbing headache, with hot perspiration of the scalp; \nnervous and hysteric headaches ; also, headaches caused by \ncold, or associated with catarrhal affections. \n\nEspecially adapted to irritable children. \n\nChina. Lacerating, darting, cutting, hammering, conges- \ntive headaches, especially when caused by debility, or by loss \nof fluids; hemicrania, with soreness of the scalp; aggravated \nby drafts of air, movement, or contact. \n\nCimicifuga. Throbbing and pressing pains in all parts of \nthe head, especially the occiput and vertex, and generally as- \nsociated with pain in the back and along the spine ; feeling of \nextreme fullness within the cranium, as though the skull would \nburst. \n\nAdapted to weak, nervous, hysterical females, especially \nwhen the catamenia are deranged ; also, to headaches caused \nby a debauch, or by excessive study. \n\nGlonoine. * Throbbing headache in the forehead, vertex and \nocciput; stitching pains in the temples, headaches arising from \nsuppression of the menses, from exposure to the sun, or from \nrush of blood to the head, especially when characterized by \nredness of the face and eyes. \n\n* See American Horn. Observer, vol. x. ; p. 477. \n\n\n\n$2 THERAPEUTIC INDICATIONS. \n\nIgnatia. Paroxysmal headache of a congestive character; \nbeating, hammering, or pulsating headache, attended by nau- \nsea, obscurity of vision, photophobia, or frequent micturition; \nalso, by soreness of the scalp and clavus. Pains are aggrava- \nted by coffee, wine, tobacco, noise, or mental emotion. \n\nIgnatia is particularly suitable for pale, irritable, hysterical \nfemales,especially in cases of hemicraniaor megrim; also,when \nthe pain is limited to a particular spot, with the sensation as of \na nail driven into the head. (Clavus) \n\nIpecacuanha. Headache with nausea, or sick headache; lac- \nerating pain in the forehead, attended by nausea or vomiting; \ntensive, aching pains extending as far as the neck and shoul- \nders ; sensation of soreness in the whole brain. \n\nSuitable after or in alternation with Nux vom. y especially af- \nter a debauch. \n\nMercurius. Tearing, shooting, boring pains in the head, \nparticularly on one side; digging, aching pains in the bones of \nthe skull ; syphilitic headache; heat and burning in the head, \nrheumatic headache ; shooting pains in the ears, neck and \nteeth; nightly perspirations which afford no relief; aggravation \nof the pains at night or when warm in bed. \n\nThis remedy is especially indicated in syphilitic cases, or \nwhen associated with eruptions on the scalp, falling off of the \nhair, or cranial exostosis. \n\nNux vom. Congestive headache, with sensation as of a \nnail driven into the head; lacerating pain in the forehead; \nheadache with nausea and vomiting, hemicrania ; headache \nfrom watching, excessive mental exertion, and the abuse of \ncoffee or spirituous li4uors ; also, catarrhal and rheumatic \nheadaches. \n\nEspecially adapted to violent, irascible dispositions, and \nparticularly after a debauch or when attended by constipa- \ntion. \n\nPulsatilla. Headache from indigestion, or from eating fat \nmeat ; headache attended with nausea from the presence of \nbile in the stomach ; beating headache, with vomiting of bile \nand mucus ; hemicrania, with shooting pains extending into \nthe ears and teeth ; lacerating, sticking pains in one side of \nthe head. Aggravation in the evening and when at rest ; \xe2\x80\x94 \namelioration by compression, and in the open air. \n\n\n\nTHERAPEUTIC INDICATIONS. 53 \n\nSuitable to females of mild disposition, especially when the \nmenses are scanty or deranged. \n\nSangninaria. Periodical sick headache, characterized by \ndaily, weekly, or monthly paroxysms, beginning in the morn- \ning, increasing during the day, and subsiding at night, and ac- \ncompanied with more or less nausea and vomiting. The pains \nare commonly sudden, sharp and severe, like electric strokes, \nand affect every part of the head, especially the forehead and \nocciput. Piercing, digging, lancinating pains, most severe on \nthe right side, accompanied by chilliness, nausea, bilious \nvomiting, and great sensitiveness to noise, light, touch and \nmotion. \n\nSepia. Paroxysmal hemicrania, occurring in violent shocks, \nespecially when connected with affections of the reproductive \nsystem ; throbbing, beating, tearing headache, frequently ac- \ncompanied by more or less heat, photophopia, nausea and \nvomiting ; headache caused by indigestion, especially in deli- \ncate females, or when associated with amenorrhcea, chlorosis, \nleucorrhcea, and other uterine derangements. \n\nStramonium. Spasmodic, beating headache, with obscura- \ntion of sight and dullness of hearing ; hammering in the ver- \ntex ; giddiness, with thirst, and disposition to faint ; conges- \ntive headache, with swelling and redness of the face and eyes. \n\nSulphur. Congestive headache, with throbbing and heat ; \npressure from within outwards, as though the head would \nburst, especially in the forehead ; jerking, shooting, or draw- \ning pains in one side of the head ; obscuration of sight ; par- \noxysms attended with nausea and vomiting. Aggravation by \nthinking, the open air, and by movement. \n\nEspecially suited to cases caused by suppression of erup- \ntions. \n\nREMARKS. \n\nCalcarea, China, Sepia, and Sulphur, are especially adapted \nto chronic cases, particularly when associated with some vice \nof constitution, or derangement of the organs of digestion \nand assimilation. Calcarea and Sulphur, particularly, are of- \nten indispensably necessary to effect a permanent cure, es- \npecially in very old, obstinate, and intractable cases. For \nfurther information consult the following tables. See also, \nTable V. \n\n\n\n54 \n\n\n\nTABLE VI. \n\n\n\n\xe2\x80\xa2Toy. Grief. ITrigh.t. Chagrin. Anger. \n\n\nw \nK \n\no \n\n1 \n\n> \nr 1 \n\n\n\' CHAMOMILL. \nIGNATIA \nAconite \n\nBelladonna \nNux vomica \n\n\' CHAMOMILL. \nLycopod. \n\nSepia \n\nNux vomica \n\nStaphysagria \n\n\' OPIUM \nAconite \nHyoscyamus \nSpigelia \n\n\' IGNATIA \nPhosphor, ac. \nNatr. mur. \nStaphysagria \n\n\' COFFEA \nOpium \nCrocus \nNatr. carb. \n\n\nACONITE \n\nBELLADONN. \n\nBRYONIA \n\nCHINA \nLACHESIS \nMERCURIUS \nNIT. AC. \nNUX VOMICA \nSULPHUR \n\nAlumina \n\nAmbra \n\nAnt. \n\nArnica \n\nAurum \n\nCalc. o. \n\nCannabis \n\nDulcamara \n\nGelseminum \n\nGlonoine \n\nIgnatia \n\nIodium \n\nKali \n\nLycopod. \n\nManganese \n\nMoschus \n\nNux vomica \n\nOpium \n\nPhosphorus \n\nPulsatilla \n\nChamomilla \n\nCoffea \n\nColocynth \n\nRhus \n\nSilicea \n\nSpongia \n\nVeratrum vir. \n\n\nQ \n\no \n\nc \nw \n\nm \n\n< \n\n\nNERVOUS. \n\nACONITE \nBELLADONN. \nNUX VOMICA \n\nChamomilla \n\nGelseminum \n\nHepar. \n\nSepr. \n\nValeriana \n\nArnica \n\nArsenicum \n\nAurum \n\nBryonia \n\nCalcarea \n\nCapsicum \n\nCimicifuga \n\nColocynthis \n\nCicc. \n\nCoffea \n\nChina \n\nCypr. \n\nGlonoine \n\nIgnatia \n\nIpecacuanha \n\nPetroleum \n\nPlatina \n\nPulsatilla \n\nRhus \n\nSilicea \n\nSpigelia \n\n\nHYSTERICAL. \n\nCIMICIFUGA \nCHAMOMILL. \nMOSCHUS \nVALERIANA \n\nArsenicum \n\nAurum \n\nCaul. \n\nCocculus \n\nGelseminum \n\nIgnatia \n\nLachesis \n\nMagn. \n\nMagn. m. \n\nNit. ac. \n\nPhosphorus \n\nPlatina \n\nSepia \n\nCapsicum \nRhus \nSpigelia \nVeratrum \n\n\nRHEUMATIC. \n\nACONITE \n\nARSENICUM \n\nBRYONIA \n\nCAUSTICUM \n\nCOLCHIUM \n\nLYCOPOD. \n\nMERCUR. \n\nNUX VOMICA \n\nPULSATILLA \n\nRHUS \n\nBelladonna \n\nCimicifuga \n\nLachesis \n\nLedum \n\nSepia \n\nSuLrnuR. \n\nArnica \nChamomilla \nChina \nIgnatia \nMagn. m. \nNitr. ac. \nPhosphorus \nSpigelia \n\n\nARSENICUM \n\nBELLADONN. \n\nBRYONIA \n\nCAUSTICUM \n\nCALC. C. \n\nPULSATILLA \n\nAconite \n\nArnica \n\nColocynth. \n\nIgnatia \n\nKali bic. \n\nSabina \n\nSepia \n\nSulphur. \n\nAurum \n\nCapsicum \n\nCicuta \n\nIpecacuanha \n\nManganese \n\nNit. ac. \n\nPetroleum \n\nPhosphor. \n\nVeratrum \n\nZincum \n\n\n> \n\n% \n\nB \nW \n\ns \n\n\nCATARRHAL \n\nACONITE \nBRYONIA \nNUX VOM. \nPHOSPH. \n\nPULSAT. \n\nBelladon. \n\nChamomil. \n\nMercur. \n\nSticta \n\nSulphur. \n\nArnica \n\nArsenicum \n\nCarb. v. \n\nChina \n\nCin. \n\nCimicifuga \n\nDulcamara \n\nIgnatia \n\nLachesis \n\nKali \n\nLycopod. \n\n\n!!!!!!! III? 1^ g|3g \n\n\n> \n\n2 \np \n\n\nBELLAD. \n\nCIMICIF. \n\nNUX VOM. \n\nPULSAT. \n\nAconite \n\nArsenicum \n\nCaul. \n\nIgnatia \n\nLachesis \n\nPlatina \n\nSepia \n\nBryonia \n\nCalcarea \n\nChina \n\nCocculus \n\nColocynth. \n\nDulcamara \n\nFerrum \n\nKali bic. \n\nMagn. \n\nNat. m. \n\nSpigelia \n\nVeratrum \n\n\nw \n3 \na \n\nH \n\n\nACONITE \nBELLAD. \nARNICA \n\nArsenicum \nCalcarea \nConium \nMercur. \n\nCicuta \nHepar. \nPetroleum \nRhus \nSulphur ac. \n\n\n\xe2\x96\xba3 \n\nd \n> \n\np \n\n\n\nH \nin \n\nn \n\n> \n\nX \n\nH \n\n\n\nTABLE VII. \n\n\n\n55 \n\n\n\nbo Ph \nE .-i \n\no tf \n\n\n\n\'g "s 1 1 \n\nco O co \xc2\xa3 \n\n\n\n5 .to \n\n\n\no u fc \xc2\xa3 \n\n\n\nbo \nC \nO \n\n\na \n\n\n5 \n\n*3 \n\n\n> \n\n\n\'5 \n\n\nO \n\n\nH \n\n\n\xc2\xa9 \n\n\n\n\n3 \n\n1 \n\n\n4-1 \n\ncS \nCD \nCO \n\n\n\xe2\x96\xa03 \n\n\n\n\n>> \n\n\n3 \n\n\na \n\n\nat \n\n\n\n\n\n\ncS \n\n\n\n\n\n\na! \n\n\no \n\n\nZ \n\n\n3 \n\n\nw \n\n\nq \n\n\n\nPi as \n\n\n\no -g \no -s \n\nco co \n\n\n\ni-3 P-. \n\n\n\n1 I \n\n\n\nP3 O \n\n\n\n0) \n\ng \n\n\n\n3 -H \n\n\n\n4 cq pq q o o \n\n\n\ncs o \n\n5 8 \n\n\n\n.5 J \n\n\n\nft 3 "S \n\n0) S ft \n\n\n\nfc K \xc2\xbb $ x oe r \n\n\n\n56 DISEASES OF THE ENCEPHALON. \n\nMENINGITIS. \n\nINFLAMMATION OF THE BRAIN AND ITS MEMBRANES. \n\nMeningitis is a term which strictly speaking, signifies in- \nflammation of the membranes of the brain ; but as it is gen- \nerally used to denote inflammation of both the brain and its \nmembranes, and as inflammation of the cerebral membranes \nseldom exist without involving, to a greater or less extent, \nthe substance of the brain itself; and since there are no char- \nacteristic symptoms that can be relied upon to distinguish \nthem from each other, we shall apply the term indiscrimin- \nately to both ; or rather we shall use it in its ordinary sense, \nto denote that exceedingly dangerous disease known as in- \nflammation of the brain. There is a form of it sometimes call- \ned tubercular or granular meningitis, depending on the pres- \nence of tuberculous deposits in the membranes of the brain, \nwhich being a separate affection we shall treat of under a dif- \nferent head. \n\nSYMPTOMS. Inflammation of the brain is divided into two \nwell defined periods, or stages, the disease being generally, \nbut not always, preceded by certain premonitory symptoms, \nsuch as vertigo, insomnia, ringing in the cars, loss of appetite, \nand general uneasiness. \n\nFirst Stage. The first stage begins with the usual symp- \ntoms of fever \xe2\x80\x94 such as chilliness, succeeded by heat, acceler- \ntion of the pulse, thirst, etc. To these are added, flushing of \nthe face, intense headache, a wild, staring expression of the \neyes^ vertigo, intolerance of light and sound, suffusion of the \neyes, ringing in the ears, restlessness, anxiety wakefulness, \ndelirium, spasmodic movements, contracted pupils, hot but \nsometimes moist skin, nausea and vomiting. The fever that \ncharacterizes it is of a high inflammatory type, attended by \na full, hard, and bounding pulse ; throbbing of the temporal \narteries, rapid and irregular breathing, throbbing, stabbing, \nand cutting pains in the head and extremities, rolling of the \neyes, excessive thirst, scanty and high colored urine, and con- \nstipation. \n\n\n\nMENINGITIS. 57 \n\nSecond stage. After the lapse of twelve, twenty-four, or \nforty-eight hours, and sometimes a week or more, according to \nthe violence of the disease, the second period ^r stage of col- \nlapse sets in. The headache now subsides, the delirium passes \ngradually into stupor or coma, the pupils become dilated, the \neyes dim and sunk in their sockets, the hearing greatly im- \npaired, the pulse small, rapid and intermittent, and the skin \ncold and clammy ; the convulsions subside into muscular re- \nlaxation or paralysis, and a general state of insensibility suc- \nceeds, which soon terminates in death. \n\nModifications. The symptoms are of course variously \nmodified according to the extent and violence of the dis- \nease, the age of tbe patient, and the nature of the exciting \ncause. Sometimes the disease begins and ends with convul- \nsions \xe2\x80\x94 at other times, pain in the head, delirium or coma, \nmay constitute the principal symptom. Indeed, no disease \npresents itself under a greater variety of forms, or with a \ngreater diversity of symptoms ; the latter, however, are gen- \nerally present in sufficient number, and are sufficiently char- \nacteristic, to make any mistake in the diagnosis both un- \nnecessary and inexcusable. \n\nEtiology. Among the exciting causes of this disease, \nmay be mentioned: external violence, teething, the suppres- \nsion of cutaneous eruptions, the translation of rheumatism \nor gout, venereal excesses, abuse of liquor, mental emotions, \nand certain fevers \xe2\x80\x94 such as typhoid fever, scarlet fever, and \nerysipelas. \n\nTREATMENT. The treatment of Meningitis is similar, and \nin most cases identical with that of Hyperaemia of the Brain. \nIn addition, therefore, to the Therapeutic Indications con- \ntained in the following Table (VIII), the practitioner should \nconsult the Indications and Tables given under the head of \nCerebral Hyperaemia. \n\nDIET AND Regimen. For the first few days the diet \nshould be restricted to such simple articles as toast water, \ngum-water, barley or rice-water, jellies, etc.; and until the \nstage of excitement is fully past, should be of the mildest \nand most unstimulating character. The room should be kept \ncool, quiet and well ventilated, and the patient as compos- \ned as possible. \n\n\n\n58 \n\n\n\nTABLE VIII. \n\n\n\nOD \n\nM \n\n< \n\nH \n\nS3 \n\n\nVomiting of bile; espe- \ncially indicated at the \ncommencement. \n\nEspecially suited to the \nlast stage. \n\nEmesis. Relaxation of \nsphincters. \n\nWorking of the jaws. \nOpisthotonos. \n\nLast stage, or when \ncaused by the reper- \ncussion of erysipelas. \n\nEspecially indicated aft- \ner retrocession of vesi- \ncular erysipelas. \n\nWhen caused by worms, \nor pseudo-meningitis. \n\n\n\'72 \n\n>\xe2\x80\x94 1 \n\n\nBurning, throb- \nbing or lanci- \nnating. \n\nThrobbing, sting- \ning and lacer- \nating. \n\nBoring, stinging, \nburning, lanci- \nnating or throb- \nbing. \n\nSharp and violent, \nor pressive and \naching. \n\nLacerating and \ncramp-like. \n\nPressing, gnawing, \nthrobbing, or \nlancinating. \n\nCramp-like. \n\n\n-A \nH \n\n>< \n\n\nRed and inflamed \nPupils contract- \ned or dilated. \n\nBurning, stinging \nand staring ; \ndimness of vis ; \npupils contract- \ned. \nRed and sparkling, \nwith distorted \norbs; pupils con- \ntr\'ted or dilated. \n\nRed and inflamed ; \nsparkling, or dim \nand glassy. \n\nStaring and in- \nflamed; pupils \ncontracted. \n\nFiery and spark- \nling, protruded \nand distorted; \ndimness of vis\'n. \n\nPupils dilated or \ncontracted; dim- \nness of vision. \n\n\n\n\nFull and hard. \n\nRapid, feeble and \nintermittent. \n\nSmall, quick and \nintermittent. \n\nQuick and hard, \nor slow and in- \ntermittent. \n\nFull and quick, or \nsmall and hard. \n\nFull and hard. \n\nGenerally quick \nand irritable\xe2\x80\x94 \nsometimes \ntrembling. \n\n\nSKIN. \n\nDry burning heat, \nErysipelas. \n\nBurning and \nSwollen\xe2\x80\x94 with \nor without \nMoisture. \n\nRed and burning \n\xe2\x80\x94Erysipelas. \n\nHot and burning, \nsometimes cold, \npale and moist. \n\nBlue or pale, Ery- \nsipelas. \n\nRed and burning, \nVasicular Ery- \nsipelas. \n\nBurning Heat, \nespecially of \nthe face. \n\n\nCO \n\n\xe2\x80\xa2A \nU \n\n\nSpasms, or Ten- \ndency to Para- \nlysis. \n\nSpasms- Paraly- \nsis. \n\nSpasms -Paraly- \nsis. \n\nCramps, Convul- \nsive Movem\'nts. \n\nCramps and Con- \nvulsions. \n\nTonic Spasms and \nConvulsions. \n\nCramps and Con- \nvulsions. \n\n\no \n\nCG \n\n\nDelirium, with \ngreat anguish. \n\nDelirium, Giddi- \nness or Insen- \nsibility. \n\nViolent Delirium \n\xe2\x80\x94 Loss of Con- \nsciousness. \n\nVertigo, Delirium \nor Sopor. \n\nVertigo, Loss of \nConsciousness. \n\nDelirium, Vertigo, \nor Insensibility. \n\nViolent Headache \nGiddiness, and \nDelirium \n\n\nREMEDY. \n\n\n\xe2\x80\x94 \n\nc \n\n< \n\n\nARSENICUM \n\nBELLADONNA.... \nBRYONIA \n\n\nC \n\n< \n\n\nm \nH \nQ \n\n< \n\xc2\xbb \n\n\n\n\n\nTABLE VIII \xe2\x80\x94 CONTINUED. \n\n\n\n59 \n\n\n\na 3 \n\n* m -2 \n\n\xc2\xbb 3 \xc2\xbb \n\npa I \n\n\'S oo o \n\xe2\x96\xa03.3 \n\n"IN \xe2\x80\xa2\xc2\xa7 \n\n2 \xc2\xab- a if \n\nH 5 \n\n\n\nSi \n\xc2\xa9\xc2\xbb-i \n.2 \xc2\xa9 \n\nSI \n\no o \n\n\n\n03 \xe2\x80\xa2 \n-* -8 \n\n-2g2 \n\n\n\n\n\n\n.5 00 \n\no \xc2\xa9 \n\nOK . \n\nft- 2 \nse \xc2\xa9a: \n\n\n\n-o^sS \n\n\n\n.5 a \n\n+s XT. -"-i \xc2\xa9 \n\nag^ga \n\n\n\nd > \n\n\xe2\x96\xa02-* \n\n\n\n3 \xe2\x80\x94 \n\n\n\nr s \n\n\n\n\n\n\nMm \n\n\n\n\xc2\xbb3 \xc2\xb0\xe2\x80\x94 ? \n\nif \xc2\xa3S^- \n\n\n\nR \n\n\n\n\xc2\xab5 tt \n\xc2\xa3,a o \n\nft fcc^ \nc3 g \n\nR \n\n\n\n2 -a \n2^ \n\n\n\n2 so h \nQ \n\n\n\nJ d \n\n2. a \n\n\n\ntL \xe2\x80\x94 \nS\xc2\xa3d \n\n\xe2\x96\xa09 MO \n\n\n\nS\xc2\xa7| \n\n\n\nSI \n\n\n\n\n\n\n[4,0 fe \n\n~ ,-d \n\nsis \n\nc c a \n\n\n\nd vr ^ \n\nc-9 a o \n\n= \xc2\xa3 ft-O \nK \n\n\n\n*3 \xe2\x80\x9efl \n\nIf: \n\n\n\n\xc2\xab ftIs \n\n\n\n-fcC \n\n\xe2\x80\xa2S3 \n\nP3 \n\n\n\n_ o \n\ng.\xc2\xa73is \n\n\xe2\x80\xa2O \xc2\xb03 u\' \nG~ O \n\nd a \n\n\n\ngo -o \n\n\n\nIK \n\n\n\n\'w \xc2\xa9IR \xc2\xa9 \n\n\xc2\xa9ca ftc \n\n\n\n<3 \xe2\x96\xba\xc2\xbb\xe2\x96\xa0* \xc2\xa9T3\' \n\nu d tt d n \n\n^ 5 \xc2\xa9 5 \xe2\x96\xa0 \n\nJ|*J a^2 \n\n\n\no \xc2\xab \n\nsag \n\n-a = \xc2\xab Q \n\n111! \nIs-as \n\n\n\na \xc2\xab -\xc2\xab \xe2\x80\x94 .- \n\n\n\nIS \n\nIP \n\n3 o d \n\n\n\n-f- i - \n\nCO \n\n\n\ng d\xc2\xae \n\ns 6fl \ns ^^ \xe2\x80\xa2 \n\nO o S -u \n\n\n\n3 &>? S \n\n\n\n^ \xc2\xa9.3 \n\n-a \n\n\n\n*\xc2\xab \n\n\n\nX ? <D \n\n3 O d \nC3f \n\n\n\nc \n\nII. \n\n\n\n\n\n\n1% \n2rf \n\n\n\n\n\n\nd d . \n\nft**- 1 aj \n\n\xe2\x96\xa011 \n\nC 0= M \n\n\n\n\xc2\xb0ss \n\n\n\n\xc2\xbb tc \n\n^ft \n\nn \n\n\n\n\n\n\nT3 u \n\xc2\xa9 O \n\n\n\n5 * \n2\xc2\xa9 \n\nr3_ft \n\nd >, \n\n\n\n\xe2\x80\xa2era A s \n\xc2\xa9 c \xc2\xa3 o \n\n"\xc2\xa7*fti \n\nc \xc2\xa9 - - \n\n\n\n\'S s-i _- p \n\nfl o s \xc2\xa9 \n\nd ,g ft \n\n\xc2\xa9"Z! \xc2\xa9 \n\n\xe2\x96\xa0aoi-i \n\n\xc2\xa322* \n\n\n\nd \n\n\xc2\xa9 d \xc2\xa9 \n\nH ft^ \n\nd O 05 \n\n\n\nttO \n\n\n\n\xc2\xa9I \n\n\xc2\xa9 > \n\n\n\n\xc2\xab5"aT \n\na a \n\n00 O 03 \n\nft^\'l \ngaPn \n\n\n\n\xe2\x96\xba \xc2\xa9 \n\nIs I \n\nas\xc2\xa9 \n\n\n\n\xc2\xa9^3 \n\ns 4 \n\n\n\nS d \n\ne M \n\noc \n\xc2\xa3.03.2 \n\nC G 03 \n\nc o >> \n\n\n\n3 03 \n\n> >> \n\ngd \n\nC h \n\nC d \n\n.ft- \n\n\n\nC u \nOPn \n\ntxaf \n\na a . \n\na c 0: \n\xe2\x96\xa0\xc2\xa3 "3 a \n\n\n\n\n\n\naa \n\na: O \n\n\n\n> d \n\n\xc2\xa9 a S \n\xe2\x80\xa2a o d \ngo P. \n\n\n\nas \n\n\n\no >> \n\n\xe2\x96\xa0ss \n\n\xc2\xa9 \xc2\xa9 \ngo \n\n.a 05 \n\n>- 33 \n\n3 O \n\n\n\nw\xc2\xa9 \n\n\n\n\n\n\n\xc2\xa9 d \n\n\n\n\xc2\xa9\xe2\x80\xa2ts \n\n\n\nCC\'_J2 \n-\'73 \n\n\xc2\xa9i-t \n\n\n\n^ a \n\n\n\ng\xc2\xab^ \n\n\n\n^__3 P . 03 \xc2\xa9 \n\na d \xc2\xa9 a 3 c .a \n\n"C 03 _ \'\xc2\xa3\xe2\x96\xa0 icjai i>> \n\nS \xc2\xa9 d s\'Sic+j \n\no3+j v,\xc2\xabda3 \n\nQ Q \n\n\n\n60 Diseases of the encephalon. \n\nCEREBRITIS-ENCEPHALITIS. \n\nINFLAMMATION OF THE SUBSTANCE OF THE BRAIN. \n\nCerebritis and Encephalitis are terms commonly used to de- \nnote partial inflammation of the substance of the brain, in \ncontradistinction to general inflammation of that organ, which \nseldom or never occurs without involving the cerebral mem- \nbranes, particularly the pia mater and arachnoid coats, and \nis therefore described under the head of Meningitis. \n\nThis disease is not only confined to a limited portion of the \ncerebral substance, but it is also generally of a more or less \nchronic character. It is, however, sometimes acute, particu- \nlarly if the inflammation involves a considerable portion of \nthe cerebral mass, in which case the inflammation passes rap- \nidly through its several stages, and may soon terminate in co- \nma, convulsions, paralysis, or death. Even when the inflam- \nmatory process is limited to a very small portion of the brain, \nit may prove speedily fatal, in consequence of the particular \npart affected; as, for example, the corpora pyramidalia of the \nmedulla oblongata, or the part contiguous to the pia mater \nand arachnoid membranes. \n\nPathology. Inflammation of the substance of the brain \ngenerally begins with exudation between the fibres situated \nalong the boundary separating the cineritious and white sub- \nstance. Sooner or later, owing to the vascular structure and \nhighly organized nature of the organ, the exudation results in \ndisorganization of the cerebral textures, producing at first \nwhat is called red softening from the presence of blood in the \nbroken down tissues, which gradually changes to yellow soften- \ning by reabsorbtion of the coloring matter of the exudation. \nSometimes, for reasons difficult to explain, the exudation \nchanges to pus, into which also, the implicated tissues are \nconverted, forming cavities or abscesses in the brain, which vary \ngreatly both in size and number. These abscesses generally \nresult from injury of the cerebral substance, but do not always \ncorrespond to the seat of injury. They are subject to a variety \nof terminations. Sometimes they become enclosed in cysts of \nfalse membrane, which, by limiting the extent of the inflam- \nmatory process, prevent any further disorganization of the \n\n\n\nGEREBRITIS \xe2\x80\x94 ENCEPHALITIS. 6l \n\ncerebral texture ; at other times they make their way into the \nventricles, or to the surface of the brain, producing inflam- \nmation of the investing membranes, and death. \n\nAbscesses of the brain, however, do not always terminate \nin death, as cases sometimes occur in which there is every \nreason to conclude that the purulent matter has been absorb- \ned ; cicatrices having been found in the brains of old people, \nwhich could only be accounted for in this manner. \n\nAmong the various pathological states incident to this dis- \nease is that of ulceration, which, however, is of comparatively \nrare occurrence. The ulcers, which vary in size from a few \nlines to several inches, are situated, for the most part, on the \nexternal surface of the brain, seldom penetrating beyond the \ngrey substance. The tissues immediately surrounding the \nulcers, as well as the adjacent membranes, usually exhibit \nsigns of inflammation ; and occasionally they are found to \ncommunicate with deep-seated abscesses. \n\nEncephalitis of a very chronic character, instead of produc- \ning softening or ulceration of the cerebral substance, sometimes \ngives rise to a state of permanent i?idnration of the part af- \nfected. The old writers relate many such cases of partial in- \nduration, all of which were of a very protracted nature. In \nsome cases the affected parts were unusually red and vascular; \nin others, they were of a pearly whiteness, and of different de- \ngrees of density, from that of semi-concrete lymph to that of \nfibro-cartilage. \n\nSYMPTOMS. The various pathological conditions above de- \nscribed, prepare us to expect a great diversity of symptoms \nin different cases; they are likewise found to be extremely \nvague and unreliable. We have already stated that the dis- \nease may assume more or less of an acute character from the \nbeginning, especially when large portions of the brain are im- \nplicated. In such cases the disease generally involves the me- \nninges of the brain, and runs a rapid course. In other cases, \ncomparatively large portions of the cerebral tissue may be \naffected without its functions being proportionately, or to any \ngreat degree, disturbed. Even when the initial symptoms are \nmost complete, they are not always sufficiently pronounced to \n\n\n\n62 CEREBRITIS \xe2\x80\x94 ENCEPHALITIS. \n\nenable us, at the outset of the disease, to distinguish it with \nany degree of certainty from other inflammatory affections of \nthe brain. \n\nFirst stage. The patient is generally attacked with severe \ndeep-seated pain in the head, commonly of a continuous, but \nsometimes of a paroxysmal character, which frequently pre- \ncedes all other symptoms. Afterwards, and sometimes from \nthe very commencement, other symptoms are experienced, \nsuch as vertigo, dimness of vision, buzzing in the ears, dispo- \nsition to faint, nausea and loss of appetite, hesitancy of \nspeech, wandering pains in the limbs, sensation of numbness \nor tingling in various parts of the body, with heaviness \nand cramps in the extremities, and an unsteadiness of gait, \nbetokening the approach of paralysis. This constitutes the \nfirst stage, beyond which there is but little, if any hope of \nrecovery. \n\nSecond stage. Although the general health is now more or \nor less impaired, the ordinary absence of fever, and of any \nderangement of the intellect, prevents, as a general rule, ap- \nprehensions of impending danger, until at last the patient is \nsuddenly seized with stupor, insensibility, and paralysis. \xe2\x80\x94 \nFrom this condition the patient may so far recover as to ex- \nhibit some signs of intelligence, but some degree of drowsi- \nness, apathy and mental weakness, as well as loss or impair- \nment of the special senses, remains. This is called the second \nstage ; and is characterized at its close by rigid contractions of \nthe flexor muscles of the paralyzed limbs. This condition of \nrigidity, or tonic spasm, is supposed to indicate the process of \nsoftening of the cerebral tissues. \n\nThird stage. If the patient survive the second stage of \nthe disease, the rigidity of the paralyzed muscles gradually \ngives way, and is succeeded by the opposite condition of re- \nlaxation and flaccidity. This marks the third stage, or that \nof complete paralysis, in which the affected portion of the \nbrain has become wholly disorganized and broken down. The \npatient now, either suddenly or gradually, sinks into a state of \nprofound coma, from which the system never rallies, and \ndeath sooner or later closes the scene. \n\n\n\nCEREBRITIS \xe2\x80\x94 ENCEPHALITIS. 63 \n\nThe above is a very imperfect sketch of the history and\' \nprogress of this disease, which is marked at different stages \nwith more or less irregularity of function, fever, delirium, and \nspasmodic action ; giving rise to a diversity and succes- \nsion of symptoms in different cases, which constitute certain \nforms and varieties of cerebritis, that our limited space forbids \nus to describe. This, however, is quite unnecessary, since the \ndescription already given is sufficiently characteristic to ena- \nble the practitioner always to identify the disease with the aid \nof the following \n\nDIAGNOSIS. Cerebritis is liable to be mistaken in the first \nstage for meningitis, and in the succeeding stages for apo- \nplexy. In cerebral meningitis the febrile excitement is very \ngreat, and is attended with spasmodic and convulsive symp- \ntoms on both sides of the body, and without decided paraly- \nsis, succeeded by collapse. In cerebral apoplexy, on the \nother hand, there is generally a more sudden invasion and \nrapid progress of the disease, together with sudden and \ncomplete paralysis, unattended at first with spasmodic \nsymptoms. \n\nWith reference to convulsions, coma and paralysis, it should \nbe remembered, that partial congestion from moderate com- \npression will produce convulsions; while increased congestion \nfrom a greater degree of compression, will produce coma and \npartial paralysis ; hence the results of cerebral congestion \nalone are sometimes similar to those of cerebral inflamma- \ntion. The diagnosis, therefore, should embrace other symp- \ntoms than those of convulsions, coma, and paralysis, such as \ndelirium, altered pulse, altered pupils, etc. This hint will be \nsufficient in most cases to prevent any serious mistake in di- \nagnosis, even when the symptoms are more than usually di- \nverse and obscure. \n\nETIOLOGY. As already stated, partial inflammation of the \ncerebral substance is frequently the result of traumatic inju- \nries, such as blows, falls, etc. It is also caused by the growth \nof foreign bodies in the brain ; such as hydatids, fibrous, fibro- \ncartilaginous, and carcinomatous tumors, and the effusion of \nsanguinous, tuberculous and scrofulous collections. But the \nmost common causes are doubtless the same as those of sim- \nple meningitis ; of these, the depressing passions, long con- \ntinued and severe mental labor, and habitual drunkenness, are \nperhaps the most constant and powerful. \n\n\n\n64 CEREBRITIS\xe2\x80\x94 EN CEPHALITIS. \n\nTREATMENT. The treatment of cerebritis in the first stage \nor what is sometimes called irritative cerebritis, should be \nsimilar to that recommended for Cerebral Hyperaemia and \nMeningitis. So long as no insterstitial change has taken place \n\xe2\x80\x94 no metamorphosis of structure \xe2\x80\x94 we may reasonably hope \nto relieve the symptoms, which are simply those of congestion \nand inflammation. But when softening has once set in, with \nits formidable train of effects, the reactive powers of the sys- \ntem are either wholly lost, or too much injured and enfeebled \nto render any hope of permanent relief. Something, howev- \ner, is always expected to be done ; and the indications being \nsimilar to those mentioned under the head of Cerebral Apo- \nplexy, the prescriber is referred to that section. Additional \ntherapeutic indications and remedies may also be found under \nthe heads of Acute Hydrocephalus and Cerebral Concussion, \nthe symptoms of which frequently correspond to those of cer- \ntain forms and stages of chronic encephalitis, and therefore \nrequire the same remedies. \n\nWe will add, on the authority of Hempel, that Kafka has \nfor some years been in the habit of employing Glonoine ist to \n2d, with the best success in encephalitis, " When the symp- \ntoms of cerebral hyperaemia predominate, and the disorganiz- \ning metamorphosis is progressing!\' \n\nWe beg leave to take exception to the condition mentioned \nin the last clause as existing in the cases, though we have no \ndoubt whatever that Glonoine will prove a valuable remedy \nin the initial and purely hyperaemic stage of the complaint. \n\nKafka also relates a case in which, " Side by side with the \nsymptoms of cerebral hyperaemia, those- of cerebral softening, \nwith progressive increase of the morbid phenomejia, likewise co- \nexisted; and in which, after the hyperaemic condition had been \nrelieved by the employment of Glonoine and Belladonna. \xe2\x80\x94 \nArsenicum was used apparently with marked success. If \nit be possible for entire recovery to take place in this disease \nafter metamorphosis of the cerebral tissue has occurred, I have \nno doubt Arsenicum will prove an efficient remedy, not only \nbecause it is capable of producing decomposition of organic \n\n\n\nACUTE HYDROCEPHALUS. 65 \n\ntissues, but because its pathogenesis as exhibited in the cepha-. \nlalgia, vertigo, wandering pains, impaired sensibility of the \nlimbs, delirium, coma, lassitude, debility, trembling, and \nnumbness of the extremities, and the tetanic spasms, or pa- \nralysis, presents a perfect picture of cerebritis, and must, \ntherefore, be truly homoeopathic to that condition. \n\nIodium is another medicine which seems to have yielded \ngood results in some cases, and so far as the pathogenesis of \nthe remedy is concerned, is certainly appropriate, but we are \nobliged to confess that our experience with it in this class of \ncases has not been satisfactory. \n\nPlumbum, also, has been strongly recommended in cere- \nbritis, but so far, we believe, only on theoretical grounds. \n\n\n\nACUTE HYDROCEPHALUS. \n\nTUBERCULOUS OR GRANULAR MENINGITIS. \n\nIf the term used to designate simple inflammation of the \nbrain is etymologically inapposite, much more so is that which \nis generally employed to distinguish scrofulous inflammation \nof that organ, namely, hydrocephalus, or dropsy of the brain, \na condition belonging only to the chronic variety, since the \nlimited effusion of serum into the ventricles, which occurs in \nsome cases of this disease, is nothing like true dropsy, in \nthe sense in which that term is usually understood ; but as \nhomceopathists both recognise and treat diseases by symptoms \ninstead of names, the inaccuracy of the allopathic nomencla- \nture is of but little consequence. \n\nPATHOLOGY. Acute hydrocephalus is essentially a scrofu- \nlous inflammation of the brain ; at least, it is generally, if not \nuniversally, associated with a scrofulous or tuberculous con- \ndition of the system; indeed, the disease is chiefly characterized \nby deposits of scrofulous matter, in the form of millet-sized \ntubercles, or granules, in the meninges of the brain ; hence it \n\n\n\n66 PRACTICE OF MEDICINE. \n\nis sometimes called granular or tuberculous meningitis* The \ngranulations are of a greyish or yellowish-white color, similar \nboth in character and appearance to those which sometimes \noccur in ordinary miliary tuberculosis in other organs. They \nare located for the most part in the pia mater at the base of \nthe brain. It is only in a small proportion of cases that they \noccur elsewhere. This, however, it should be stated, is con- \ntrary to the original observations of Rilliet and Barthez, who \nfound them to occur most frequently upon the convex surface \nof the brain. The truth is, they are situated mainly along the \ncourse of the great vessels, particularly in the fissure of Silvius. \nIn some instances they are so closely aggregated as to coalesce, \nforming tuberculous masses of the size of a pea or bean. There \nis also to be found in the sub-arachnoidal space, adjoining the \nblood vessels, a jelly-like exudation similar to what occurs in \nsimple meningitis. There is generally much softening of the \ncerebral tissue around the ventricles, owing probably to the \neffusion into them of a greater or less quantity of serum. As \nalready stated, miliary granules, tubercles, and other evidences \nof scrofulosis, are generally found in other portions of the body, \nparticularly in the lungs, bronchial glands and peritoneum, \nproving conclusively that acute hydrocephalus is nothing more \nnor less than a true scrofulous inflammation of the brain, \xe2\x80\x94 a \nfact the knowledge of which is of the greatest consequence so \nfar as prognosis and treatment are concerned. \n\nSYMPTOMS. Acute hydrocephalus may occur at any period \nof life, but is almost wholly confined to infancy and childhood. \nIts course exhibits four different stages, or periods, the charac- \nteristic symptoms of which are so different, that, for the purpose \nof comparison, we present them in tabular form. (See pp. 68, \n69.) \n\nEtiology and Prognosis. Acute hydrocephalus is so \nexceedingly fatal, in consequence of the scrofulous diathesis of \n\n* See Am. Horn, 05s., vol. 7, p. 58. \n\n\n\nACUTE HYDROCEPHALUS. 6j \n\nthe patient, and the presence of tuberculous matter in the \ncerebral meninges, that the only chance for successful treat- \nment lies in its early recognition.* Hence it is of the utmost \nimportance that proper treatment be instituted during the pre- \nmonitory or congestive stage, as then the symptoms will gener- \nally be found to yield. At the same time we would caution \nthe practitioner always to be on his guard, since, in consequence \nof the strong predisposition existing in these cases, and the \nirritation caused by the presence of foreign matter within the \ncranium, there will be a constant tendency to relapse upon ex- \nposure to any exciting cause, such as falls, blows, exposure to \ncold or heat, the irritation produced by worms or teething, \nrapid jolting or exercise, the repercussion of cutaneous erup- \ntions, ordinary attacks of fever and inflammation, or indeed \nanything calculated to quicken the circulation and cause a de- \ntermination of blood to the brain. Hence the greatest care \nshould be taken in such cases to keep the child quiet ; to guard \nagainst external violence or undue excitement of any kind ; to \n\npromote the general health by gentle passive exercise ; and to \nregulate the motions of the bowels and the functional activity \nof the skin by diet, bathing, friction, etc., with the greatest \ncare. \n\nDIAGNOSIS. The disease with which acute hydrocephalus \nis most apt to be confounded is simple meningitis, which some- \ntimes bears so close a resemblance to this affection as to render \nit extremely difficult to distinguish it from the scrofulous va- \nriety. Doubtless the most certain diagnostic sign is the co- \nexistence of a general scrofulous condition of the system. If \nthere should be no external marks of scrofula, no hereditary \ntaint, nor any signs of disease within the chest or abdomen, \nthere is reason to hope that, however characteristic the brain \nsymptoms may appear to be, the inflammation is simple ; on \nthe other hand, when such evidences of scrofulosis exist, there \nis great reason to fear that the disease is granular meningitis. \nWhen, in addition to the scrofulous or tuberculous diathesis, \nthe disease is protracted to two or three weeks, or more, the \nproof of its scrofulous nature may be regarded as conclusive. \n\n\n\nSee Am. Horn. Obs., vol. vii, p. 59. \n\n\n\n6S \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\nin \n\no \n\nH \nPh \n\nen \n\nI \n\na> \n\n< \n\nCM \n\nw \nu \n\no \n\nP4 \n\nQ \n\nw \n\nH \nU \n\n<: \nI \n\nx" \n\ni\xe2\x80\x94i \n\nw \n\xe2\x80\xa2J \n\n<: \n\n\n\no \n\n\n\n\nJ \n3 \n\n\n\n\no \n\nB \n\n\n\xc2\xab \xc2\xa3 \n\n\n\n\n\n\n\n\n\n\n\n\n\n\no \n\n\n\n\n\n\n2 \n\n\n"3 \n\n\n\n\n\n\n\n\n\n\n\n\n< \n\nCO \n\n\n4> \n\nc \n\n3 \n.2 \n\n1 ti \n\no.S \n\n11 \n\n0) CO \n\n\n\n\n"o \no \n\n\nO \n\n\n73 >. \n\n\n\n\n\n\n4) \n\n3 \n\n\n\n\no < \n\n5 < \n\nft. \n\n\n\xc2\xb0 e * \n\n\nrt o \n\n\nH > \n\n4) ^ \n\nbb<u \n>>- . \n\n\xe2\x96\xa0 c o S \ng co rt \n\n\n\n\n\n\n^5 \n\nCO \n\nO \n\n4) \nO \n\n"o \nu \n\n\n\n\n\xc2\xab \n\nD \nO \n\n\n*J 4> \n\ns \n\no \n\n\nG \n\no \n\n\nEl \n\n\n\xe2\x80\x94 \'S \n\nrt"" \n\nE \n\n\na \n\n3 \n\n\n\n\n\n\no \n\'3 \n\n\n\n\no \n\n\nfa \n\n\n\n\nCfl \n\n\nPh \n\n\n\n\n\n\n- \n\n\n\n\n\n\n\n\n\n\n\n\n\n\nJjU^J \n\n\nE \n\n\nLm \n\n\n\n\n\n\nfc \n\n\n\n\n\n\n\n\n3 3 \xe2\x80\x94 \n\n\n\xe2\x80\xa23 \n\n\nJ3 \n\n\n4) \nO \n\n\n\n\nO \n\na \n\no \n< \n\nE- . \n\n\xc2\xab2 \n\nO H \n.,< \n\n2* \n\nK W \n\n\n13 C-S \n\xc2\xabS3:2 \n\nI\xc2\xabB \n\n3 vTG \n\n\n\'o \n\nE \n\n\n\n\n3 \n\n\nT3 \xc2\xab,2 \nrtjS\'-S \n\n11 1} \n\n\n4> CO \n\ny " \n\n\nc5 \n\n4) \n<*- \n\no \n\n\n\n\nCOfi \nO <" rt \nu \n\n\n4> \n\ne \n\n\n\n\na \nn \n\n\n\n\n4) \n\n> \n\n\nll \n3 \n\n\n3 \n\n\n\n\nw \n\nft. \n\nQ \nW \n\n\nco rt 3 \nCO * " \n\n\no \no \n\n\n\n\nT3 \xe2\x80\xa2\' l- 4) \n^rt\xc2\xa7 u \n\nc ? ao \n\n\n~T3 \nrt u \n\n\nE \n\no \n\nrt \n\n\no \n\nE \n\n\ns \n\n\nC \n\n\n>. \n\n\n\n\n\n\ns \n\n\n\n\n\n\n33 \n\n\nE- \n\n\nU3 \n\n\nA \n\n\n\n\nA \n\n\nH \n\n\n\n\n\n\n\n\nC\xc2\xab \n\n\n\n\n"*r \n\n\n4> \n\n\n\n\n\xe2\x96\xa0" \n\n\n"-^ ?? \n\n\n\n\n\n\n\n\n\n\n1 \n\ns \n< \n\n\nl\xc2\xa7 \n\n\n\xc2\xa3 \n\n\n\n\n\n\n_M\xe2\x80\x94 .5 \n\n\n\n\n\n\n\n\nrt \n\n\nJ \n\n\n\n\n\n\n\n\n\n\nia ba 4> \n\n\n\n\n\n\n\n\no \n\n\n\n\n13 10 \n\n\n>. \n\n\n\n\n\'e . \n\n- \xe2\x80\xa2- \n\n13 u \n\n\n.S E \no ^ o \n\n4) rt 4> \n\n\n\n\n\n\n\n\no \n\n\nz . \n\nM Cd \n\xc2\xab O \n\n" to \n\n\nrt - n \n\n10 u \n\n10 C13 \n\n\n.s \n\n\xe2\x96\xa03 \n\nrt \n\n\n\n\n> \n\n\n\n\n\n\nc \no \n3 \n\n\n. \n\n\n^ u c{ \n\n\n<*H \n\n\n\n\n\n\njj rt \n\n\n\n\n\n\n\n\n\n\no >\xe2\x80\xa2 \n\n\no3\xc2\xab \n\n\no \n\n\n\n\nrt >, \n\n\n\n\n>\xc2\xbb \n\n\n\n\n\n\n\n\nK o \nW h \n\nc < \n\n2 \n\n\nrt o\\jC \n\n|*& \n\n\nT3 \n\nc \n8*3 \n\n\n\n\nll \n>>\'Lo \nS rt \n\n\n\n\n\n\no \n\nc \n\n\n4) \n\nft \n\nJ: \n\nU] \n\n\nO . \nu \n\n\n_4> CJ-. \n\n\n\n\nI- O \n4) O \n\n\n\xe2\x80\xa2gS a \n\n\n3 \n\n\n\n\nJ- \n\n\n\'>. \n\n\n[I] \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nhi \n\n\nco \n\n\n> \n\n\n\n\n\n\nO \n\n\nrt \nCM \n\n\n\n\n\n\n\n\nQ \n\n\nW \n\n\njj U O (J \n\n\no ^* \n\n\n\n\nJ2-c \n\n\n3 O \n\n\n\n\n\n\nc \n\n\n\xc2\xab \n\n\n> \n\nH \n\nCO \n\nW \nO \n\nz \n\no \nu \n\n\xc2\xab w \no o \n.,< \n\n\xc2\xa3 \n\no \n5 \nw \n\nft. \n\n\nco C M O. \n\n^"\xe2\x80\xa2_3 4) uj \n^^S" 4) \n\ny rt u - \n\nrt- o g \nrt.3 \xc2\xa332 \n\nC B \xc2\xab \xe2\x80\xa2 \n\n|*co~\xc2\xa7 \n\n3 c- rt<i2 \n\n\nu E \n\n-a 3 \n\nrt \n\n^\xc2\xa3 \n\nrid H \nrt \xc2\xab \n\nd (o \n\n\n\n\nV > S \n\no o c \n*\xe2\x80\xa2\xc2\xa3 JJ \n\nI) X \n\n\xe2\x80\xa2g >>\'\xc2\xab \n\xe2\x96\xa0SI\'S \n\nco 3 rt \nv o - \n\nis! \n\n\no \n\nII \n\n5 4) \n\n&2 bi \n\nsis \n\n\n\n\n\n\n4) \n\nH \nft \n\n13 \nC \nrt n- \n\n4> O \n\nrt"rt \n\nC 4) \n\n\n\'3 \n\ncr \n\n13 \n\nC \nrt \n\n13 \n\n4) \n\nll \n\nc2 \n>> \n\n\xc2\xab\xe2\x80\xa2\xc2\xa7 \n\n4> E5 \no \n\n\nCO \n\n\n4)^ \nV \n\n\n\n\ns \n\n\nB\xc2\xb0* \n\n\n\n\n\n\nS^ \n\n\nE \n\n\nO \n\n\n\xc2\xa3 \n\n\n\n\no \na) \n\n\ns \n\n\n\n\n\n\n^ \n\n\n\xc2\xa7 \n\n\nw \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nS \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nH \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nb. \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\no \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nz \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\no \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nH \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nw \n\n\ns \n\nz \n\no \n\n\nz \n< \n\n\ng \n\n\n\n\n\n\nw \n\nco \n\n\n\n\n\n\n\n\n\n\n\n\no \nz \n\n\nu \n\n\n\n\n5 \n\n\n\n\nD \n\n\n> \n\n\n\n\n\n\n< \n\n\no \n\n\n\n\nPC \n\n\n\n\nir \n\n\n\n\n\n\nP- \n\n\n\n\nH \n\n\n\n\n\n\n\n\nft \n\n\n\n\nh \n\n\n\n\n\nACUTE HYDROCEPHALUS. \n\n\n\n6 9 \n\n\n\nS"8 \n\n\n\n,0.0 \n^ 3 \n\n\n\n?N \n\n\n\nS \xc2\xa3 5 \n\n\n\n\n\n\n... rt^\'S \n\n3 2 2 S \xc2\xab \n\nc \n\n\n\n\n\n\n* \xc2\xa3 3." \n\n> s o \n\nCo \n\nO G ^ \n\nIS \n\n\n\nWT3 C I .3T3 \n\n\xc2\xa3 0) O C \xc2\xab 3 \n\nSi ^.l-S \n\n\xc2\xab 3 s \n\n\n\n2 c \n\nO M \n\n\n\n71 M \xe2\x96\xa0/) C 2 \n\n\xe2\x96\xa0-\xe2\x80\xa2\xc2\xa3 41 O O \xe2\x80\xa2 \n\n\xe2\x80\x9e \xc2\xab E~ -IS \n\nm-5 8 ^^3 \n\nrt o o\'pVo s \n\xc2\xa3.,0 \xc2\xa30 rt \n\n\n\n5 rt \n\n\n\nP \xc2\xb0 \n\n\n\n.3 \xc2\xab \n\n\n\n.2 o \n\n3 * \n\n\n\nbP \n\n\n\n?\xe2\x80\xa2=\xe2\x96\xa0 C \xe2\x80\xa2" \n\n\n\n\xe2\x80\xa2- w o o-r o aw \n^"2-a\'Srt gs \n\n3 ~ w \xe2\x80\xa2" 4) O- 4> \n\nb/j \xc2\xab c c w rt ui \n3 1.. "0 u 0^3 c \n3 g>J3CJ Bo " \n\nci .- o e rt - o \n(/i<-\xc2\xab u\\3 -a o \n\nbfO ,\xc2\xabcu|!o \n\n.S S m! S c-co \ng-^.S\xc2\xa7S2S.S \n\n\n\no \n\n\n\n11 41 \n\n\xe2\x80\xa2\xc2\xab s \n\n\xe2\x96\xa0t. 41 \n\na \n<! \n\n\n\n\xc2\xa3 B 0_ \nO\'lufi \n\n\n\nS| \n\nII \n\nb a +j \n\n*E"S \n\n\xc2\xab*! \n\nrt"o r; \n<U U w \n\nbiu:\'-5 \n\n\n\n.gag- \xc2\xab\'g.- \n\n>\xc2\xab g M 3.c \n\n3 \xc2\xa3 u E\'tf, _ \xc2\xab \n\n\n\n\n\n\n_o \n\n.582 -Ss\xc2\xabuS,S \n\n\n\n\n\n\nc > \n\nO rt \n4-. 41 \n\n\n\n*\xe2\x96\xa0 a c* \n\nI\'f B \n\xc2\xab u: tj be \n\n.9-3 8.3 \n-jri rt\'^j= \n\n\n\no \xc2\xa3 u 3 >;E \n\n^aiof \n\xe2\x80\xa2o \xc2\xb0 E \xc2\xb0^^^ \xc2\xa3 \n\n3 \xe2\x80\x9e \nri o \n\n\n\n1 >> K^ 5- \n\n\n\n4) ., \n\n\n\n)S_>>0 \n\n\n\nB u, bJO^-p ^ 3 \n\n\n\nS-\'t >wSa \n\n\n\nui rt O \xe2\x80\xa2 - j_ O 4, \n.3 g . i> e \n\n^-3 ,ia \xe2\x96\xba \xe2\x80\x9e I \n\ni _\xe2\x96\xa0 t, 4J 41 ,0 \n\n"\xc2\xa3 rt bfido\'5 1 \n\n\n\nJO PRACTICE OF MEDICINE. \n\nTreatment. The remedies which will be found most use- \nful in the early stages of acute hydrocephalus are: ACONITE, \nBelladonna, Glonoine,* and Mercurius. Bell, alone, or \nthe alternate use of Aeon, and Bell., ox Bell, and Glo., in the first \nand second stages, and of Bell, and Merc, in the second and \nthird, with proper attention to hygienic influences, will often \nprove successful in arresting this very formidable disease. The \nspecial indications for the employment of these and other suit- \nable remedies, have already been given under the heads of \nCerebral Hyperoemia and Me?tingitis, whose symptoms corres- \npond to the curative stages of this disease, and to which \nreference should be made for the requisite treatment. Nor, \nconsidering the scrofulous nature of the affection, should the \nremedies suitable to that condition, mentioned under Scrofula \nand Tuberculosis, be overlooked. \n\n\n\nCHRONIC HYDROCEPHALUS. \ndropsy of the brain. \n\nChronic Hydrocephalus, unlike most chronic affections, \nbears no affinity whatever to the acute, the latter being \nan inflammatory disease, modified by constitutional and local \ncauses, while the former, as its name imports, is a true \ndropsy of the brain, consisting of an accumulation of water or \nserum within the ventricles and membranes of the brain. It is \nalmost entirely confined to children, and is both congenital and \nacquired. Congenital cases are comparatively rare ; and owing \npartly to mechanical violence, and, in some case, to defective \ndevelopment of the cerebral mass, generally prove fatal at the \ntime of birth. Extra-uterine cases generally manifest them- \nselves during infancy, or soon after birth, before the fontanelles \nare closed, and while the cranium is capable of expansion. \n\nEnlargement. The chief feature in these cases, and \nthat which first attracts attention, is the enlargement of the \n\n*A m. Horn, 05s., vol. vii, p. 60. \n\n\n\nCHRONIC HYDROCEPHALUS. 7 1 \n\nhead. This takes place gradually in every direction, except at \nthe base of the cranium, but is the most prominent in the \nfrontal, temporal and occipital regions. As a general rule, the \nface is but little, if any enlarged, so that the front and sides \nproject in such a manner as to give the head a remarkably \nwedge-shaped appearance, resembling an inverted cone or \npyramid. Sometimes, however, the enlargement takes place \nequally in every direction, giving to the head the appearance \nof an immense animated ball, too heavy to be supported with- \nout some external aid. \n\nSymptoms. Aside from the enlargement, which from the \nfirst is generally quite manifest to the eye, the earlier symp- \ntoms are sometimes difficult of recognition. The increased \nweight of the head, however, no less than the functional dis- \nturbance of the oppressed brain, give to the child a somewhat \nuncertain and tottering gait, which is characteristic of the dis- \nease. After a while the symptoms become more pronounced ; \nthe child becomes dull and peevish ; tremors of the limbs set \nin, so that he can no longer walk ; the senses gradually fail ; \nthere is more or less insensibility of the skin ; taste becomes \nperverted and weak ; the sense of smell is diminished ; dim- \nness of vision follows ; and finally hearing itself fails. The \ndigestive functions generally remain longer unimpaired, but \nthey, too, at last become involved ; vomiting occurs, and ema- \nciation, notwithstanding an increase in the amount of food, is \nlikewise produced. Costiveness and scanty urine are also at- \ntendant symptoms. At last, symptoms of paralysis set in ; \nthe eyes are turned to one side, the pupils are dilated, and \nvision becomes extinct. The rectum and bladder become im- \nplicated, so as to lose all control over their contents. Finally, \nafter successive attacks of spasms and convulsions, the paraly- \nsis becomes complete ; suffocative fits occur, during which the \nbreathing becomes labored and stertorous ; insensibility fol- \nlows ; the pulse becomes small, feeble and intermittent ; and \ndeath closes the scene. \n\n\n\n72 PRACTICE OF MEDICINE. \n\nPROGNOSIS. Although chronic hydrocephalus is gener- \nally fatal, it is not necessarily so. A large proportion of cases \nwill recover if taken in time and suitable treatment instituted. \nIndeed, there is no good reason why, at any period previous to \nthe consolidation of the cranium, it should not be as amenable \nto treatment as any other form of dropsy. \n\nTreatment. This is either general or local. Local treat- \nment has in the great majority of instances been productive of \nmore harm than good ; and may therefore be dismissed with \nbut a passing remark. Tapping is claimed to have permanently \nrelieved a few cases, but the ordinary result of the measure, as \nmight have been anticipated, has been to hasten, and some- \ntimes to cause a fatal termination, by exciting inflammation of \nthe brain and its membranes. " Methodical Compression." as \nit is called, by means of adhesive strips so applied as to pro- \nduce uniform compression of the cerebral mass, after the man- \nner of Barnard, has for the most part either proved entirely \nnugatory, or else been attended with dangerous consequences \nfrom compression of both the brain and the pericranial vessels; \nthe practice, however, still has its advocates, and is claimed by \nits author and others to have been successful in a number of \ninstances. It is only applicable to cases in which the bones of \nthe cranium are loose, and the vital powers weak, and even \nthen should be employed with the greatest caution, being \nabandoned whenever the symptoms of compression are aggra- \nvated by it. \n\nThe general treatment may be gathered from the fol- \nlowing \n\nTHERAPEUTIC INDICATIONS. \n\nArsenicum. \xe2\x80\x94 Swelling, particularly of the head and face ; \nvomiting on being raised up in bed ; impairment of the special \nsenses ; emaciation and muscular weakness ; constipation ; re- \ntention, or involuntary discharge of urine ; anxious and op- \npressed breathing at night, or in the evening, in bed. \n\n\n\nCHRONIC HYDROCEPHALUS. 73 \n\nCalcarea carb. \xe2\x80\x94 Scrofulous swelling ; old, pale and hag- \ngard look ; trembling and weakness of the limbs ; tottering \ngait ; emaciation and great physical prostration ; non-closure \nof the fontanelles ; constipation. \n\nHelleborus. \xe2\x80\x94 Dullness of the senses ; sopor; pale, yellowish \nface, with puffiness or swelling ; great weakness of the limbs ; \nspasms and convulsions ; small, feeble pulse ; suppression of the \nurine ; paralysis. \n\nMercunus. \xe2\x80\x94 Great restlessness ; swelling of the head ; dil- \natation of the pupils ; impairment of the senses ; spasmodic \nparoxysms; collapse of the system ; paralysis. \n\nPlumbum acet. \xe2\x80\x94 Heaviness of the head, with pressure as \nthough the skull was too full ; dropsy ; emaciation, weariness, \nand increasing debility ; nausea and vomiting ; trembling of the \nlimbs ; restlessness and sleeplessness, or somnolence and loss \nof the senses ; retention, or involuntary emission of urine ; \npulse, small and frequent, or slow and feeble ; constipation ; \nspasmodic paroxysms and paralysis. \n\nSilicea. \xe2\x80\x94 Scrofulous swelling of the head ; feeling as though \nthe head was filled with living things ; dullness of the senses ; \npale, swollen face ; suppression of stool and urine ; great pros- \ntration and muscular weakness ; suffocative breathing ; spasm \nof the limbs ; numbness, swelling and paralytic weakness. \n\nSulphur. \xe2\x80\x94 Scrofulous enlargement of the head ; heaviness \nand languor of the limbs ; trembling gait ; dullness of the \nsenses ; pale, bloated face ; emaciation ; constipation ; reten- \ntion of urine ; paralysis. \n\nZincum. \xe2\x80\x94 Small, weak pulse ; loss of consciousness ; cold- \nness of the body ; great weakness and heaviness in the limbs, \nwith tremor ; oppression of breathing ; constipation ; drowsi- \nness; heaviness in the head ; nausea with trembling and tend- \nency to paralysis. \n\nDiet and Regimen. \xe2\x80\x94 The diet should be light and nutri- \ntious, consisting of such articles as milk, oatmeal porridge, \n\n\n\n74 PRACTICE OF MEDICINE. \n\nwild game, lean, tender, broiled beef, oysters, and soft boiled \neggs, etc. Care should be taken to give the child the advantag- \nes of sufficient light, air and exercise, carefully guarding it from \nexposure to the action of all depressing agents, or to bodily or \nmental excitement. In short, everything possible should be \ndone to invigorate the body, and to guard against any prema- \nture development of the mental faculties. \n\nCEREBRAL APOPLEXY. \n\nThe term Apoplexy, from a Greek word, signifying / strike, \nis used to denote a sudden loss, more or less entire, of sensation, \nconsciousness, and voluntary motion, depending upon cerebral \npressure produced by congestion or extravasation within the \ncranium ; the circulation and respiration being continued. This \ndefinition is perhaps as perfect as any that can be framed ; yet \nthe attack is not always sudden, the condition sometimes set- \nting in gradually, even when produced by cerebral hemorrhage. \n\nPATHOLOGY. \xe2\x80\x94 All cases of true apoplexy are caused by hy- \nperaemia of the brain, by cerebral hemorrhage, or by sudden \neffusion of serum within the cranium ; hence some pathologists \nhave divided the disease into three varieties, the simple or con- \ngestive, the sanguineous or hemorrhagic, and the serous. These \ndistinctions, however, are of but little practical importance, since \nit is generally impossible to determine with certainty, previous \nto the death of the patient, which of the three conditions exist \nin any particular case ; and since, moreover, in consequence of \nthe pressure which they alike exert upon the brain, the symp- \ntoms in either case are similar. \n\nSome pathologists restrict the term apoplexy to cases of \ncerebral hemorrhage alone ; but although such cases are much \nthe most frequent, nothing is more certain than that death oc- \ncasionally occurs with all the symptoms of apoplexy, in which \nthe only observable lesions of the brain are : a greater or less \namount of hyperaemia of the cerebral vessels, or an abnormal \n\n\n\nCEREBRAL APOPLEXY. 75 \n\neffusion of serum into the ventricles, or into the cavity of the \narachnoid. As just stated, however, the most common lesion in \ncerebral apoplexy is hemorrhage, the blood being effused either \nupon the surface of the brain or its membranes, in the ventricles, \nor in the cerebral tissue itself. As would naturally be inferred, \nthe principal seats of hemorrhage are those portions of the \nbrain most abundantly supplied with blood vessels, such as the \ncorpora striata, optic thalami, etc. The quantity of blood ef- \nfused varies from a few drops to several ounces. It is some- \ntimes infiltrated into the adjoining tissues, producing more or \nless suppuration, laceration and softening of the cerebral struct- \nure; but generally it is collected into one or more separate \ncavities, corresponding to the points of rupture in the cerebral \nvessels. The extravasated blood gradually undergoes absorp- \ntion, disappearing in some cases in the course of five or six \nmonths ; in others it becomes encysted and may continue sev- \neral years. The number of coagula generally corresponds with \nthe number of sanguineous effusions which have at different \nperiods occurred ; no less than a dozen clots, in different stages \nof absorption, having been found in the same brain. These \nfacts are of the greatest interest and importance, as showing \nhow nature at once sets up a process of reparation, which if \nproperly encouraged, and not interfered with by depletion, or \nother depressing treatment, is capable of effecting a complete \nrestoration of the injured organs. \n\nETIOLOGY. \xe2\x80\x94 The chief predisposing causes of cerebral apop- \nlexy are inheritance and old age. Statistics show that it attacks \nthe descendents of apoplectic parents much more frequently \nthan others, owing either to a similarity of physical conforma- \ntion, or, which is more likely, to some inherited weakness of \nthe system, the existence of which in the parents constitutes the \noriginal predisposition to the complaint. Old age, however, is \nthe principal predisposing cause, and is doubtless the most pow- \nerful, as the great majority of cases occur beyond the age of \n\n\n\n76 PRACTICE OF MEDICINE. \n\nfifty. Hence, people advanced in life, especially if they are, or \nhave been very hard thinkers, or addicted to excesses of any \nkind, are very apt to be cut off in this manner. For these reas- \nons, women, whose habits of life are generally more regular \nthan those of men, are less liable to the complaint. Cardiac \naffections are supposed to favor the disease by causing more or \nless hyperaemia of the brain, and when other circumstances con- \ncur to produce it, no doubt they contribute to the result. The \nsame may be said of the state of the system denominated \nplethora, arising from free living and sedentary habits. \n\nAlthough the exciting causes of cerebral apoplexy are \nnumerous, they can be reduced to a very few heads. Whatever \ntends to produce congestion of the brain, such as exposure to \nthe sun\'s rays, violent mental emotion, heavy lifting or strain- \ning, hard coughing or vomiting, playing upon wind instruments, \nexcessive venery,the free use of alcoholic stimulants, compression \nof the vessels of the neck, dependent position of the head, as in \nin stooping, etc. To these may be added repelled eruptions, an \noverloaded state of the stomach, the sudden suppression of \nhabitual discharges, and exposure to either excessive heat or \n\ncold. \n\nDIAGNOSIS. \xe2\x80\x94 Cerebral apoplexy is liable to be confounded \nwith both syncope and coma. In syncope, however, the sur- \nface is pale and cold, the features are contracted, the pulse is \nlost at the wrist, and the respiration is suspended ; in apo- \nplexy, on the other hand, the very reverse occurs. Coma, from \nthe great resemblance of its symptoms to those of apoplexy, \ncan only be distinguished from it by the cause, which in cases \nof apoplexy generally depends upon sudden pressure on the \nbrain, while in other cases it is symptomatic of narcotic poison- \ning, inebriation, cerebral inflammation, hysteria, etc. The diff- \nerences between these affections and true apoplexy are so \ngreat, that notwithstanding the similarity of their general ap- \n\n\n\nCEREBRAL APOPLEXY. 77 \n\npearance, a mistake in diagnosis would be alike discreditable to \nthe practioner and injurious to the patient. No such error, how- \never, can occur if sufficient attention is paid to the symptoms. \n\nPROGNOSIS. \xe2\x80\x94 Cerebral apoplexy is always a serious disease, \nand, sooner or later, generally proves fatal. This is especially \ntrue of cases caused by effusions or extravasations within the \ncranium. On the other hand, cases depending on cerebral \nhyperemia merely, without serous effusion, vascular extravasa- \ntion, or other lesion, may be regarded favorably. But as it is \nusually impossible, particularly soon after the attack, to deter- \nmine these questions with any degree of accuracy, the progno- \nsis is always more or less doubtful. \n\nAs a general rule, it may be stated, the danger to life is \nproportional to the extent of the paralysis ; and is greatest \nwhen, in addition to the mental functions, the paralysis involves \nthe organs of circulation and respiration. Among the more im- \nportant signs threatening a fatal issue are : protracted coma, \nconvulsions, general paralysis, dilated pupils, obstructed respir- \nation, foaming at the mouth, frequent vomiting, coldness and \nclamminess of the surface, and involuntary evacuations. Still, \nif the vital powers are husbanded, the patient may possibly sur- \nvive even these formidable symptoms, though it must be con- \nceded, that if the patient escape for the time, he is very liable to \nsink sooner or later, either from a recurrence of the attack, or \nby a general failure of the vital powers resulting from the injury \ndone to the brain. If, however, the patient survive the first on- \nset of the disease without any subsequent aggravation of the \nsymptoms, there will always be room for hope, even when ex- \ntravasation of blood has taken place. But it should be remem- \nbered in this connection, that about the eighth or tenth day of \nthe seizure is a critical period, for then inflammation sets in \nabout the clot, and may destroy the patient. \n\n\n\n78 PRACTICE OF MEDICINE. \n\nSymptoms. \xe2\x80\x94 In the majority of cases, the attack is preced- \ned by certain premonitory symptoms, such as pain in the head, \nringing in the ears, impaired vision, giddiness, loss of memory, \ndrowsiness, and other evidences of cerebral hyperaemia ; to \nwhich are added, in many cases, more or less numbness, or \npricking, in the extremities. In other cases, the patient, pre- \nviously in apparent health, falls down insensible, with a total \nabolition of the sensorial functions, or manifests a momentary \napprehension of impending danger, by raising his hands to his \nhead, and making some alarming exclamation, at the very in- \nstant of falling. The degree to which the sensorial functions \nare affected varies. In very severe cases, sensation, conscious- \nness, and voluntary motion, are all lost ; in others, there is a \ngreater or less degree of senso-motory impairment, the patient \nbeing in a state of semi consciousness, sensible to outward im- \npressions, and capable, to some extent, of voluntary move- \nments. The pupils are at first generally contracted, frequently \nin an unequal degree ; but in some cases they are largely dila- \nted, and insensible to the stimulus of light. More or less \nparalysis is associated with the attack, however light the stroke. \nGenerally, one side of the body is motionless, constituting \nhemiplegia. The tongue is twisted towards the paralyzed side, \ndeglutition is lost, or greatly impaired, respiration is slow and \nheaving, and the breathing loud and stertorous. Constipation \nand retention, or involuntary discharge of urine, are also attend- \nant symptoms. Though the power of voluntary motion is gen- \nerally entirely lost, there is sometimes more or less rigidity or \nspasmodic contraction of the muscles, confined, of course, to the \nunparalyzed side. The pulse is sometimes slow, full and bound- \ning ; at other times it is weak, small and intermittent. In the \nformer case, there is more or less heat and flushing of the face, \nwith warmth of the extremities ; in the latter, the face is pale \nand shrunken, and the extremities cold. \n\n\n\nCEREBRAL APOPLEXY. 79 \n\nTREATMENT. \xe2\x80\x94 During the paroxysm the patient should be \nkept in such a position as will favor the return of blood from \nthe head. The head and shoulders should be raised by pillows ; \nthe clothing loosened about the neck and chest, and obstructed \naccess of cool air to the patient\'s chamber at all times secured. \n\nThe lower extremities should be kept warm by means of \nfrictions, warm foot baths, flannel wrappings, etc. ; and the \nbowels emptied from time to time with lavements of tepid wat- \ner, to which may be added, if necessary, a tablespoonful or two \nof sweet oil. Attention, also, should be paid to the bladder, \nand the urine drawn off with the catheter whenever necessary. \n\nDiet and Regimen.\xe2\x80\x94 In the early stages of the attack, \nthe diet should consist exclusively of gum water, barley or rice \nwater, toast water, and such like farinaceous drinks ; but as the \ncase advances, and improvement sets in, more nutritious sub- \nstances may be cautiously administered, such as milk, soft \nboiled eggs, beef tea, etc., provided no ill effects are thereby \nproduced ; but if, on strengthening the diet, the face becomes \nflushed, and headache ensues, all stimulating articles of diet \nshould be immediately withdrawn. \n\nTHERAPEUTIC INDICATIONS. \n\nArnica. \xe2\x80\x94 Drowsiness, with moaning and insensibility ; \neyes staring and dim ; pupils contracted or dilated ; pulse full \nand strong ; respiration labored and snoring ; involuntary \nevacuations of faeces and urine ; paralysis, especially of the left \nside. This remedy is suitable for cases depending either upon \nextravasations or determinations of blood. \n\nBaryta. \xe2\x80\x94 Drowsiness, semi-consciousness, or coma somno- \nlentum ; obscuration of vision ; pulse small and irregular ; \nbreathing short and suffocative ; frequent discharges of urine \nand faeces ; paralysis, especially of the right side ; mouth and \ntongue drawn to one side ; great restlessness and moaning. \n\nBelladonna. \xe2\x80\x94 Drowsiness, stupor, loss of consciousness ; \n\n\n\n80 PRACTICE OF MEDICINE. \n\neyes red and staring ; pupils dilated ; pulse full and slow ; \nbreathing labored, irregular and stertorous ; convulsive move- \nments ; paralysis of limbs, tongue, etc. ; involuntary discharges \nof faeces and urine ; redness of the face and icy coldness of the \nextremities. \n\nCocculus. \xe2\x80\x94 Vertigo, stupor, and loss of consciousness ; spas- \nmodic rolling of the eyes, with the lids half closed ; dimness of \nvision ; pupils contracted or greatly dilated ; pulse small and \nhard ; breathing tight and oppressed, with snoring; frequent \nevacuations ; convulsions and paralysis, especially of the lower \nlimbs ; and strong determination of blood to the head. \n\nLacliesis. \xe2\x80\x94 Drowsiness, sopor and insensibility ; eyes dim \nand distorted ; pulse small, weak and irregular, or full and hard ; \nrespiration labored, with slow, heavy, whizzing breathing ; bow- \nels generally constipated ; trembling of the muscles ; paralysis, \nespecially of the left side ; and congestion to the head, with \nblueness of the face. \n\nLaiirocerasiis \xe2\x80\x94 Insensibility, with complete loss of con- \nsciousness and sensation ; eyes distorted and staring ; vision \nlost ; pupils contracted and immovable ; pulse small, slow and \nirregular ; convulsions, with subsequent paralysis, including \nparalysis of the sphincters ; great coldness, with deficient \nsusceptibility to the action of remedial agents. \n\nMercnrins. \xe2\x80\x94 Vertigo and loss of consciousness ; dilatation of \npupils, with vanishing of sight ; feeble, slow and trembling \npulse ; dyspnoea ; urine dark and turbid ; constipation ; spas- \nmodic movements ; paralysis ; great sinking and prostration. \n\nNux Vom. \xe2\x80\x94 Sopor, with snoring ; eyes dull and blurred ; \npulse full and hard, or small and collapsed ; suffocative fits, or \nanxious dyspnoea ; retention of urine; constipation ; paralysis, \nespecially of the lower limbs ; attacks preceded by vertigo, \nroaring in the ears, headache, etc. \n\nOpium. \xe2\x80\x94 Sopor, preceded by vertigo, cephalalgia, etc. ; \n\n\n\nCEREBRAL APOPLEXY. Si \n\npupils dilated and insensible ; pulse, slow, weak and intermit- \ntent ; respiration slow and snoring ; constipation ; retention of \nurine ; convulsive movements, with trembling of the limbs ; red \nand puffed face ; attacks preceded by cerebral congestion \ndisposition to sleep, and vacant look. \n\nPulsatilla. \xe2\x80\x94 Drowsiness and loss of consciousness ; eyes \ndull and bleared ; pulse very weak ; respiration impeded and \nrattling ; retention or incontinence of urine ; constipaticn ; ex- \ncessive debility and trembling ; crimson hue of the face, with \nswelling ; and, if occurring at or before the climacteric period, an \narrest or disturbance of the menstrual functions. \n\nStramonium. \xe2\x80\x94 Vertigo, stupor and insensibility ; pupils \ndilated and insensible ; pulse small, irregular and almost ex- \ntinct ; deep stertorous breathing ; frequent blackish stools ; \ninvoluntary emissions of urine ; spasmodic rigidity and trem- \nbling ; loss of sense and of voluntary motion, with suppression \nof all the secretions. \n\nZinc. met. \xe2\x80\x94 Great drowsiness, with frightful dreams, or \nstupor ; weariness, with vanishing of sight ; quick and irregular \npulse ; spasmodic dyspnoea ; retention of urine ; constipation ; \nparalytic weakness, heaviness and trembling ; cold hands and \nfeet, stupefying headache, and livid face. \n\n\n\nCOUP de SOLEIL ; SOLIS ICTUS-SUNSTROKE. \n\nSunstroke may be defined to be a paralysis of the cere- \nbral functions caused by heat, the result, generally, of long con- \ntinued exposure to the direct rays of the sun. It is a disorder, \nwhich, so far as the general symptoms are concerned, bears a \nclose resemblance to apoplexy ; indeed, until within a recent \nperiod, it has commonly been regarded as a species of that dis- \nease. Since, however, the term is used to denote two different \nconditions, namely, true sun stroke and ther7nic exhaustion, it is \n\n\n\n%2 PRACTICE OF MEDICINE. \n\nwell to remember, that while the former is distinguished by in- \ntense fever, the temperature ranging from 108 to 112 , togeth- \ner with symptoms denoting a profound depression of the ner- \nvous system, such as insensibility or loss of consciousness, dys- \npnoea, lividity of the face, stertorous breathing, coma, convul- \nsions, paralysis, etc. ; the latter, on the contrary, is character- \nized by faintness, or a tendency to syncope, a pallid countenance, \na pale, cool and moist skin, and a rapid but feeble circulation. \nSYMPTOMS. \xe2\x80\x94 The attack is generally preceeded by certain \npremonitory symptoms, such as excessive thirst, more or less \ngiddiness or vertigo, a sense of faintness, frequent disposition \nto urinate, stupidity, and sometimes drowsiness. The bowels \nare generally constipated, but sometimes diarrhoea occurs, es- \npecially in the case of children. Unless relieved, the patient \neither gradually or suddenly, falls into a state of insensibility, \nattended with coma, stertorous breathing, convulsions, etc. ; \nor he is attacked with syncope, which not unfrequently proves \nimmediately fatal. \n\nETIOLOGY. \xe2\x80\x94 A hot, moist* and close atmosphere, over \nexercise, tight and unreasonable clothing, the breathing of \nvitiated air, and whatever tends to produce suffocation, all con- \nspire to produce an attack ; especially if there be superadded, \ngreat bodily fatigue, a heated atmosphere, or prolonged expos- \nure to the direct rays of a tropical sun. Hence, soldiers serving \nin hot climates often suffer from sunstroke, their warm, tight- \nfitting uniforms, heavy accoutrements, and long, weary marches, \npredisposing to, and frequently precipitating such attacks, es- \npecially when exposed to the rays of a burning sun. \n\nDr. R. R. Gregg, of Buffalo, the author of what is known \n\n* " When the air is already charged with vapor, evaporation takes place slowly. Hence \nthe deadly nature of heat and moisture when combined. The evaporation from \nthe skin being checked the body has lost its power of cooling itself. In these facts is to \nbe found the explanation of the circumstance, that in the dry air of southern central Africa, \nsunstroke is least frequent, whilst it is most fatal in the moist climate of the low plains of \nIndia. Moisture in the air is therefore a favoring circumstance for the production of sun- \nstroke."\xe2\x80\x94 Dr. H. C. Wood, Jr. \n\n\n\nCOUP DE SOLEIL. 83 \n\nas the "vapor theory!\' assumes the cause of sunstroke to be \n" pressure upon the brain by vapor generated from the water of \nthe blood by the excessive heat of the body that exists in such \ncases." This may possibly be true, at least in some cases, but \nas it is a mere hypothesis, it is not entitled, in the present state \nof our knowledge on the subject, to any great weight. One \nthing, however, is certain, the true and only known cause of sun- \nstroke is heat, and heat alone, but the modus operandi of its ac- \ntion has not yet been demonstrated. \n\nPATHOLOGY. \xe2\x80\x94 As already remarked, the opinion was long \nentertained, that sunstroke is simply a form of congestive apop- \nlexy. Hence, the old, but generally fatal treatment by bleed- \ning. It is now known that the chief pathological state is one of \nextreme pulmonary congestion, the brain itself being in a nor- \nmal or nearly normal condition. This fact is well illustrated \nby the post-mortem appearances in the three fatal cases observ- \ned by surgeon Russel, of the 68th regiment of British troops \nstationed at Madras, and described by him in a communication \nread before the London College of Physicians, and afterwards \npublished in the Medical Gazette. " The brain," he says, " was, \nin all, healthy ; no congestion or accumulation of blood was ob- \nservable ; a very small quantity of serum was effused under the \nbase of one, but in all three tlie lungs were congested even to \nblackness througJi their entire extent ; and so densely loaded \nwere they, that complete obstruction must have taken place. \nThere was also an accumulation in the right side of the heart, \nand the great vessels approaching it."* In these, as in other \ncases, death resulted from asphyxia. \n\nTreatment. \xe2\x80\x94 The burning temperature of the surface, es- \npecially of the head and neck, should be reduced as quickly as \npossible by the free application of cold water, ice, cool air, etc., \nto the surface, at the same time that the great nervous depress- \n\n\n\n* Graves\' " Clinical Medicine," Th\'d. Am. Ed. s p. 118. \n\n\n\n84 PRACTICE OF MEDICINE. \n\nion, and consequent embarrassment of the circulation, is over- \ncome by the cautious administration of stimulents. Whenever \npracticable, the cold effusion to the head, neck and shoulders, \ncontinued until the temperature sinks to 98 or ioo\xc2\xb0, is the \nmost speedy and effective way of rescuing the patient from his \nstate of extreme danger. The same end, also, may be speedily \nand safely accomplished by the judicious use of warm water, so \napplied as to promote evaporation from the surface.* Thermic \nexhaustion on the contrary, and the various complications and \nsequelae, such as convulsions, nausea, vomiting, meningitis, etc., \nwill be best met by time \xe2\x80\x94 which is an essential element of cure \nin most cases \xe2\x80\x94 aided by suitable internal medication, agreeable \nto the following : \n\nTHERAPEUTIC INDICATIONS. \n\nAconite. \xe2\x80\x94 Burning heat, especially in the head and face, \nwith burning dryness of the skin, excessive thirst, redness of \nthe eyes and cheeks, restlessness and anxiety, nausea, vertigo, \nand headache aggravated by warmth. \n\nAconite is well adapted to relieve the sufferings excited by \nsunstroke, or by exposure to intense heat, and also to guard \nagainst the dangers of excessive reaction ; but it should never \nbe employed in a low form at least, until the period of greatest \ndepression is fully passed. \n\nAntimonium tart. \xe2\x80\x94 The leading indications for the use of \nthis remedy are similar to those given for Aconite, and it should \nbe used with the same precautions ; but it is more especially in- \ndicated when, in addition to those symptoms, there is much \ngastric disturbance, great prostration, languor and sense of ex- \nhaustion, or when attended with syncope, convulsions, or \nparalysis. \n\nBelladonna. \xe2\x80\x94 This remedy is indicated whenever brain \nsymptoms predominate, such as severe headache, vertigo, deliri- \n\n\n\nSee Am. Horn. Ois., vol. vi, p. 55. \n\n\n\nCOUP DE SOLEIL. 85 \n\num, sensitiveness to light and sound, great anguish, etc., and also \nwhen the attack is sudden, the patient falling down insensible, \nas in apoplexy, with coma, stertorous breathing, lividity of the \nface, and other symptoms of cerebral and pulmonary congestion. \n\nBryonia. \xe2\x80\x94 is indicated when, in addition to most of the \nsymptoms already mentioned, there is heaviness and weakness \nof the limbs ; when the slightest exertion occasions fatigue ; \nand when there is a marked tendency to syncope, or much un- \neasiness and apprehension ; also when there is great weakness \nof digestion, with more or less nausea, vomiting and diarrhoea, \nespecially in children. \n\nCamphor* \xe2\x80\x94 During the first stage, when great depression of \nboth the nervous and circulatory systems exist ; also, after re- \naction sets in, provided Aconite, Belladonna and Bryonia fail \nto relieve. \n\nGlo?ioine. \xe2\x80\x94 Intense headache, with throbbing in the front, \ntop and back part of the head, especially when followed by sud- \nden loss of consciousness. \n\nHelleborns. \xe2\x80\x94 Persistent headache, attended with drowsi- \nness, or other evidence of serous effusion within the cranium. \n\nHyoscyamus. \xe2\x80\x94 When attended with cephalalgia, sleepless- \nness, delirium, convulsions, syncope, enuresis, or diarrhoea. \n\nSilicea. \xe2\x80\x94 Frequent micturition, obstinate constipation, \ngreat thirst, nausea, vomiting, and other gastric derangements. \n\nVeratrum vir. \xe2\x80\x94 Thermic fever, with great heat of skin, \npersistent diarrhoea, violent dyspnoea from pulmonary en- \ngorgement, convulsions, paralysis, or syncope. \n\nDiet and Regimen. \xe2\x80\x94 Gastric derangements, disturbances \nof the circulation, and various cerebral affections, such as \nepilepsy, insanity and paralysis, resulting from the profound de- \npression of the nervous system, and consequent injury sustained \nby the great nerve centres, are among the more persistent \nsymptoms of sunstroke, and give rise to great physical prostra- \ntion, which often lasts for years ; calling for the exercise of \n\n\n\n86 PRACTICE OF MEDICINE. \n\nsound discrimination and judgment as to diet, clothing, exer- \ncise, climate, and other hygienic influences. The food should \nbe plain and of easy digestion, special regard being had to such \narticles of diet as are rich in phosphorus, such as fresh scale \nfish, raw oysters, corn and oat-meal pudding, Graham bread, etc. \nThe clothing should be carefully adapted to the season, and \nthe sensibility of the patient, being neither too thick and warm, \nnor too thin, since both heat and cold are oppressive and injur- \nious.* For this reason, the patient should, if possible, go north \nin summer, and south in winter; and this should be repeated, \nif necessary, from year to year, until such time as the patient \ncan bear the varying temperature of his own home. If this is \nimpracticable, underclothing made of soft buck-skin, or fur, may \nbe worn in winter, and such other precautions taken against the \neffects of cold and heat as the peculiar circumstances of each \ncase may require. Finally, the patient should be encouraged \nby the assurance, that but few cases are so hopeless that time \xe2\x80\x94 \nwhich, as already stated, is often an essential element of cure \xe2\x80\x94 \nwill not, in conjunction with suitable remedial measures, be at- \ntended with entire relief. \n\nCONCUSSION OF THE BRAIN. \n\nWe shall close our chapter on diseases of the brain, with a \nfew remarks on concussion, which though an injury instead of \na disease, requires medical treatment for its management, and \ntherefore belongs to the domain of medicine, rather than surgery, \nwhere it is commonly placed. \n\nConcussion may be defined to be, a shock communicated \nto the nervous system by some external violence, such as a \nblow or fall, whereby its functions are temporarily suspended, \nand the vital powers more or less depressed. Sometimes the de- \npression is very slight, and the patient quickly recovers ; at \nothers, the shock is so severe as greatly to impede the circula- \n\n\n\n* See Am. Horn. Obs., vol. ix, p. 210, et seq. \n\n\n\nCONCUSSION OF THE BRAIN. 87 \n\ntion and retard recovery; while at other times the depressed \ncondition continues, and the patient sooner or later sinks. In \nthe more severe cases, when the system rallies, vomiting is apt \nto ensue ; this is a favorable sign, as it tends by equalizing the \ncirculation to promote recovery. \n\nDEGREE OF INJURY. \xe2\x80\x94 As might be inferred, every degree \nof injury has been observed in fatal cases. Sometimes actual \nrupture occurs ; at others, a soft or semi-diffluent state is pro- \nduced ; while in other cases, even in those in which the shock \nand consequent depression are the greatest, no lesion whatever \ncan be discovered. In these cases, no doubt, the patient dies \nfrom the effects of the shock alone ; while in the others, the in- \njury to the brain interferes with the circulation through it, and \nthough the effects of the concussion upon the general system \nmay be no greater, the character of the injury is such as to \npermanently depress the vital powers,and death, sooner or later, \nis the inevitable consequence. \n\nFINAL RESULTS. \xe2\x80\x94 The final results of the injury are as \nvarious as the immediate effects. As we have said, some cas- \nes soon recover ; others rally slowly, the paralysed brain grad- \nually regaining its power and functions ; and the patient, after \nremaining, it may be, for hours in a cold and semi-moribund \ncondition, slowly recovering his activity and senses ; but suffer- \ning for a longer or shorter period from headache, confusion of \nthought, giddiness, and impairment of the mental powers. In \nother cases, again, should the patient survive the immediate \neffects of the injury, an irritable state of the brain may re- \nmain, or such an impairment of its functions, as to render it \nliable to inflammation under the operation of almost any ex- \nciting cause, such as excess in eating and drinking, mental \nemotion, etc. \n\nSymptoms \xe2\x80\x94 The symptoms of concussion are, generally, a \ngreater or less degree of pallor, coldness, flaccidity of the mus- \ncles, and insensibility. Commonly, all power of motion is \n\n\n\n88 PRACTICE OF MEDICINE. \n\nlost ; and if the patient is capable of being partially aroused, \nhe immediately relapses again into a stage of semi-unconscious- \nness or insensibility. In this stage the pulse is slow and feeble, \nthe pupils contracted, and the surface pale and cold. The sec- \nond stage is characterized by returning warmth and color, the \nrestoration of consciousness and the power of motion, and the \ngradual re-establishment of the circulation. This stage is gen- \nerally accompanied by more or less vomiting, depending upon \nthe severity of the concussion. The third stage is marked by \nextreme physical prostration, a cold, clammy, semi-moribund \ncondition, continuing sometimes for hours, and at last gradually \nyielding to recovery, or terminating in death. \n\nTreatment. \xe2\x80\x94 This should be directed, first of all, to over- \ncoming, as speedily as possible, the depression of the vital pow- \ners, being careful at the same time not to over-stimulate \nthe circulation, but simply aiming at the re-establish- \nment of the normal condition. This can generally be best \neffected by wrapping the patient in warm blankets, applying \nfriction to the surface, and using dry heat* to the extremities \netc. As soon as the patient is able to swallow, he may be al- \nlowed to drink moderately of simple warm teas ; but alcoholic \nstimulants should be carefully avoided, unless the depression is \nso great as to imperatively demand their administration, when \nthe quantity should be regulated by the exigencies of the \ncase. \n\nThe chief remedies for concussion, together with the lead- \ning Therapeutic Indications, are given in the subjoined \ntable. Consult, also, Table XII, and the Therapeutic In- \ndications, under the head of Apoplexy. \n\n\n\n* In the case of young children, the warm bath, or hot foot bath, may be used with the \ngreatest advantage, care being taken to prevent the patient getting chilled during its administra- \ntion ; but in the case of adults, dry heat is generally the handiest as well as the safest mode of \napplying heat to the surface, the patient being surrounded by hot bottles, or some equivalent \nsubstitute. \n\n\n\nCONCUSSION OF THE BRAIN, 89 \n\nTABLE XL \n\nCONCUSSION. \xe2\x80\x94 SYNOPSIS OF TREATMENT. \n\ni. Premonitory Symptoms. \xe2\x80\x94 Bell., Dig., Euphor., Hep. \nIgn., Phos. ac, Rut., Sulph., Verat. \n\n2. First Stage, \xe2\x80\x94 Arn., Ars., Cic, Cocc., Con., Laur., \nVerat. \n\n3. Second Stage. \xe2\x80\x94 Arn., Bry., Chin., Euphor, Hep., Ign., \nNux. v., Op., Phos., Rhus., Sulph., Verat. \n\n4. Third Stage. \xe2\x80\x94 Ang., Cic., Cocc, Con., Dig., Ign., Iod., \nMerc, Phos. ac, Rhus., Sulph., Zinc \n\n5. Muscular System. \xe2\x80\x94 Ang., Calc, Euphor., Iod., Phos. \nac, Puis., Sulph., ac. ; trembling \xe2\x80\x94 Aug., Cic, Cin., Hep., Ign., \nNux. v. ; spasms \xe2\x80\x94 Arn., Ars., Cocc, Con., Laur., Rhus., Sulph., \nVerat., Zinc ; paralysis \xe2\x80\x94 Ang., Calc, Cin., Euphor., Hep., Ign., \nPuis., Rut., Sulph. ac. ; tendency to paralysis. \n\n6. Sensorium. \xe2\x80\x94 Dig., Euphor., Hep., Ign., Phos. ac, Rut., \nSulph., Verat. ; giddiness \xe2\x80\x94 Aug., Cin., Con., Iod., Puis., Rhus., \nSulph. ac ; drowsiness \xe2\x80\x94 Arn., Ars., Calc, Cic, Cocc, Laur., \nMerc, Zinc. ; insensibility and u/iconsciousuess. \n\n\n\n90 PRACTICE OF M EDICINE. \n\nTABLE XII. \n\nCEREBRAL DISEASES AND REMEDIES. \n\nA. HYPEREMIA.\xe2\x80\x94 Acon., Arn., Bell., Bry., Coff., \nMerc, Nux. v., Op., Puls., Rhus., Verat., Anac,Calc,Cham. y \nChin., Con., Dig., Dulc, Ign., Ipec, Lyc, Phos., Sil., Sulph., \nCamph., Caps., Coloc, Hyos., Sep., Spig , Tart., e. \n\nB. ANEMIA.\xe2\x80\x94 Ars., Chin., Fer., Nat., Puls., Staph., \nCafe, Carb. v., Cin., Hep., Kal., Lyc, Lack., Merc, Nat. m., Nux. \nv., Phos., Phos. ac., Sep., Si/., Sulph., Verat., Arn., Bell., Bry., \nCham., Nit. ac, Rhus. \n\nC. VERTIGO.\xe2\x80\x94 Acon., Arn., Bell., Bry., Lyc, Nat., \nNux. v., Petr., Phos., Rhus., Calc., Camph., Cann., Carb. v., \nCocc., Dig., Graph., Ipec, Nat. m., Nit. ac., Op., Puis., Sec. c, \nThuja., Verat., Amb., Merc, Mosch.. Phos. ac, Strain. \n\nD. STUPOR.\xe2\x80\x94 Ant. t., Cro., Op., Verat., Ant. c, Bell., \nBrom., Camph., Cic, Con., Hell., Lact., Later., Phos. ac, Puis., \nPlumb., Stram., Zinc, Arn., Ars., Bar. c, Caus., Cocc, Dig., \nLach., Led., Phos., Sec. c, Sep. \n\nE. INSOMNIA.\xe2\x80\x94 Calc, Camph , Cham., Chin., Coff., \nKal., Lyc, Merc, Mosch., Puls., Rhus., Sep., Ars., Bell., \nBry., Cin., Con., Fer., Hep:, Hyos., Nat., Sil., S?dph., Aeon., \nAnac, Cann., Caus., Dig., Dulc, Ign., Lach., Led., Nat. m., Nit. \nac, Nux. v., Phos., Plumb., Sang., Spong., Thuja., Verat. \n\nF. CEPHALALGIA.\xe2\x80\x94 Acon., Bell., Cim., Coloc, \nGlon., Merc, Nux. v., Puls, Sang., Stram., Bry., Calc, \nCham., Chin., Igna., Ipec, Sep., Camph., Caps., Cupr., Con., \nDulc, Hyos., Op., Rhus., Sil., Spig., Sulph., Tart, e., Tong., \nVerb., Vio. t., Ver. v. \n\n\n\nCEREBRAL DISEASES. 91 \n\nG. MENINGITIS.\xe2\x80\x94 Acon., Bell., Bry., Hel., Hyos., \nOp., Stram., Sulph., Ars., Arn., Campli., Cauth., Chi., Con., \nCupr., Dig., Lack., Merc, Rhus., Coff, Crot., Glon., Nux. v., \nPhosp., Puis., Sil. \n\nH. CEREBRITIS.\xe2\x80\x94 Acon., Ars., Bell, Glon., Iod., \nPLUMB, Am., Bry., Hyos., Hep., Sulph., Con., Merc., Phos., \nRhus., Crot, Coff, Nux. v. Puis, Ver. \n\n/. ACUTE HYDROCEPHALUS.\xe2\x80\x94 Acon,, Arn, Ars, \nBell, Bry, Hel, Merc, Sulph, Cin., Con., Dig., Hyos., \nLach., Merc., Op., Stram., Coff., Nux. v. Puis, Ver. \n\nJ. CHRONIC HYDROCEPHALUS.\xe2\x80\x94 Ars, Calc, \nHel., Merc, Plumb, Sil. Sulph, Zinc, Apoc. a., Apoc. c, \nAscl. s., Collin, c, Dig., Equiset., Eup. p., Junip. Sumb. \n\nK. APOPLEXY.\xe2\x80\x94 Arn, Bar. c. Bell, Cocc, Lach, \nNux. v. Op, Puls, Acon., Anac, Ant. t., Coff., Con., Dig., \nHyos., Ipec, Laur., Merc, Strain., Zinc, Ant. c, Ang, Calc.) \nCin, Ign, Iod, Verat. \n\nL. COUP DE SOLEIL.\xe2\x80\x94 Acon, Ant. t. Bell, Bry, \nCamph, Glon, Helleb., Hyos., Sil, Ver. v, Carb. v., Nux. \nv.. Op., Thuj., Zinc, Amyl. n., Gels., Scut. 1. \n\nM. CONCUSSION.\xe2\x80\x94 Arn., Ang., Ars., Bell., Calen, \nCic, Con, Euphor., Hep., Merc, Petr, Puls., Rhus., Rut., \nSulph., Verat., Calc, Cin., Cocc, Dig., Ign., Iod., Laur-, Op., \nCoff-, Hyos., Ipec, Stram., Zinc. \n\n\n\n92 PRACTICE OF MEDICINE. \n\n\n\nCHAPTER II \n\n\n\nDISEASES OF THE PROSOPON, OR FACE. \n\nSECTION I. \n\nPROSOPALGIA, OR FACE-ACHE. \n\nTIC DOULEUREUX; NEURALGIA TRIGEMINI. \nAs we shall find it most convenient to describe the various \nforms of neuralgia in their anatomical, rather than in their \nphysiological relations, this will be the proper place to treat of \none of its most common and painful varieties, namely, prosopal- \ngia, or, as it is generally termed, tic douleureux y or face-ache. \nThis is, for the most part, an affection of the trigeminus, or \nfifth pair of nerves ; but inasmuch as the portio dura, after pass- \ning through the parotid gland, is connected with a twig of the \ntrigeminus, the pain is sometimes, though rarely, felt also in the \ncourse of that nerve. Commonly but one branch of the trige- \nminus, the superior maxillary of one side, is affected ; but not \nunfrequently two, and sometimes all three of the branches are \ninvolved ; and the pain, by implicating the opposite branches, \nmay even extend to the other side of the face. \n\nSymptoms. \xe2\x80\x94 As already stated, the most frequent form of \nprosopalgia is that involving the middle branch of the trigemi- \nnus. The pain is generally first felt in or near the infraorbital \nforamen ; and being seated in the nerve of that name, extends \nto the inner canthus of the eye, the lower eyelids, the muscles \nabout the zygoma, those of the cheek, especially the buccinater, \nthe upper lip and the alae of the nose. Subsequently the trunk \nof the nerve, and the branches given off from it in its passage \nthrough the infraorbital canal, become affected, the pains being \nfelt in the palate, tongue, zygomatic fossa, the upper teeth and \nthe nasal cavity. As the disease progresses, the pain may ex- \ntend, as in other forms of prosopalgia, to all parts of the face- \n\n\n\nPROSOPALGIA. 93 \n\nThe pain is never continual, but occurs in paroxysms of greater \nor less violence and duration. When fully formed, the \nparoxysms are frequently attended by a copious salivation. \n\nNext in order of frequency, the pain commences near the \nsupraorbital foramen, and extending outward along the branches \nof the frontal nerve and its ramifications, is experienced in the \nsoft parts covering the anterior portion of the cranium ; or it \nmay extend in the opposite direction along the trunk of the \nnerve, and be felt at the bottom of the orbit. Subsequently, \nthe tunica conjunctiva and adjacent parts become affected, pro- \nducing redness of the conjunctiva and lids, with more or less \nlachrymation and swelling. Sometimes it causes extreme \nphotophobia, the eye becoming so exceedingly painful and \nsensitive to light, that the patient can scarcely tolerate a single \nray. Finally, as in other cases, the pain passes beyond the \nparts supplied by the frontal nerve, extending itself to the \nsupraorbital, the maxillary, and sometimes, through communi- \ncating filaments, to the facial, temporal and occipital nerves. \n\nLess common than either of the preceding, but, when con- \nfirmed, equally intense and obstinate forms of prosopalgia, is \nthat affecting the inferior maxillary nerve. The pain is gener- \nally first felt at or near the anterior mental foramen, and ex- \ntends to the teeth, lower lip, chin, temple and neck. As in the \npreceding forms of the disorder, the associated branches of the \ntrigeminus, as well as the portio dura of the seventh, frequently \nbecome implicated, and then the paroxysms of pain become \nmore or less general over one side of the face and head. \n\nWhen the motor nerves become implicated, the muscles \nsupplied by them twitch convulsively, producing distortion of \nthe features, and, in some cases, more or less spasmodic action \nof more distant parts ; the latter being caused, doubtless, by the \nextreme pain. The irritability of the affected nerves frequently \nbecomes so great during the paroxysms, that the impressions \nproduced merely by movement, as in talking, sneezing and \n\n\n\n94 PRACTICE OF MEDICINE. \n\nchewing, or by currents of cold air, etc., are often sufficient to \nrenew the attacks. The pains are of a shooting, rending or \nburning character ; and when the paroxysm is at its height, \nthey frequently become so intolerable, that the patient is utter- \nly unable to suppress his cries. \n\nDIAGNOSIS. \xe2\x80\x94 Prosopalgia is very liable to be confounded \nwith hemicrania and rheumatism. From the former it may be \ndistinguished by the seat of the pain corresponding accurately \nwith the course and distribution of the affected nerves ; and \nfrom the latter, by the exacerbation being provoked by the \nslightest touch, by the limited duration of the paroxysm, and \nby the intolerable character of the pain. From ordinary tooth- \nache it may be distinguished by the transient character and \nrapid succession of the pains, the convulsive twitchings of the \nmuscles, and the coursing of the pains along the tracks of the \naffected nerves. With reference to those cases in which the \nportio dura of the seventh pair of nerves becomes implicated, \nthey are sometimes exceedingly difficult to distinguish from \nthose in which only the branches of the trigeminus are involved. \nThe chief difference is, the pains are no longer confined to the \ncourse of the trigeminus, but, in consequence of its communica- \ntion with the other nerves of the face, the agony soon becomes \ngeneral over the entire side of the head. \n\nEtiology. \xe2\x80\x94 The causes of this affection are generally \nvery uncertain and obscure. Sometimes, particularly when \nthe main trunk is affected, it can be traced to tumors, or \nbony growths, pressing upon the affected nerves ; and occa- \nsionally the attack can be satisfactorily referred to such \ncauses as wounds, decayed teeth, the suppression of accus- \ntomed discharges, rheumatism, gout, syphilis, poisonous \ncosmetics, etc ; but in the majority of cases, no known cause \ncan be assigned. Even the most careful anatomical and \npathological investigations generally fail of eliciting any satis- \nfactory explanation. True, the affected nerves are sometimes \n\n\n\nPROSOPALGIA. 95 \n\nfound red and inflamed, but the ordinary absence of fever, the \nsudden, transient, and intermittent character of the attacks, \ntheir frequent occurrence in debilitated states of the system, \nand the usual absence of tenderness on pressure, are suffi- \ncient proofs that the cause, whatever it may be, is not gen- \nerally of an inflammatory character. Probably the most fre- \nquent exciting cause is cold. Next to this, those causes which \ninduce cephalagia, such as mental emotion, severe mental and \nphysical labor, excess in eating and drinking, the abuse of \nspirituous liquors, tea, coffee and tobacco, excessive venery, \netc., no doubt contribute greatly to produce it in those who are \npredisposed to the affection. What particular class of persons \nare predisposed to it, however, is not so clear. It is doubtful \nwhether sex has any special influence in this direction, as some \nsuppose, though there are peculiarities in the female constitu- \ntion which undoubtedly predispose it to other forms of neural- \ngia, especially such as have their origin in the spine. Probably \nwhat is called the nervous temperament, or an excitable dispo- \nsition, furnishes as strong a predisposing cause as any of which \nwe have any knowledge. \n\nPROGNOSIS. \xe2\x80\x94 The possibility, or even the probability of \na cure, depends upon a variety of circumstances. When caused \nby malarious influences, general debility, pernicious habits, or \nby cold, a cure is generally easily effected ; but when, on the \nother hand, structural changes, such as tumors and other morbid \ngrowths, give rise to it, there is but little hope of relief. Even \nin the milder forms of the disease, the patient frequently re- \nmains more or less subject to the complaint as long as he lives. \nDeath very seldom results from the attacks, however severe \nthe paroxysms ; but it always has a more or less pernicious \neffect upon the system, undermining the general health, and \nrendering the mind feeble and the nervous system extremely \nsensitive and irritable. \n\n\n\n96 PRACTICE OF MEDICINE. \n\nTreatment. \xe2\x80\x94 It follows from the purely subjective char- \nacter and limited range of the symptoms, that the treatment of \nprosopalgia needs to be conducted with special reference to \nthe cause. Hence it becomes necessary, first of all, to institute \na careful scrutiny into the general state of the patient\'s health, \nhis habits and surroundings, traveling, as it were, beyond the \nboundaries of the symptomatic indications,in order to ascertain, \nif possible, the true cause of the malady. In this way the pre- \nscriber is enabled to make his anatomical, physiological and \npathological knowledge contribute not only to the diagnosis, \nbut, in a large proportion of cases, to the cure of this obscure, \nobstinate and very painful disease. Even with all the light \nwhich can be thrown upon it in this manner, the practitioner \nwill often have great difficulty in selecting a suitable remedy, \nand will as frequently be disappointed ; but it is evident that \nin no other way, in many cases, can there be any reasonable \nhope of success. Thus directed, however, the symptomatic in- \ndications are generally sufficiently definite to suggest the prop- \ner remedy ; and, as a consequence, homoeopathy has produced \nmany brilliant cures in the domain of this opprobium medicorum \nof the old school. \n\nTHERAPEUTIC INDICATIONS. \n\nArsenicum. \xe2\x80\x94 Burning, stinging, or tearing pains in the tem- \nples and around the eyes ; inflammation of the conjunctiva ; \nwatering of the eyes ; great restlessness, distress and prostra- \ntion ; paroxysms occur, or are aggravated, in the evening or at \nnight. \n\nThis remedy is particularly useful when the attacks occur \nperiodically, or when they are caused by miasmatic influences. \n\nBellado7ina* \xe2\x80\x94 Pains of a cutting or tearing character, es_ \npecially when following the course of the infra-orbital nerve, and \n\n\n\n* See Am. Horn. Observer, vol. ii., p. 108; also vol. iii, p. 66. \n\n\n\nPROSOPALGIA. 97 \n\nmore particularly when associated with symptoms of vascular \nexcitement, such as heat, redness and swelling of the face and \neyes, flashes of light before the eyes, and lachrymation ; also \nwhen there are convulsive twitchings of the facial muscles, stiff- \nness of the neck, shooting pains in the jaws, zygomatic process \nand nose. The pains are excited or aggravated by rubbing the \naffected parts and by movement. \n\nBelladonna is especially applicable to cases caused by con- \ngestion or inflammation, particularly when produced by the \nabuse of mercury. \n\nChininum Sulph. \xe2\x80\x94 This remedy is preeminently adapted \nto cases pending upon miasmatic influences. Hempel says of \nit in these cases. "Say what you please against Quinine, it is \none of the most indispensable antidotes to the intermittent \ntype of paroxysms resulting from the influence of malaria. We \nhave so often and so satisfactorily cured prosopalgia with five \nor ten grains of Quinine, administered in grain doses every two \nhours during the apyrexia, that we can recommend its use to \nhomoeopathic physicians with all the earnestness of one whose \nknowledge is based upon the most unimpeachable experience, \nand we advise our friends not to mind the absurd twaddle of a \nfew antiquated ignoramuses, who would fain confine homoeo- \npathy to the narrow horizon of their own childish folly." \n\nAlthough a firm believer ourself in the homoeopathic prin- \nciple or cure, and, as a general rule,* in the adequacy of small \ndoses to overcome diseased action, we can nevertheless heartily \nsubscribe to these views of Prof. Hempel, deeming them by no \nmeans inconsistent with rational, that is to say, homoeopathic \npractice. On the contrary, as before inculcated, ( See the \nINTRODUCTION to this work ; also, remarks under the head of \nDiphtheria,) we should be greatly wanting in consistency, and \n\n\n\n* We say "as a general rule," because diseases depending upon mechanical, chemical \nand toxicological influences, frequently so overpower the vital force, as utterly to preclude \nthe possibility of exciting in the system any permanent reaction, so long as the exciting \ncause contimies to act upon it. In such cases, it is just as absurd to expect the dynamic forces \nalone to conquer as it is for a stream of water to seek a higher level than its source. \n\n13 \n\n\n\n9$ PRACTICE OF MEDICINE. \n\nalso, as we conceive, in a proper estimate of the true sphere \nof homoeopathy, did we not strongly endorse all that he says \non this subject. For whether the nervous system be primarily \naffected in this condition or not, it is generally admitted that, \nlike a string of a puppet, its action corresponds, both in charac- \nter and duration, to the special influences operating upon it. It \nis also admitted that Quinine is an antidote to the miasmatic \npoison. It follows, therefore, that it should be administered in \nsufficient quantity to antidote, or, if any one likes the expres- \nsion better, to counteract the poisonous principle, whether it be \nmild or severe. Nor does it alter the question, so far as the \nmatter of dose is concerned, whether, the action of the poison \non the nervous system is mediate or immediate ; whether, in \nfact, the poisonous principle acts primarily upon the blood, and \nthrough it upon the nervous system, thus derangeing its func- \ntions, or whether it acts in some other and more occult manner ; \nit is sufficient for us to know that a poison, sui generis, is affect- \ning the constitution, and that a true and sufficient antidote is \nneeded for it. \n\nColocynthis. \xe2\x80\x94 Darting and tearing pains particularly on \nthe left side of the face, with redness and swelling of the affect- \ned parts ; aggravated by the slightest touch, by cold, and by \nmovement of the facial muscles. \n\nThis medicine is of great use in catarrhal cases, or when \ncaused by mortified feelings, (Hartman), or by cold. \n\nGelseminum. \xe2\x80\x94 Darting pains, especially around the eye, \nor in the course of the infraorbital nerve and dental branches ; \nalso when there are twitchings and contractions of the facial \nmuscles, particularly of the eyelids ; or where there is great \nnervousness, a semi-paralyzed condition of the voluntary mus- \ncles, or a distorted appearance of the eye. \n\nThis remedy has been employed with marked success in \nperiodical cases, especially of the quotidian type, (LlJDLAM.) It \nis equally valuable in catarrhal cases, if used low. \n\nHepar Sulph. \xe2\x80\x94 Drawing and tearing pains in the cheek \n\n\n\nPROSOPALGIA. 99 \n\nand temple, sometimes extending into the ears, and aggravated \nby pressure and by warmth ; also, pains in the teeth, aggravat- \ned by contact or by eating. \n\nHepar sulphuris is suitable for cases caused by the abuse of \nmercury, as in salivation. \n\nIris Versicolor. \xe2\x80\x94 Prosopalgia involving all or any one of \nthe branches of the trigeminus, especially when associated with \n"sick-headache," beginning in the morning and subsiding at \nnight. \n\nKalmia* \xe2\x80\x94 Violent rending and drawing pains in the \ncheek, with redness ; darting pains in the jaws and teeth ; and \nthrobbing pains in the head. \n\nThis medicine is said to have acted with magical effect in \nmany cases of prosopalgia where all the usual remedies had \nfailed, (SNELLING.) \n\nMercurins. \xe2\x80\x94 Tearing, stinging or stitching pains, occur- \nring in the evening or at night, and aggravated by the warmth \nof the bed ; also, facial pains caused or aggravated by carious \nteeth, or by cold, particularly if accompanied by great rest- \nlessness, wakefulness, swelling, ptyalism, or perspiration of \nthe face and head. \n\nMercurius is an appropriate remedy in catarrhal cases; \nalso in those of an inflammatory character. \n\nMezereum. \xe2\x80\x94 Stupefying and pressive pains, chiefly in the \nleft zygomatic region, occurring in paroxysms, and extending \nover the face, head and shoulder. The pains are accompanied \nby twitching of the facial muscles ; and are aggravated or re- \nnewed by warmth, especially by eating anything hot. \n\nThis remedy is particulary applicable to cases of a syphili- \ntic origin, and also to cases arising from the abuse of mer- \ncury. \n\nNux Vomica. \xe2\x80\x94 Rending and drawing pains in the infra-or- \nbital region, sometimes extending into the ear, with redness of \n\n\n\n* See Am. Horn. Obs., vol. i, p. i( \n\n\n\n100 PRACTICE OF MEDICINE. \n\nthe face, or of one of the cheeks ; tingling and twitching of the \nfacial muscles, lachrymation, and more or less numbness of the \naffected parts. \n\nNux vomica is very suitable for coffee drinkers, particular- \nly those of an irritable disposition ; also for cases occurring \nafter a debauch, severe mental labor, watching, etc., especially \nwhen attended by constipation, or by derangement of the diges- \ntive organs. \n\nPlatina. \xe2\x80\x94 Creeping pains, with a feeling of coldness and \nnumbness, especially on the right side of the face ; renewal or \naggravation of the sufferings at night, and during rest. \n\nPlatina is well adapted to hysteric females, especially when \ntroubled with anguish of the heart, or palpitation, or when the \ncatamenia are deranged. \n\nRhus Tox. \xe2\x80\x94 Rending, stinging, burning or drawing pains, \nespecially in the supra-orbital and superior maxillary nerves; \nrenewal or aggravation of the pains at night, and increased by \nthe warmth of the bed, or by rest. \n\nThis remedy is suitable to catarrhal cases, or such as are \ncaused by exposure to cold and dampness. \n\nSepia. \xe2\x80\x94 Tearing, drawing or aching pains in the face and \nnose, with swelling of the cheeks, and with or without redness \nor flushing of the affected parts. The pains frequently extend \nthrough the ear, especially the left, and are aggravated or re- \nnewed by either hot or cold things taken into the mouth. \n\nThis is one of the most useful remedies in the prosopalgia \nand toothache to which delicate, sensitive, nervous females are \nsubject, particularly when the uterine functions are disturbed. \n\nSpigelia* \xe2\x80\x94 Violent tearing, shooting and jerking pains in \nthe supra-orbital, orbital and malar regions, excited or aggravated \nby motion, contact, cold and dampness, occurring in paroxysms, \nand sometimes periodical. The pains are accompanied by more \nor less precordial anguish, lachrymation, and glossy swelling \nof the affected parts. \n\nSpigelia is one of the most useful remedies in prosopalgia \nespecially in cases of a catarrhal or rheumatic character. \n\nVerbascum. \xe2\x80\x94 Flashing, stupefying or jerking pains, seated \nchiefly in the left zygomatic region, and aggravated by motion, \ncontact and exposure to cold. The paroxysms are short but \nviolent, and are often renewed by the slightest touch, and even \nby talking, chewing or sneezing. \n\n\n\n* See Am. Horn. Ois., vol. x, p. 237, 3d. \n\n\n\nPROSOPALGIA. IOI \n\n\n\nConsult also the following table. \n\nTABLE XII.\xe2\x80\x94 Prosopalgia/ \n\nArthritic\xe2\x80\x94 COLOC, Merc, RHUST., Canst, Nux. v., Spig, \nBell., Bry., Calc., Hep. s., Igna., Lye., Puis., Sep., Staph., \nSulph. \n\nCatarrhal. \xe2\x80\x94 Bry., Coloc, Gels., Lyc, Merc, Nux. v., \nRhus, t., Sep., Spig., Calc, Chin., Cin., Graph., Staph., Aeon., \nCaust., Cep., Cham., CofF., Phos., Puis., Sulph. \n\nHysteric \xe2\x80\x94 Bell., Gels., Igna., Plat., Aur., Lach., Puis., \nSep., Calc., Carb. v., Caust., Iris v., Kal., Phos., Sab., Staph., \nSulph., Verbas. \n\nInflammatory. \xe2\x80\x94 AcON., Arn., Bell., Bry., Merc., Phos., \nStaph., Sulph., Bar. c, Lach., Plat, Thuj., Ver. a., Calc., \nCham., Hyosc, Nux. v., Puis. \n\nMercurial.\xe2\x80\x94 Carb. v., Chin., Hep. s., Mez., Aur., Bell., \nNit. ac, Sulph:, Puis., Staph: \n\nNervous. \xe2\x80\x94 Bell., Iris, v., Kal:, Lach., Nux. v., Plat,, \nSpig., Verbas:, Caps., Hyos., Lyc, Sep., Sol. n., Aeon., Caust., \nCham., Chelid. m., Coff., Coloc., Kal. bic. \n\nOdontalgic \xe2\x80\x94 Bell:, Cham., Gels., Merc, Nux. v., Aeon., \nArs., Coff., Hyos., Igna., Rhus, t., Sep., Spig., Calc, Carb. v., \nCaust., Chin., Phos. ac., Sab., Staph. \n\nPeriodical. \xe2\x80\x94 Ars., Chin, s., Gels., Bry., Caps., Ced., Chin., \nNux. v., Puis., Aeon., Arn., Bell., Cauth., Calc., Carb. v., \nCaust., Coff., Con., Merc., Rhus t., Sep., Sulph. \n\nRheumatic \xe2\x80\x94 ACON., Arn., Bry., Merc, Mez., SULPH., \nCaust., Chin., Hep. s., Lach., Nux. v., Cim. r., Phos., Puis., \nSpig., Ver. a. \n\n\n\n102 PRACTICE OF MEDICINE. \n\nSECTION II. \n\nDISEASES OF THE EYE. \n\nOphthalmic diseases, especially those of an inflammatory \ncharacter, have hitherto, for the most part, been regarded by \nus, as well as by many allopathists, as a single affection, where- \nas the structures which enter into the composition of the eye \nare, like those of the encephalon, so diverse as to require sepa- \nrate consideration. For what resemblance, except in a general \nway, is there between conjunctivitis, iritis, scleritis and retinitis, \nto say nothing of the various forms which even the first men- \ntioned disease assumes in different cases ? We do not propose, \nhowever, to describe, much less to enter into any considerable \ndetail concerning many diseases to which this organ is subject \xe2\x80\x94 \nthis must be left to special treatises \xe2\x80\x94 but simply to describe \nthe more common forms of inflammatory and other diseases of \nthe eye, in a manner sufficiently ample and accurate to enable \none, by means of the symptomatic indications, to treat diseases \nof this organ with the same scientific precision that characteris- \nes our treat; nent of other diseases. For it must be confessed \nthat, until within a very recent period, ophthalmic medicine in \nour school has not kept pace with the general advance of homoe- \nopathic practice. On the contrary, it has hitherto remained, for \nthe most part, in its very infancy ;* so that our ophthalmic \nliterature furnishes but a modicum of pure grain, in comparison \nwith the large amount of chaff with which it abounds. This \narises, however, from no defect in our system of practice, since \nthe success which has attended the treatment of eye diseases \nunder the law of similia y has been much greater than that \n\n\n\n* The only work we now have is Angell\'s " Treatise on Diseases of the Eye" the fourth \nedition of which, just published, is, I regret to say, very deficient both in description and treat- \nment ; especially the latter. \n\n\n\nDISEASES OF THE EYE 103 \n\nunder allopathic treatment, as evidenced by the fact that the \nauthorities have substituted the former for the latter in some of \nthe great public charities ;* and also by the fact that certain \ndiseases not amenable to allopathic treatment, such as incipient \ncataract, have in some instances unquestionably yielded to \nhomoeopathic medication. Perhaps this very success has been \nthe meansof retarding, rather than advancing.this special branch \nof medicine among us, by satisfying the demands of the public \nwith less than what would have satisfied it, had the result of \nallopathic treatment been greater. \n\nThe chief difficulties under which we labor in these cases are \ntwo-fold ; first, the limited number of symptoms pertaining to \nthe disease, depending for the most part upon the purely local \ncharacter of the affection ; and, secondly, the defects of our \nMateria Medica, so far as the eye symptoms are concerned, \narising from the incomplete, careless and imperfect character of \nour provings. The latter only can be remedied, and is there- \nfore the principal road to improvement in this branch of medi- \ncal science. If under such adverse circumstances the superior- \nity of the homoeopathic ophthalmic practice is manifest, what \nbrilliant results may we not justly expect, when our Materia \nMedica shall be freed from its incomplete and unreliable symp- \ntoms, and indications based upon scientific observations, be sub- \nstituted in their place ? Meanwhile, and as a humble initiatory \neffort in this direction, we shall attempt to make such use of the \nmaterials before use, as will fairly represent the existing state of \nour knowledge on this important subject. \n\nANATOMY OF THE EYE. \n\nIt is not necessary, nor would this be the proper place, to \ngive even a general description of the anatomy of the eye, as \nevery physician is supposed to be sufficiently acquainted with \n\n\n\nSee Am. Horn. OZ>s., vol. iv, p. 386. \n\n\n\n104 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\nboth its structure and physiology. It will be well, however, \nbefore entering upon the study of the various affections which \nwe shall have to consider under this head, to refresh the mem- \nory by means of the following diagrams, which, in connection \nwith the explanatory references, will be found to be of far \ngreater practical value than the most labored description. \n\n\n\ni. Sclerotic coat, or sclera, \nconsisting of a white, fibrous, \ndense, and somewhat elastic \nmembrane, covering the pos- \nterior five-sixths of the globe, \nand giving shape and firmness \nto the organ. \n\n2. Chotoid, or second tunic. \nThis is a thin vascular coat, \nwhich, like the sclera, covers \nthe posterior portion of the \neye, and is pierced near the \ncentre to admit the optic \n\nIn front it unites with, and \n\n\n\n\nHORIZONTAL SECTION OF THE RIGHT BYE. \n\n\n\nnerve and vessels of the retina, \nforms a part of the ciliary body and iris. The outer portion of \nthis coat consists of the larger vessels, connected by a delicate \ncellular tissue, and an abundance of brownish pigment ; the \ninner portion consists of the capillary vessels of the mem- \nbrane. \n\n3. The cornea, or "window" of the eye,* consisting of a \ntransparent fibrous membrane, similar in structure to the sclera, \ncovering the anterior sixth of the globe. It is composed of five \nlayers ; an outer epithelial layer ; the elastic layer of Reichert ; \nthe true cornea ; the layer of Descemet ; and an internal epithe- \nlial layer ; the two latter constituting the anterior or corneal \n\n\n\n* This is popular language only, since the pupil is the only true window, or opening of \nthe eye. \n\n\n\nDISEASES OF THE EYE. 10 5 \n\nportion of what is generally known as the membrane of the \naqueous humor. The cornea, though largely supplied with \nnerves, contains no blood vessels ; consequently it never exhibits \nany appearance of vascularity, except when diseased . \n\n4, 5- The membranes of Descemet and Reichert. (See \nCornea.) \n\n6. The iris. This is a beautifully colored vertical mem- \nbrane, or curtain, attached by its margin to the ciliary processes, \nhaving an opening near its centre called the pupil. Its struc- \nture is similar to that of the choroid coat, of which it may be \nregarded as an extension, just as the cornea may be considered \nan extension of the sclera ; it differs, however, from the choroid \nin being more muscular, having a circular set of muscular \nfibres for diminishing, and a radiate set for enlarging, the pu- \npillary opening. It is abundantly supplied with nerves as well \nas blood vessels ; and is covered posteriorly with a pigment \nlayer, called the uvea. \n\n7. The canal of Fontana or Schlemm, giving passage to a \nplexus of veins ; and generally known as the circular venous \nsinus of the iris. \n\n8. The conjunctiva ; a transparent and highly vascular \nmucous membrane covering the anterior portion of the globe, \nand reflected from the globe to the internal surface of the lids, \nat the ciliary margin of which it is perforated by the ciliary \nducts. The former portion is called the occular conjunctiva ; \nand the latter the palpebral ; the posterior portion, where it is \nreflected from the globe to the lids, is frequently called the \nretro-tarsal fold\\ the ciliary edge of the membrane being \nknown as the tarsal conjunctiva. The entire membrane forms \na sac, the opening of which corresponds to the edge of the \nlids. It is abundantly supplied with nerves as well as blood- \nvessels, the former being derived chiefly from the first, or \nophthalmic branch of the trifacial. The palpebral portion is \n\n\n\n106 PRACTICE OF MEDICINE. \n\nthickly studded with papillae, which, when enlarged by disease, \ngive to the membrane a villous or granular appearance. \n9. Vena vorticosa ; 10. Optic nerve. (See retina.) \n11. Intervaginal space ; 12. Lamina cribrosa. \n\n13. The retina, or occular expansion of the optic nerve, \nforming the internal, or third principal membrane of the eye. \nIt is divided by recent anatomists into no less than ten layers, \nthe principal of which are : the layer of nerve fibres, the layer \nof rods and cones, and the pigment layer. The first of these \nis but a simple expansion of the optic nerve fibres, being thick- \nest at the optic disc, where the expansion begins, and gradually \nthinning down as it approaches the ciliary processes in front. \nIt lies next the internal limiting layer or surface of the retina, \nand forms the conducting layer, as that of the rods and cones \nconstitutes the perceptive layer. \n\n14. The macula lutea, or central transparent spot of the \nretina, having in its centre a depression called the fovea \ncentralis. \n\n15. The or a serrata, or posterior edge of the ciliary pro- \ncesses. The engraver has represented this with a regular curve \nline, whereas it should be serrated, to correspond with the name. \n\n16. The zonule of Zinn, or suspensory ligament of the lens. \n\n17. The crystalline lens, a double convex body, suspended \nfrom the ciliary processes immediately behind the iris. It is en- \nclosed in a transparent capsule, the anterior and posterior por- \ntions of which are denominated the anterior and posterior \ncapsules. The lens is transparent, laminated, and increases in \ndensity or hardness towards the centre, or nucleus, where it has \nabout the consistency of soft wax. At birth it is perfectly \ncolorless, but as age advances it acquires more or less of an \namber tint, impairing to some extent its transparency. \n\n18. Ciliary processes. The ciliary processes are some \nseventy-five or eighty in number, and constitute what is known \nas the ciliary body. This is composed chiefly of the ciliary \nmuscle, covered by the choroid and pigment layer. (See \nchoroid.) The ciliary muscle is composed of two sets of fibres ; \n\n\n\nDISEASES OF THE EYE. \n\n\n\n07 \n\n\n\nan anterior set which are circular, and a posterior which are \nradiating or meridional. \n\n19. The anterior chamber, or concavity, bounded by the \ncornea and iris. \n\n20. The posterior chamber, bounded anteriorly by the uvea, \nand posteriorly and laterally by the lens, a portion of the \nzonula, and the ciliary processes. The anterior and posterior \nchambers communicate by the pupil ; and are filled with a \ntransparent watery fluid, called the aqueous humor, which \nreadily escapes whenever the cornea is punctured, but is rapidly \nrestored by secretion. \n\n21. The vitreous humor. This is a transparent, jelly-like \nsubstance, containing neither vessels nor nerves, which occupies \nthe entire cavity of the retina. So far as simple appearance is \nconcerned, it bears a striking resemblance to glass, whence it \nderives its name. It consists of a loose cellular texture, con- \ntaining water in its interstices, the latter constituting some \nninety-eight per cent, of its bulk. The membrane inclosing the \nvitreous body, and which is but an external condensation of the \ncellular mesh-work, is called the hyaloid membrane, so named \nby its discoverer, Fallopius. \n\nLachrymal organs.* \na, a, Puncta lachry7nalia y or \nopenings of the lachrymal \ncanals, in the lids. \n\na, b y c t d, Lachrymal canals- \n\nb, b. Blind dilatations, or \nsmall culs-de-sac, at the orbital \nextremities of the lachrymal \ncanals, where they turn inward \nto the lachrymal sac. \n\ne > fy g- Lachrymal sac. \n\n\n\n\nTHE LACHRYMAL APPARATUS.. \n\n\n\n* After Sommering;. \n\n\n\n108 PRACTICE OF MEDICINE. \n\ne. The blind end of the lachrymal sac. \n\ng. Termination of the lachrymal sac, at which point there \nis a slight contraction which serves to distinguish between the \nsac and duct. \n\nh, i. The ductus ad nasum, or nasal duct. \n\ni. Opening of the nasal duct into the nose. \n\nk, I. Lachrymal gland. This is a small conglomerate \ngland situated just within the orbit, near the external angular \nprocess of the frontal bone. It communicates with the surface \nof the conjunctiva by means of seven or eight small excretory \nducts, which open just above the external angle of the eye. \n\n\n\nDIV. I.\xe2\x80\x94 OPHTHALMIC INFLAMMATION. \n\nART. I. \xe2\x80\x94 CONJUNCTIVITIS. \n\nOf the various forms of ophthalmic inflammation, we shall \nfirst describe Conjunctivitis, as that is not only the most fre- \nquent, but also the most important affection of the eye which \nthe busy practitioner is called upon to treat. It is referred to \nunder different names \xe2\x80\x94 Ophthalmia, Ophthalmitis, Conjunc- \ntivitis, etc., the first of which is the most common, the last the \nmost correct. As the name implies, it is simply an inflammation \nof the conjunctival mucous membrane. This membrane is not \nonly the most exposed to atmospheric influences, but also to \ndirect external injuries, to irritations arising from the pressure \nof dust, cinders, and other extraneous substances in the eye, to \ninverted or misdirected cilia, and to tumors, changes in the lids, \netc. ; all of which excite more or less inflammation of the con- \njunctiva. It may also arise indirectly from scrofulous, syphi- \nlitic, or other unhealthy states of the constitution, or as a con- \nsequence of other inflammations, either simple or specific, in \nother organs or in other parts of the same organ. The simple \nform, conjunctivitis simplex, does not differ in any essential par- \nticular from the catarrhal, so that it is unnecessary to describe \nit separately. The treatment, also, is similar, the special indi- \ncations depending chiefly upon the intensity of the inflammation ; \nthese, in severe cases of simple conjunctivitis, being identical \nwith those of the milder varieties of catarrhal ophthalmia. \n\n\n\nDISEASES OF THE EYE. \n\n\n\nI09 \n\n\n\nFIG 3. \n\n\n\n\nI.-CATAEEHAL CONJUNCTIVITIS. \n\nCATARRHAL OPHTHALMIA; MUCOUS OPHTHALMIA. \n\nThis is a simple inflammation of \nthe conjunctiva, resulting from ex- \nposure to cold and damp. When \nthe inflammatory process extends \nto the sclera, catarrhal conjunc- \ntivitis becomes either catarrJw- \n\xe2\x96\xa0rheumatic or catarrho-arthritic con- \njunctivitis ; and when it involves \nthe lids, the affection is called \nblepharoconjunctivitis, or simply \n\nCATARRHAL CONJUNCTIVITIS. bUfkaHHS. \n\nSymptoms. \xe2\x80\x94 Dryness, itching, smarting and stiffness, with \nmore or less redness, lachrymation, sensitiveness to light, and a \nfeeling as though sand or some other foreign object had gotten \ninto the eye. Sometimes this is really the case, even in catarrhal \nconjunctivitis, but it is much more apt to occur in the simple \nform of the affection, since it is in that manner that simple con- \njunctivitis is generally exdted. The symptom in question is \ngenerally due to the roughness of the conjunctival surface, \ncaused by the enlarged and tortuous vessels which characterize \nthe inflammation. Vision is often impaired, especially towards \nevening, on account of the abundance of mucus secreted at \nthat time and deposited upon the cornea. The palpebral con- \nconjunctiva is of a bright vermilion hue, frequently flecked with \nslightly ecchymosed patches of a deeper color, and is sometimes \nso much increased in extent by relaxation, especially the great \nfold of the membrane, as occasionally to be twice its usual \nvolume. In some cases, slightly diaphanous granulations, of a \nlighter color than the general surface, may be perceived upon \nthe general surface, particularly of the upper lid.* Sometimes \n\n*This is agreeable to most authorities, and is undoubtedly true of the chronic variety, \nin which alone granulations form a prominent feature; but in the more simple subacute \nforms, I have generally found them to be most conspicuous upon the lower lid, or rather \nin the conjunctival folds between the lid and the globe, and such also appears to have \nbeen the experience of Eble. \n\n\n\n110 PRACTICE OF MEDICINE. \n\nalso little vesicles, or pustules, consisting of slight elevations of \nthe mucous membrane, and containing a serous fluid,* are situ- \nated about the margin of the cornea. The eyelids generally \nparticipate more or less in the inflammation, whenever the con- \njunctivitis is of an active character. \n\nDiagnosis. \xe2\x80\x94 The vessels of the occular conjunctiva have a \nmore or less regular distribution (See Fig. j.) ; their trunks are \nturned towards the circumference of the globe, from which they \nrun forwards in a slightly tortuous, but nearly parallel course, \nsubdividing and inosculating as they approach the cornea, and \nterminating in very fine points at the distance of about two \nlines from the outer edge of the cornea, leaving a space around \nit in the form of a band which is free from redness. The dis- \ntended vessels are quite superficial, and may easily be displaced \nby moving the lids. This form of inflammation seldom causes \nmuch swelling of the mucous membrane, and is not to be com- \npared with the chemosis associated with the more acute inflam- \nmations of the conjunctiva. In addition to these diagnostic \nsigns, other mucous surfaces suffer when the conjunctivitis is \nsevere, producing more or less coryza, headache, and catarrhal \nfever. The symptoms, both local and general, remit in the \nmorning, and undergo exacerbation at night. \n\nPrognosis. \xe2\x80\x94 Catarrhal conjunctivitis if properly treated \nundergoes resolution, and is therefore, generally speaking, free \nfrom danger ; but if violent, and especially if wholly neglected, \nor improperly treated, it may extend to the cornea and sclera, \nproducing opacity and ulceration of the former, granulation \nand ulceration of the conjunctiva, and other serious conse- \nquences. \n\nETIOLOGY. \xe2\x80\x94 Cold and damp are the chief exciting causes \nof catarrhal ophthalmia as they are of catarrhal affections \nin general. Great and rapid atmospheric changes, especially \nfrom heat to cold, often produce an attack ; so also do cold \n\n\n\n*And therefore not true pustules, though frequently so called. \n\n\n\nDISEASES OF THE EYE. Ill \n\nwinds, especially when combined with rain or snow. Changes \nof clothing, especially such as favor a chill of the surface, \nare capable of producing it, particularly if the head itself is \nexposed. Getting wet, either partially or generally, expo- \nsure to drafts of air, and whatever causes a chill of the body, \nmay all give rise to it ; it is also sometimes caused, appar- \nently, by certain atmospheric influences, the nature of which \nhas never been satisfactorily explained. \n\nTreatment. \xe2\x80\x94 The proper treatment for catarrhal con- \njunctivitis is that which is best adapted to catarrhal inflamma- \ntions in general, and particularly to coryza, with which it is fre- \nquently associated. Hence the principal remedies are : \n\nAconite* especially at the beginning of the attack. This \nremedy alone will frequently allay the inflammation, provided \nno untoward complications exist. \n\nApis mel. \xe2\x80\x94 This remedy is often associated with Aconite, \nespecially in the first stage, and, not unfrequently, with great \napparent benefit. \n\nBelladonna* \xe2\x80\x94 This medicine is best adapted to the more \nviolent forms of catarrhal conjunctivitis, particularly when there \nexists considerable sensitiveness to light. \n\nEuphorbinm. \xe2\x80\x94 This is often a very efficient remedy in \nviolent forms of the disorder ; also in chronic catarrhal con- \nditions, with dryness and itching of the lids and canthi. \n\nEuphrasia is an excellent medicine, similar in its action to \nBelladonna, and especially adapted to cases complicated with \ncoryza, or with copious mucous discharges from the nasal pas- \nsages. It also generally has an excellent effect when applied \nlocally in suitable cases. \n\nHepar Sulph. \xe2\x80\x94 This remedy is best adapted to the sub- \nacute forms of catarrhal inflammations ; also in the acute after \nAconite and Belladonna, particularly the latter. \n\nMercurius.. \xe2\x80\x94 This is one of our most efficient remedies in \n\n\n\n*See Am. Horn. Obs., vol. iv., p. 440, (sub-acute; A, 1-10,) \n\n\n\n112 PRACTICE OF MEDICINE. \n\nobstinate cases, especially when associated with a general \ncatarrhal condition of the system. \n\nRhus Tox. has also been found useful in bad cases of \ncatarrhal ophthalmia, attended with more or less cedematous \nswelling of the conjunctiva. \n\nThe chief remedies for the more chronic forms of catarrhal \nconjunctivitis are : \n\nA rsenicum, especially when there is ulceration of the cornea \nand the margin of the lids ; also when there is oedema, lachry- \nmation, and nightly agglutination. \n\nCalcarea. \xe2\x80\x94 This remedy is particularly useful in cases \nsimilar to the above, and of long standing, especially if aggra- \nvated by reading or sewing. \n\nHydrastis Canaden. \xe2\x80\x94 This medicine may be used to ad- \nvantage, both locally and generally, in chronic catarrhal con- \njunctivitis, especially when attended with ulceration ; it is also, \nlike Hepar Sulph., frequently useful in the acute and sub-acute \nforms. \n\nIodinm. \xe2\x80\x94 This remedy is suitable to obstinate cases occur- \nring in lymphatic constitutions, and in which there is more or \nless redness and swelling of the eyelids, with nightly aggluti- \nnation. \n\nPhosphorus. \xe2\x80\x94 In cases similar to the above, associated with \ncoryza, or with a more general catarrhal condition of the system. \n\nStaphysagria. \xe2\x80\x94 This medicine is well adapted to cases \nwhich have become complicated with inflammation of the lids, \nespecially when the meibomian glands are implicated. \n\nSulphur. \xe2\x80\x94 This remedy is suitable to almost every form of \nchronic catarrhal inflammation, especially when attended with \nulcerations of the margins of the lids, with swelling of the con- \njunctiva or with opacity or ulceration of the cornea. \n\nThuja.\xe2\x80\x94 This remedy is found useful in the most violent \nforms of chronic catarrhal conjunctivitis, attended with thicken- \ning and granulation of the lids. See Chronic Purulent Con- \njunctivitis \xe2\x80\xa2, \xc2\xa7 2 (2). \n\n\n\nDISEASES OF THE EYE. 1 13 \n\nAlthough the above list of remedies is amply sufficient for \nthe successful treatment of every variety of catarrhal conjunc- \ntivitis, additional remedies, together with their symptomatic in- \ndications, will be given after the other forms of ophthalmia have \nbeen described. See Tables XIV. and XV.; also Therapeutic \nIndications at the end of the Section on Ophthalmic Diseases. \n\nLocal Treatment. \xe2\x80\x94 Topical treatment, under homoe- \nopathic medication, is seldom required in either the acute or \nsub-acute forms of catarrhal conjunctivitis. If, however, owing \nto constitutional weakness, or other causes, the inflammation, in \nspite of the indicated constitutional remedies, runs very high, \nand especially if there be much chemosis, or swelling, cold com- \npresses will generally give great relief, and aid materially in \nbringing about speedy resolution. Irritating collyria, however, \nare never admissible during this stage. It is not until the in- \nflammation has been somewhat subdued, or else is disposed to \nlinger, or become purulent, that collyria are beneficial ; and \nthen they should be of the most simple character, such as a \nsolution of one grain of nitrate of silver, one or two of the \nsulphate of copper or zinc, two or three of alum, the same \nquantity of the acetate of zinc, or five or six grains of borax, \nto the ounce of distilled water. These should be interchanged \nfrom time to time, using such only as are found to be most \nbeneficial and agreeable to the patient, and either discontinued \naltogether or conjoined with the use of the cold compress, \nwhenever active inflammatory symptoms supervene. If the \ncollyrium, however weak it may be (and it should never be very \nstrong in the early stages of the disease), causes much pain, it \nshould either be abandoned, or greatly reduced in strength, as \n\nexperience shows that such washes generally do more harm than \ngood under such circumstances. By carefully adapting them, \nhowever, to the requirements of each particular case, they may \nbe made to contribute to both the comfort and benefit of the \npatient. If the inflammation prove obstinate, and especially if \nthe discharge assume a purulent character, the case should be \ntreated as directed in the following section. \n\nis \n\n\n\n114 PRACTICE OF MEDICINE. \n\n\n\n2 -PURULENT CONJUNCTIVITIS. \n\nCONJUNCTIVITIS BLENNORRHOICA ; PURULENT OPHTHALMIA. \nWe propose to describe under this head the varieties of \nconjunctival ophthalmia originating in the mucous membrane of \nthe eye, and oft^n confined to it, characterized by an increased \nsecretion of a purulent or puriform character. They are : \n\na. Conjunctivitis neonatorum, or purulent ophthalmia of \nnewly born infants. \n\nb. Conjunctivitis purulenta, or purulent ophthalmia in the \nadult. \n\nc. Conjunctivitis gonorrhoica, or acute gonorrhceal ophthal- \nmia. \n\nThese varieties of conjunctivitis are strikingly similar in \ntheir symptoms, course and terminations, are all very destruc- \ntive to the integrity of the organ, and are chiefly distinguishable \nfrom each other by the age of the patient, or by the nature of \nthe exciting cause. \n\n\n\nA\xe2\x80\x94 Conjunctivitis Neonatorum. \n\nPURULENT OPHTHALMIA OF INFANTS. \n\nSymptoms. \xe2\x80\x94 This form of conjunctivitis generally sets in \nabout three days after birth, but it sometimes begins at an \nearlier and sometimes at a later period. At first it is limited to \nthe palpebral conjunctiva, which is red and velvety ; the edges \nof the lids, also, are somewhat red, particularly at the corners, \nwhere they adhere slightly to each other, the adhesion arising \nfrom their being kept closed in consequence of pain experienced \non exposure to light, and to the secretion by the inflamed mem- \nbrane of a small quantity of white mucus, which may be seen \n\n\n\nPRACTICE OF MEDICINE. 115 \n\non everting the lower lid. This blepharo-blennorrhcea, or bleph- \naritis, as it is termed, constitutes what is called the first stage. \n\nThe second stage is marked by the extension of the disease \nto the ocular conjunctiva, the redness and inflammation being \ngreatly increased, and the inflamed membrane pouring out a \ncopious puriform secretion, which causes adhesion of the palpre- \nbal edges, and the accumulation between the swollen and \ninflamed lids of more or less of the purulent matter. In this \nstage, there is always considerable tumefaction both of the lids \nand conjunctiva, the loose folds of the latter being distended \ninto fiery rolls, having a finely granulated or villous appearance, \nand producing in many cases temporary ectropium of one or \nboth of the lids. Photophobia is always great, and generally \nextreme, the child contracting its brow, and resisting as much \nas possible every attempt at exposure to the light. Whenever \nthe lids are separated, especially in the morning, a profuse \npurulent discharge generally gushes out, and pours over the \nface of the child ; and in all cases the puriform secretion is \nsufficiently abundant to agglutinate the lids, and, when sepa- \nrated, to conceal from view the inflamed surfaces. The dis- \ncharge is of different degrees of consistency, and of various \nshades of color, being generally of a purulent or muco-purulent \ncharacter, but sometimes ichorous or sanious and even bloody. \n\nThe third stage stage is characterized by a gradual sub- \nsidence of the inflammation ; the redness and tumefaction abate ; \nthe secretion is not only diminished in quantity, but altered in \nquality, becoming bland and muculent; the photophobia sub- \nsides, so that the child will even open its eyes when the light is \nsubdued; and the temporary ectropium, resulting from the \neversion and strangulation of the lids, disappears, so that the \neye can now be carefully examined. \n\nRESULTS. \xe2\x80\x94 Opacity, ulceration and more or less sloughing \nof the cornea, as well as adhesion of the iris to its inflamed or \nulcerated surface, may all occur in the second stage of the com- \n\n\n\nIl6 CONJUNCTIVITIS NEONATORUM. \n\nplaint. When the whole cornea sloughs and the humors escape, \nthe eye shrinks greatly in size, appearing like a flattened tubercle \nat the bottom of the orbit, when the humors are retained, the \nfront of the globe only is flattened. When, in consequence of \nextensive sloughing of the cornea, the iris prolapses and becomes \nadherent, staphyloma, either partial or general, commonly super- \nvenes; sometimes, however, the tumor thus formed gradually \ndiminishes until only a small brown point remains in the cornea, \nimpairing the vision more or less, according to its situation and \nextent. The cicatrices *left after healing of the corneal ulcera- \ntions are opaque, and consequently interfere more or less with \nvision. Permanent opacity of the cornea, {leucoma albugo,) \nresulting from a greater or less amount of interstitial deposition, \nmay be either partial or general; in such cases, of course, vision \nis more or less permanently impaired ; but when the opacity is \nsuperficial, or results from a slight degree only of interstitial \ndeposition, the effusion will ultimately be absorbed, and the \ntransparency of the cornea fully restored. \n\nPrognosis. \xe2\x80\x94 When the disease is severe, neglected, or \nbadly treated, the danger to the eye becomes very great, and \nvision is apt to be permanently injured. On the contrary, if \nthe case be taken in hand early, before the cornea becomes \nseriously affected, the inflammation can almost always be sub- \ndued in time to avert the dangers to which this form of con- \njunctivitis is subject. Indeed, if the cornea remains clear, \neven if the inflammation has extended to the ocular conjunc- \ntiva, but little risk is incurred, provided the most prompt and \nefficient means are employed. But if extensive ulceration or \nsloughing of the cornea has occurred, or if inflammation has \nextended to the deeper structures of the eye, producing adhe- \nsion of the iris, {synechia anterior^) or impairing the transparency \nof the humors, the loss of vision will be unavoidable. \n\nETIOLOGY. \xe2\x80\x94 Purulent conjunctivitis of new-born infants has \nbeen proven in many instances to be contagious ; and the gen- \n\n\n\nPRACTICE OF MEDICINE. 117 \n\neral appearance of the disease on the second or third day after \nbirth, taken in connection with the fact that, in a large propor- \ntion of cases, the mothers have been observed to have a morbid \nvaginal discharge, such as leucorrhoea or gonorrhoea, renders \nthe received notion of its contagious origin from contact of these \nmorbid secretions, highly probable, to say the least. On the \nother hand, conjunctivitis neonatorum frequently attacks the \nchildren of healthy mothers, or, at least, of such as appear to \nbe quite healthy, so that the question as to the contagious \norigin of the complaint still remains to some extent unsettled.* \nWhether contagious or non-contagious, however, one thing is \ncertain, namely, that those influences that excite other forms of \nconjunctivitis are capable of producing this ; thus it is found to \nbe most frequent and destructive among weakly children, and \nsuch as are inadequately and improperly nourished, clothed and \nhoused ; also, that it is more prevalent and destructive where \nlarge numbers are collected together, as in foundling hospitals, \nespecially those which admit children of the lowest class, the \nmothers of which are frequently affected with leucorrhceal or \nother vaginal discharges, and whose infants are often puny, \npremature and badly nourished. \n\nTreatment. \xe2\x80\x94 In order to avoid unnecessary repetition, \nwe shall mention in this place only a few of the leading medi- \ncines adapted to this variety of ophthalmic inflammation, refer- \nring to Tables XIV and XV, and also to the Therapeutic \nIndications at the end of the Section on Ophthalmic \nDiseases, for such additional remedies as may be required in \nexceptional cases. \n\nAconite. \xe2\x80\x94 This medicine appears to be incapable of causing \na true inflammatory exudation of plastic lymph or pus, and is \ntherefore of no value in this form of inflammation, except \n\n*It is true, the most recent authorities regard every form of purulent conjunctivitis, even the \ncatarrhal, as somewhat contagious, and this is no doubt true ; but our own experience, no les \nthan that of many others, to say nothing of the general history of the disease, is not such as to \nwarrant us in giving an unqualified opinion on the subject in question. \n\n\n\nIl8 CONJUNCTIVITIS NEONATORUM. \n\nduring the first stage of the complaint, and even then it will be \nmost useful if given in alternation with Argent, nit, or Bella- \ndonna. \n\nArgentum nit. \xe2\x80\x94 This remedy enjoys the reputation of being \na specific for this form of conjunctivitis ; it is well to alternate \nit with other medicines whenever special symptoms demand a \nchange of remedies. \n\nBelladonna. \xe2\x80\x94 This remedy is well adapted to the first stage \nof conjunctivitis neonatorum, especially in the less acute grades \nof the disease ; its use, however, should not be persisted in after \nthe secretion has become thick and copious, but the practitioner \nwill do well, as a general rule, to resort at once to \n\nBryonia: \xe2\x80\x94 This medicine is adapted to the second stage, \nwhen the conjunctiva has become more or less infiltrated, the \nsecretion being thick and slimy and the lids agglutinated ; but, \nunless improvement rapidly follows, resort should be had to \n\nHepar Sulph., or to the Muriate of Hydrastia, either singly, \nor in alternation with Bryonia or \n\nMercurius. \xe2\x80\x94 This is perhaps the most reliable remedy after \nthe second stage has become fully established and plastic exu- \ndation has taken place, especially if pustules or ulcers have \nalready formed on the cornea. \n\nRhus tox. \xe2\x80\x94 This medicine is also well adapted to the second \nstage of the disorder, especially when there is very great swell- \ning of the lids and conjunctiva, with redness and hard swelling \nof the tarsal edges. \n\nThuja. \xe2\x80\x94 This remedy, which is better adapted to severe \nforms of catarrhal conjunctivitis, has been recommended chiefly \non theoretical grounds ; yet it has been proven to be of consid- \nerable value in many cases, especially when there is very \nhigh inflammation, with great redness and swelling of the lids \nand ulcerations of the tarsi and cornea. \n\nAuxiliary Treatment. \xe2\x80\x94 Great care should be taken to \ncleanse the eyes, as often as may be needed, with warm milk \n\n\n\nPRACTICE OF MEDICINE. 119 \n\nand water, by means of fine old linen rags, never using the \nsame piece twice, and never opening the lids without first soak- \ning them until the dried and glutinous matter is entirely \nremoved. A light linen compress, saturated with a solution of \nBelladonna or Thuja, of the strength of fifteen or twenty drops \nof the mother tincture to the glass of water, and frequently \nchanged, may be used to advantage in the first and second \nstages respectively ; and a solution of A rgentum Nitratum, one \ngrain to the ounce of distilled water, and kept in the dark, may \nbe dropped into the eye, or applied to diseased surfaces, every \nsix hours during the suppurative stage, by means of a camel\'s \nhair pencil, being careful to cleanse the pencil with warm water \nevery time it is used. This application not only destroys the \ncontagious character of the secretion, but acts favorably upon \nthe inflammation, by limiting the exudative process and pro- \nmoting the absorption of the exudation ; and, if carefully and \ntimely applied, it will insure resolution of the inflammation, by \npreventing disorganization of the ocular structures and conse- \nquent loss of vision. \n\nDiet and Regimen. \xe2\x80\x94 From what has been said respect- \ning the nature and causes of this disease, it is evident that the \nnutrition of the infant is a matter of the highest importance ;* \nand for this purpose, healthy maternal breast-milk should, if \npossible, be obtained. If, however, the babe must be fed with \nartificial food, well-cooked oat-meal, prepared with half water \nand half milk, and strained, will, as a general rule, be found to \nbe the best substitute. Due attention to cleanliness, the use of \na proper amount of warm, clean clothing, and a plentiful supply \nof pure air, are matters also which the practitioner should be \ncareful to enjoin. \n\n\n\n* To those practitioners who are accustomed in this complaint to rely wholly on medi- \ncation, these directions may appear both antiquated and unnecessary; but an experience of \nmany years in its treatment, and the disastrous results which in many cases we have \nobserved to follow the neglect of suitable hygienic measures, especially in public institutions, \nnot only authorize, but demand, we think, their observance in all cases. \n\n\n\n120 PRACTICE OF MEDICINE. \n\nB\xe2\x80\x94 Conjunctivitis Punilenta. \n\nPURULENT OPHTHALMIA OF THE ADULT ; MILITARY OR \nCONTAGIOUS OPHTHALMIA. \n\nThis form of conjunctivitis is of different degrees of severity, \naccording as it occurs in civil life and under favorable circum- \nstances, or in the army, in over- crowded barracks, hospitals, etc. \nIn the former case, it is generally a comparatively mild affec- \ntion, differing in no respect from the milder form of conjuncti- \nvitis neonatorum just described, except as modified by age and \nother accidental circumstances. Indeed, there is reason to \nbelieve that in some instances it is nothing more than a severer \nand more dangerous form of the catarrhal. In the latter case, \nhowever, owing doubtless for the most part to exposure, a scor-\' \nbutic state of the system and want of cleanliness, it has proven \nexceedingly destructive, no less than eleven hundred cases of \nblindness having occurred in the Prussian army out of thirty \nthousand attacked. Sometimes, also, the ravages of the disease \nare alarming even in civil life, as when it breaks out in asylums \nand large schools, or when, through neglect of sanitary precau- \ntions, or the non-observance of suitable hygienic measures, it \nbecomes epidemic. The latter constitutes what is generally \nknown as \n\n(I.) \xe2\x80\x94 ACUTE PURULENT CONJUNCTIVITIS. \n\nSymptoms. \xe2\x80\x94 As in ophthalmia neonatorum, the redness \nand inflammation are at first confined to the palpebral conjunc- \ntiva ; there is also more or less lachrymation, stiffness of the lids, \nand accumulation of whitish mucus on the inflamed membrane. \nThis is the first stage, or blepharo blennorrhea. The inflamma- \ntion soon extends to the conjunctiva oculi, producing great \nredness and swelling of the affected membrane, and copious \ndischarge. At first there is simple stiffness of the globe and \nlids, but this is soon followed by a feeling as though sand or \ncinders were in the eye. The lachrymation of the first stage is \nsucceeded by a puriform discharge, so copious as to frequently \n\n\n\nDISEASES OF THE EYE. \n\n\n\n121 \n\n\n\n\nfig. 4- overflow the lids and face. Che- \n\nmosis, from swelling of the ocular \nconjunctiva, becomes so great as \nfrequently to overlap and nearly \ncover the cornea, forming with the \nswollen membrane of the lids, two \nlarge pinkish rolls or protuberances, \nwhich so effectually close the eye \nas to render a satisfactory view of \nthe cornea quite impossible. When the inflammation extends \nto the sclera, the pain is greatly augmented, becoming at times \nalmost intolerable ; the constitution also sympathises with the \naffection, producing a feverish state of the system, attended by \nheadache, throbbing in the temples, loss of appetite, etc. The \nvascular exitement and suffering remit or abate from time to \ntime, generally in the morning, and sometimes they become \ndistinctly periodical. This is the second stage, commonly called \nophthalmo-blennorrhoea. The third stage is marked, by a general \nsubsidence of the foregoing symptoms ; the pain, swelling and \ndischarge diminish, leaving however for a considerable period \nmore or less eversion of one or both of the lids. \n\nResults. \xe2\x80\x94 Among the effects sometimes resulting from \nacute attacks of purulent ophthalmia, we have opacity, rupture, \nsloughing, suppuration and ulceration of the cornea, interstitial \ndeposition into and between its laminae, prolapsion and adhesion \nof the iris, vascularity, thickening and separation of the mucous \nmembrane covering the cornea, staphyloma, ectropium, en- \ntropium, and enlargement or collapse of the globe. Even when \nno such effects follow the inflammation, a certain degree of \nimpaired vision (amblyopia) sometimes remains, owing to - \nchanges in the lens, choroid coat, vitreous humor, and vessels of \\ \nthe orbit and brain. \n\nDiagnosis. \xe2\x80\x94 The violence of the disease, the purulent char- \n\n\n\n16 \n\n\n\n122 PRACTICE OF MEDICINE. \n\nacter of the secretion, and the changes above-mentioned, \nespecially the chemosis, which, as a dropsy of the conjunctiva, \nis not to be compared with the swelling of the conjunctiva in \ncatarrhal ophthalmia, will serve to distinguish it from the latter, \nwith which alone it is liable to be confounded. Severe cases of \ncatarrhal ophthalmia, attended by puriform secretion, some- \ntimes bear a close resemblance to this disorder, and, as already \nstated, may perhaps be properly regarded as mild cases of the \ndisease ; but the fact that the inflammatory process commonly \naffects the whole conjunctival surface at once, instead of being \nconfined for a time to the palpebral conjunctiva alone, as in \npurulent ophthalmia, will, in connection with the history and \nprogress of the case, generally serve to establish a satisfactory \ndiagnosis between them.* \n\nPROGNOSIS. \xe2\x80\x94 Notwithstanding the formidable character of \nthe inflammation, if the cornea be unaffected, suitable treat- \nment will generally arrest the disorder ; but if the cornea, and \nespecially the globe, be involved in the inflammation, the event \nis more or less doubtful. Interstitial deposition, suppuration, \nand even ulceration, unless considerable, and occurring in a bad \nstate of the system, do not necessarily involve the loss of vision, \nmuch depending, of course, on the extent and situation of the \nchanges ; if the centre of the cornea, or any considerable por- \ntion of it, remains clear, the sight is not likely to be greatly im- \npaired. The general prognosis depends, of course, on the more \nor less rapid progress of the inflammation ; the more rapidly it \npasses through its several stages, the more danger we shall have \nto fear. Whenever the true nature of the exciting cause can be \ndetermined, we shall have still surer ground upon which to base \nthe probable results. Thus, if the blenorrhcea depends upon \n\n\n\n* The following is the diagnosis of Prof. Arlt, Vienna : " The upper lid is to be everted, \nand if the conjuctiva is sufficiently transparent for us to see the lines of the meibomian glands \nrunning toward the eye, of the tarsus, we have a catarrh; if the infiltration is so great as to \nhide these glands, we have no longer a catarrh, but either a purulent or some graver form of \nophthalmia."~ANGELL on Diseases of the Eye, p, 28. \n\n\n\nPURULENT CONJUNCTIVITIS. 1 23 \n\ninfection, forty-eight, or even thirty-six hours may be sufficient \nto produce irreparable injury to the cornea, and consequently \nto vision. \n\nETIOLOGY. \xe2\x80\x94 Severe catarrhal and mild purulent ophthalmia \nare so closely related, that it cannot be positively denied tftat \nthe latter may sometimes originate in the same causes that give \nrise to the former ; but it is generally admitted to be of an in- \nfectious origin and nature; indeed, in most cases it can be traced \ndirectly to some contagious or blenorrhceic secretion, emanating \neither from the eyes or from the genital organs. The contagion \nis promoted, of course, by everything which tends to favor it, \nsuch as the crowding together of large numbers in the same \napartment, thus accounting for its comparatively frequent oc- \ncurrence in asylums and large schools, and in army hospitals. \nThe same circumstances, likewise, superadded to exposure, \nwant of cleanliness, and a scorbutic or psoric condition of the \nsystem, greatly facilitate the spread of the contagion, and hence \nthe fearful ravages which the disease sometimes makes in the \narmy. \n\nIn proof of its contagiousness, it is only necessary to cite \nthe fact that it has frequently been communicated by direct in- \noculation, not only accidentally in persons, but intentionally in \nanimals, the disease having been repeatedly produced in dogs \nand cats by the application of the purulent secretion to their \neyes. Additional confirmation is found in the fact that, being \nendemic in Egypt, it was first brought to Europe by the English \nand French armies \xe2\x80\x94 whence the name of Egyptian Ophthalmia, \nby which it is sometimes known \xe2\x80\x94 and from this source its pro- \ngress was traced from the infected to the uninfected, until the \nEuropeon surgeons were, with but few exceptions, cgnvinced of \nits contagious character. On the other hand, as Lawrence \nobserves, " this notion of a specific contagion, imported from \nEgypt, originated in Europe, never having occurred in the sup- \nposed birth-place of the virus. Assalini, and the other medical \n\n\n\n124 PRACTICE OF MEDICINE. \n\nobservers who actually witnessed the affection in Egypt, refer \nit to the ordinary causes of ophthalmic disease." In confirma- \ntion of the latter opinion, it may be stated, that where collec- \ntions of individuals affected by it have been separated, the \ndisease, instead of being propagated to others, generally abates. \nThe only rational conclusion, therefore, that we can come to on \nthis subject, is, that as a general rule, when the disease breaks \nout in over-crowded, filthy, and disease-producing situations, \nthe malady becomes highly contagious and virulent ; while on \nthe other hand, in situations and under circumstances favorable \nto health, it soon undergoes amelioration, generally losing, to a \ngreat extent, at least, its contagious character, and becoming \nmilder and more manageable.* This will satisfactorily account \nfor the milder form which the disease often assumes, not only \nin civil life, but also in the army, whenever suitable hygienic \nregulations are observed. \n\nTreatment. \xe2\x80\x94 This should be similar to that recommended \nfor ophthalmia neonatorum, only, as the inflammation is gener- \nally of a higher grade, the treatment should, if possible, be still \nmore energetic. As the same indications exist, the same reme- \ndies will be found applicable, and it will therefore be uneces- \nsary to repeat them here. See Treatment of Conjunctivitis \nNeonatorum, and consult also the remedies mentioned in Table \nXIV, at the end of the section on Ophthalmic Diseases. \n\nLocal Treatment. \xe2\x80\x94 Most authors recommend ice and \nice water compresses for external use, and when well-borne and \nregularly and judiciously applied, they are found to be a very \nefficient means of subduing the inflammation, but it should be \nremembered that such applications are extremely hazardous in \nunreliable* and inexperienced hands. We have often obtained \nmuch better results from water of a moderate coldness only, \napplied constantly by means of light linen rags, frequently \nrenewed, taking care to cleanse the eyes from time to time with \n\n\n\n* See Am. Horn. Obs., vol. il, p. 309, et seq. \n\n\n\nPURULENT CONJUNCTIONS. 125 \n\nfresh portions of the same. Sometimes even this degree of \ncold cannot be borne without great pain, in which case it should \nbe used tepid, or else omitted altogether, except for purposes of \nablution. \n\nAfter the redness and swelling of the inflamed membrane \nhave somewhat subsided, and the pain and soreness have \nmostly disappeared, astringent washes, composed of such sub- \nstances as we have already mentioned, will prove most beneficial, \nespecially when used in conjunction or alternation with a solu- \ntion of Argentum Nitratum, of the strength of from three to \neight grains to the ounce, according to the severity of the case, \napplied by means of a camel\'s hair pencil, in the manner \nrecommended for the purulent conjunctivitis of infants ; \nremembering always to rinse the lids immediately after making \nthe application, and not to repeat it oftener than twice a day \nIf the caustic applications are made prematurely, before the \ninflammation is sufficiently reduced, they will aggravate the \ncomplaint, and should at one be suspended, until, by the use of \nAconite internally and cold compresses externally, the inflam- \nmation is so far lessened that they can be resumed with benefit. \n\nDIET AND REGIMEN. \xe2\x80\x94 If the general*health of the patient \nis good, the diet should be very light, consisting only of farina- \nceous food, wholesome fruits, and light, unstimulating drinks ; \nbut if weak and emaciated, and especially if there is a scroful- \nous or scorbutic state of the system, the diet should be liberal \nand nutritious. Should the case linger from any cause, as it is \nfrequently apt to do in a depraved state of the constitution, and \nespecially if the loss of vision be threatened by progressive \nulceration of the cornea, such articles as milk, eggs and beef \nshould be prescribed, and if necessary even a moderate amount \nof port wine should be allowed ; since, in these cases, notwith- \nstanding the inflammation, the danger to the integrity of the \norgan arises rather from under than from over stimulation. But \nbefore resorting to even the mildest stimulative measures, the \npractitioner should be certain that he has correctly interpreted \nthe constitutional state ; otherwise irreparable mischief will be \nthe consequence. \n\n\n\n\n126 PRACTICE OF MEDICINE. \n\nGEANULAR CONJUNCTIVITIS. \n\nCHRONIC PURULENT OPHTHALMIA ; TRACHOMA. \n\nFig - 5 - This much the most \n\ncommen form of Puru- \nlent Ophthalmia, espec- \nially in civil life. It is \ndistinguishable from the \nacute form just describ- \ned, chiefly by its being \nconfined, except in very \nrare instances, to the \npalpebral conjunctivia ; \n\nGRANULAR CONJUNCTIVITIS. , ,, \n\nby its generally running \na comparatively mild and very chronic course; and by a gradu- \nal change of the mucous lining of the lids, especially of the \nlower, which, after the lapse of several weeks or months, are, so \nto speak, over-run with patches of minute fleshy growths, or \nvegetations, called " granulations," which give to the affected \nmembrane a rough, mulberry like appearance, (trachoma)) The \nsize and color of the granulations are generally proportioned to \nthe intensity of the inflammation ; when the conjunctivitis is \nmost intense, they are commonly of a deep red or garnet color, \nand of a rough, warty, or condylomatous appearance ; but \nwhen the inflammation is less violent the palpebral conjunctiva \nis paler, and appears as if sprinkled with dust or fine sand. At \nfirst the granulations are soft and tender, and bleed easily ; \nafterwards they become more and more indurated, and give to \nthe conjunctiva a somewhat seamed or cracked appearance.* \n\nSYMPTOMS. \xe2\x80\x94 The disease often sets in so gradually as \nscarcely to attract attention. Commencing with the symptoms \n\n\n\n* It is important to distinguish between granulations , properly so called, and enlarged \npapillce. The latter ordinarily accompany the former, but are more superficial ; granulations, \nproper are an inflammatory product, appearing, even before changing into cacatricial tissue, \nas distinct formations, like grains of sand, lying immediately under the conjunctiva. \n\n\n\nPRACTICE OF MEDICINE. 1 27 \n\nof catarrhal ophthalmia, the patient experiences more or less \nuneasiness in the eye, attended with a feeling of heat or burn- \ning, especially of the tarsal edges, which exhibit more or less \nredness ; sometimes the inflammation is confined to the tarsal \nportion of the lids for a considerable period ; afterwards, when \nthe inflammation has spread towards the globe, the patient \ncomplains of a feeling of dryness and roughness in the eye, as \nif caused by particles of foreign matter beneath the lids. There \nis now an increased secretion of tears and of mucus, but little or \nno pain. The disease may continue in this mild form for two \nor three weeks, and then terminate under proper treatment? \nor, in consequence of unfavorable circumstances, it may increase \nin intensity until it reaches a higher grade, the conjunctiva be- \ncoming redder and more swollen, and secreting a thick, glutin- \nous, or puriform matter. The affected membrane now takes \non the characteristic granulated appearance ; the lids partici- \npate in the general swelling ; and the pain becomes more con- \nsiderable. This, the most inveterate form of the complaint, \nmay last for several weeks or months before it terminates, eith- \ner by resolution, or, which is more common, by reaching a still \nhigher degree of intensity \xe2\x80\x94 a grade which, like the former, it \nmay assume from the beginning. This stage or degree of the \ninflammation generally supervenes suddenly on the condition \njust described ; and from its great violence may work irrepara- \nble mischief to the organ within a few hours. The pain is now \nsevere, and of a burning, aching or stabbing character ; the \ngranulations become warty and luxuriant ; the lids swell enor- \nmously ; the purulent discharge becomes profuse ; and a condi- \ntion of the palpabral conjunctiva succeeds similar to what oc- \ncurs in the third stage of acute purulent ophthalmia, except as \nmodified by the granulated state of the lids. \n\nRESULTS. \xe2\x80\x94 The ordinary and characteristic results of \nchronic purulent ophthalmia, are such as arise from the thick- \nening and granulation of the lids. Even after the removal of \n\n\n\n128 GRANULAR CONJUNCTIVITIS. \n\nthe symptomatic affections, so long as the granulations exist \nthere will remain more or less weakness of vision, arising from \nirritation, together with swelling of the eyelids, a lessening of \nthe palpebral fissure, and, in some cases, more or less eversion \nof the tarsi. \n\nIn addition to these changes, there is commonly more or \nless vascularity and opacity of the cornea, generally of its \nupper half, arising from the friction of the granulated surface of \nthe conjunctiva, which is chiefly limited to the upper lid. The \nvascularity of the mucous covering of the cornea may become \nso great as to constitute what is technically termed pannus. As \nthe results of severe inflammation, we may also have ulcer, \nleucoma, prolapsion and adhesion of the iris, and staphyloma. \n\nPrognosis. \xe2\x80\x94 This is generally favorable ; though there \nwill always remain great liability to relapse, the weakened ves- \nsels of the conjunctiva becoming congested by very slight caus- \nes. The constitution, habits and occupation of the patient, as \nwell as the state of tne weather, and other accidental circum- \nstances, will have much to do with the progress and termina- \ntion of the case. The disease which appears greatly improved \nto-day, may be greatly aggravated to-morrow. In this way \nmonths and even years sometimes elapse, the superficial and \ninterstitial changes of the palpebral conjunctiva gradually be- \ncoming greater and greater, until it is even doubtful in some \ncases whether the affected membrane can ever be fully restored \nto a healthy state. \n\nEtiology. \xe2\x80\x94 The causes of chronic purulent ophthalmia \nare the same as those which give rise to the acute form,and need \nnot therefore be repeated. Less commonly, the disease suc- \nceeds to the acute form ; the latter, owing to bad management, \nor some vice of the constitution, not undergoing complete reso- \nlution. , \n\nTreatment.* \xe2\x80\x94 As surgeon in charge of the Ophthalmic \n\n*See Am. Ho7n. Obs., vol. ^., p. 466. \n\n\n\nPRACTICE OF MEDICINE. 120, \n\nDepartment of Brown General Hospital, our experience in the \ntreatment of this disease during the late war was by no means \ninconsiderable ; and as the result of that experience, and of \nover twenty years practice in civil life, we desire at the outset \nto express our emphatic disapproval, except in the inveterate \nform called trachoma ficosa, of the escharotic method of treat- \nment. We are convinced that the indiscriminate use of power- \nful escharotics in every form and stage of the complaint, has \nbeen the means of practicing, and, in many cases, of confirm- \ning this formidable affection ; (1) by aggravating the local ex- \ncitement ; (2) by increasing the tendency to relapse ; (3) by \nrenewing and increasing the inflammation ; and (4) by taking \nthe place of more rational and efficient treatment. So far as \nlocal measures are concerned, the following distinctions will be \nfound to be of great practical importance : \n\n1. When the conjunctiva, instead of having its natural pol- \nished surf ace, is villous or velvety, or when the gra7iulations are \nsmall, pale, and sand- like ; in short, when the so-called granula- \ntions are quite recent, or when they consist simply in a swollen \nor hypertrophied state of the conjunctival papillce escharotics \nare unnecessary, and generally harmful. In these cases, the ap- \nplication of cold salt-water compresses, whenever demanded by \nan increase of inflammatory action, and the employment, in the \nintervals, of mild astringent lotions, such as we have recom- \nmended for the acute form, with due attention to diet, pure air, \nand exercise, with repose and protection of the organ,* will \ngenerally be found to give the most prompt, marked and per- \nmanent relief. \n\n2. When the granulations are large, flabby, and easily \ntorn y the above treatment, aided by internal remedies, may still \nhold them in check, and even promote their absorption ; if not, \n\n\n\n* Dr. Dobrowelski, of St. Petersburg, in Annates a Oculistique, pointr out the com- \nparative value of blue, and grey or smoked glasses as a protection against the sun\'s rays, \ngiving the preference to the latter. See Am. Horn. Obs., vol. xi. p, 555. \n\n\n\n130 GRANULAR CONJUNCTIVITIS. \n\nit may be aided by a wash of Kali HYDRIODICUM, or by touch- \ning them with a crystal of the Sulphate of Copper, the lat- \nter being used only to suppress the exuberance of the granula- \ntions. \n\n3. When the granulations have a firm, pale, zvart-like \nappearance, and cnt like cartilage, escharotic treatment is not \nonly admissable, but required. In these cases we have derived \nthe greatest benefit from passing a pencil of Argent. CUM, \nCALCE freely over the granulated surface, being particular be- \nfore restoring the lid to its natural position, to wash it carefully \nwith water or diluted vinegar, in order to prevent any farther \naction of the escharotic. (See Fig. 5.) This application should \nnever be repeated oftener than once a week, nor the sulphate of \ncopper oftener than once in two, three or four days, according to \nthe amount of local excitement produced by it ; remembering in \nall cases that, whenever local treatment causes any aggravation \nof the symptoms, the irritation and increased vascularity must \nbe allowed to subside before repeating it ; that some cases will \nbear much stronger applications than others ; that when their \nuse is attended by a sense of relief, they are always beneficial ; \nbut when pain and increased vascularity are permanently ex- \ncited by them, they will always do harm, especially if too fre- \nquently applied. \n\nThe internal remedies especially adapted to this variety of \nophthalmic inflammation, in addition to those previously re- \ncommended, are : \n\nAcidum nit. \xe2\x80\x94 This medicine is suitable for most cases of \nchronic purulent ophthalmia, especially such as are associated \nwith a syphilitic or mercurial cachexia. \n\nGraphites. \xe2\x80\x94 This medicine is especially indicated when \nthe edges of the lids are implicated, particularly the meibomian \nfollicles. \n\nIodium. \xe2\x80\x94 -This remedy is adapted to every stage of the \ncomplaint, especially when there is a psoric state of the sys- \ntem. \n\n\n\nPRACTICE OF MEDICINE. 13 1 \n\nKali Hydriodicwn. \xe2\x80\x94 In cases similar to those for which \nIodium is recommended. \n\nLycopodium. \xe2\x80\x94 Specially adapted to casrs attended with \ninflammation and ulceration of the tarsal edges. \n\nMercurius. \xe2\x80\x94 This remedy is no less useful in the chronic \nthan it is in the acute form of purulent ophthalmia. \n\nSulphur. \xe2\x80\x94 The same remark may also be applied to this \nremedy, which is particularly adapted to the chronic form of \nthe complaint, especially when attended with ulceration. \n\nThuja. \xe2\x80\x94 We mention this remedy because it is strongly \nrecommended by others, and not because we have had any \nexperience with it ourselves. \n\nFor other medicines and for fuller details, see Tablts XIV. \nand XV. ; consult, also Therapeutic Indicatioiis, at the end of \nthe Section on Ophthalmic Diseases. \n\nDiet and Regimen. \xe2\x80\x94 As granular conjunctivitis is not \npnly contagious, but, like the simple form of purulent ophthal- \nmia, is aggravated by squalor, impure air, want of cleanliness, \nimproper or deficient nourishment, over-crowding of apartments, \ndampness, miasm, etc., it follows that too much attention can- \nnot be paid to hygienic regulations. Indeed, experience shows \nthat without due attention to these particulars, in the vast ma- \njority of cases the improvement, if any, will be slow and un- \nsatisiactory ; while on the other hand, good nutritious food, \nclean clothing and comfortable surroundings contribute in no \nsmall degree towards affecting a permanent cure. \n\n\n\n132 PRACTICE OF MEDICINE. \n\nC,\xe2\x80\x94 Conjunctivitis Gonorrhoea. \n\nACUTE GONORRHCEAL OPHTHALMIA. \n\nThis variety of conjunctivitis differs in no essential respect \nfrom the acute form of purulent ophthalmia already described, \nexcept in the specific nature of the exciting cause, and in the \nmore violent and rapidly destructive character of the inflam- \nmation. Instead, therefore, of giving a detailed description of \nsymptoms, which, for the most part, would be but a repetition \nof those mentioned in the preceding article, we shall content \nourselves with merely pointing out the characteristic features \nof the disease, by way of \n\nDIAGNOSIS. \xe2\x80\x94 Gonorrhceal conjunctivitis in its most severe \nform is, with perhaps a single exception, the most rapidly de- \nstructive form of purulent ophthalmia known ; frequently de- \nstroying the eye, or producing irreparable mischief to the organ, \nwithin a few hours. The disease, which at first is generally \nconfined to the conjunctiva, producing symptoms similar to \nthose of simple catarrhal or purulent ophthalmia, soon extends \nto the globe, causing the most severe and agonizing pains in \nthe head and eye, accompanied with great chemosis, excessive \nphotophobia, and a more or less violent febrile movement of \nthe circulation. At this stage the tumefaction, both of the lids \nand the orbital conjunctiva, is extreme, completely closing the \neye, and rendering a satisfactory view of the cornea utterly im- \npossible. As the oedema declines, one or both of the eyelids \ngenerally become everted, producing temporary ectropium. \n\nAs between the highest degree of catarrhal inflammation \nand the milder form of simple purulent ophthalmia there is a \nstriking resemblance in the local symptoms, so between the \nseverest grade of purulent inflammation and acute gonorrhceal \nophthalmia there is a similar resemblance. The swelling of \nthe eyelids, which is always considerable, is generally more \nmarked in the former, while the chemosis, or oedema of the con- \n\n\n\nCONJUNCTIVITIS GONORRHOICA. 1 33 \n\njunctiva oculi, is greater in the latter; the discharge, also, is \ngenerally of a brighter yellow, more creamy in consistence, and \nmore abundant. But the chief difference between them is that \nthe latter sets in suddenly with the greatest violence, and \nproceeds with such rapidity as to terminate in a few hours or \ndays, either by resolution, or what is more common, by destruc- \ntion of the organ. Again, gonorrhceal ophthalmia, with but \nfew exceptions, attacks only one eye, while the purulent or con- \ntagious disease generally affects both. Finally, sloughing of the \ncornea, which is a frequent consequence of gonorrhceal inflam- \nmation; seldom or never occurs in simple purulent ophthalmia. \n\nRESULTS. \xe2\x80\x94 The immediate results, unless relieved by treat- \nment, are : ulceration, suppuration, and more or less sloughing \nof the cornea, together with interstitial deposition into and be- \ntween its laminae. The more remote consequences are : corneal \nopacity, synechia anterior, obliteration of the pupil, staphyloma, \nand collapse of the globe. Sometimes the sloughing process, \nthough general, is limited to the anterior laminae of the cornea, \nthe posterior layer or membrane of the aqueous humour being \nleft, so that the anterior chamber is not exposed ; in which case \nthe front of the eye remains flattened, or is bulged forward by \nthe protruding iris, forming what is called stapliyloma racemo- \nsum. \n\nPrognosis. \xe2\x80\x94 In a large proportion of cases, vision is either \nlost or seriously injured. Since the inflammation is not equally \nviolent in all cases, the prognosis chiefly depends upon its \ncomparative mildness or severity, and upon the state of the \ncornea. If the latter should be clear, the sight may be saved ; \nbut if it has lost its transparency, and especially if the inflam- \nmation is of the most acute character, vision will probably be \nlost or seriously impaired. On the other hand, if the inflam- \nmation be subdued before extensive sloughing or ulceration \noccurs, the sight may be restored. \n\nETIOLOGY. \xe2\x80\x94 This form of ophthalmic inflammation always \n\n\n\n134 PRACTICE OF MEDICINE. \n\narises from some kind of connection, either innoculative, con- \nstitutional or metastatic, with the gonorrhceal virus. It has \nbeen satisfactorily proven that the application of gonorrhoeal \nmatter, either from the patient\'s own urethra or from that of \nanother person, is capable of exciting the disease in its most \nintense form. In a large proportion of cases, however, no such \ndirect application of matter can be traced ; and hence the in- \nference is unavoidable, that the disease frequently arises either \nfrom metastasis, as orchitis or mammitis arises from mumps, or \nelse that it depends upon some peculiar condition of the con- \nstitution, in the same manner that rheumatic or arthritic oph- \nthalmia depend upon similar states of the system to those in \nwhich they respectively occur. Probably the latter hypothesis \nis the true one, since the urethral inflammation is never sup- \npressed by the transference of the disease to the eye, and \nhence a true metastasis, or translation of the disease, cannot be \nsaid to occur in these cases. Moreover, the sudden stoppage \nof gonorrhoea by treatment is not followed by ophthalmic in- \nflammation, and hence its origin cannot be referred to the cessa- \ntion of the disease in the urethra. \n\nTreatment. \xe2\x80\x94 The treatment, both local and general, \nshould be similar to that recommended for acute purulent oph- \nthalmia. The first application should consist of a saturated \nsolution of Ar^entum Nitratum, which should be promptly \napplied to the diseased surfaces, in the manner described under \nthe head of ophthalmia neonatorum. After the swelling and \nother effects of the application subside, the remedy should be \nrepeated, observing to lessen the strength of the solution in \nproportion as the purulent discharge diminishes and the inflam- \nmation abates. As a general rule, one application per day will \nbe found to suffice, provided it be sufficiently thorough. It is \nbest made by everting the lids, and passing the camel\'s hair \npencil, loaded with the solution, quickly over the distended \nconjunctiva, taking care to avoid touching the cornea, and to \n\n\n\nCONJUNCTIVITIS GONORRHOICA. 1 35 \n\nwash the lids afterwards with tepid water before returning \nthem, especially the first time the application is made. (See \n\nFig- 5-) \n\nIt should be borne in mind that the saturated solution of \nArg. nit. here recommended is required only in the severest \nform of the disease. Many cases of gonorrhceal ophthalmia \nare so mild as to resemble the simple purulent form of conjunc- \ntivitis, and then require the same treatment. [See \xc2\xa7 B.) \n\nLight linen rags wet with a weak solution of Alum en or \nMuriate of Hydrastia, and frequently renewed, should be kept \nconstantly applied to the affected eye. \n\nThe internal treatment consists mainly of the following \nremedies : \n\nAcidum Nitricum. \xe2\x80\x94 This remedy is not only pathogen et- \nically appropriate, but its use in this form of ophthalmia has \nbeen attended with the best results. \n\nCannabis sativa. \xe2\x80\x94 This medicine, used low, is useful in \nevery stage of the complaint, especially if there is opacity of \nthe cornea, or a spasmodic pressure of the lids. \n\nCantharis. \xe2\x80\x94 This remedy is indicated in the first stage, \nwhen attended with violent stinging and burning pains in the \neye and urethra. \n\nClematis \xe2\x80\x94 This medicine is most useful in the latter \nstages of the disorder, in cases similar to those for which Can- \ntharis is recommended. \n\nHepar siilph. \xe2\x80\x94 This is one of our best remedies in gon- \norrhceal ophthalmia, especially in the second and third stages. \n\nMercurins. \xe2\x80\x94 The same remark applies to this remedy, \nMercurius being one of the best, if not the very best remedy \nfor this complaint ; it is more particularly adapted to the high- \nest state of inflammatory action. \n\nAdditional remedies for this disorder are given in TABLES \nXIV and XV ; consult also the THERAPEUTIC INDICATIONS \nat the end of the Section on Ophthalmic Diseases. \n\n\n\n136 PRACTICE OF MEDICINE. \n\n3.\xe2\x80\x94 Diphtheritic Conjunctivitis. \n\nOPHTHALMIA DIPHTHERITICA; CONJUNCTIVIVAL CROUP. \n\nClosely allied in some respects to gonorrhceal conjunctivi- \ntis, but differing widely in others, is the diphtheritic. This \ndisease, which seldom occurs in an idiopathic form in this \ncountry, and still more rarely in England and France, is not \nuncommon at Berlin and in Holland. As it appears with us \nit is most commonly associated with diphtheria in other parts, \nespecially the throat, from which it is transferred either by di- \nrict contact of the irritating secretions, by sympathy, or by ex- \ntension of the disease from the nasal passages through the \nlachrymal canals.* The violence of the disease is such as to \nrender it extremely dangerous to vision ; and when secondary, \nthe danger is greatly increased by the liability to constitutional \ninfection. The idiopathic form is characterized by the follow- \ning \n\nSymptoms. \xe2\x80\x94 The disease sets in suddenly, with heat, pain \nand stiffness of the lids, which soon become distended, hard and \nrigid, owing to a fibrinous exudation into the conjunctival \nand episcleral tissues. There is also chemosis of the ocular \nconjunctiva, from effusion of the same fibrinous material, the \npressure of which upon its vessels, by interfering with the cir- \nculation, gives rise to scattered points of extravasated blood. \nThe discharges are at first thin, watery, and of a dirty gray \ncolor, or yellowish and flocculent ; afterwards they become more \nor less purulent, the pus globules being mixed with shreds of \nfibrin and disintegrated false-membrane. On examining the \nlids, the palpebral conjunctiva is found to be covered with a \nfirm fibrinous membrane, which manifests a disposition to sep- \narate at the edges, and may be easily detached with the for- \nceps. The rapidity with which it is reproduced is truly aston- \n\n\n\n* See Am. Horn. Obs., vol. v, pp.70, 71. \n\n\n\nDIPHTHERITIC CONJUNCTIVITIS. 137 \n\nishing, the false-membrane sometimes attaining a thickness of \ntwo or three lines in the course of twenty-four hours. \n\nEtiology. \xe2\x80\x94 The exciting causes of diphtheritic conjunc- \ntivitis are doubtless the same as those which give rise to diph- \ntheria in other parts ; hence it is found to prevail during the \ncold and damp seasons of the year Although adults are \nsometimes attacked, it is generally confined to children between \ntwo and ten years of age. According to Williams, some fam- \nilies exhibit a constitutional predisposition to the complaint, \nthe children being successively attacked on reaching a certain \nage. \n\nPrognosis. \xe2\x80\x94 The result, notwithstanding the greatest care \nand attention, is apt to be unfavorable. The chief danger lies \nin the great liability to ulceration and sloughing of the cornea \nfrom defective nutrition, the corrosive action of the secretions, \nand the strangulation of the implicated tissues. As an ultimate \nconsequence, we sometimes have entropium, the result of con- \ntraction and other structural changes in the conjunctiva and \ntarsal cartilages. \n\nTreatment. \xe2\x80\x94 The local treatment should be similar to \nthat already recommended for Acute Purulent Conjunctivitis, \nusing, when well borne, ice and ice-water compresses in the first \nstage, to which may be added a solution of Kal. chl., 3ij to Oj. \nIn the second stage, when the discharge becomes thick and \npurulent, the escharotic treatment recommended for Gonorrhe- \nal Conjunctivitis, should be adopted. (Seethe previous section.) \nIf only one eye is affected, the other should be bandaged as a \nprecautionary measure. \n\nThe internal remedies which have given the greatest satis- \nfaction, and from which most benefit may be expected, are the \nfollowing: Aconite, Kali chl., Kali bich., Phytotacco dec, during \nthe first stage : Acidum nit., Argentum nit., Arsenicum, Hepar \nsulph., Mercurius ; during the purulent and ulcerative stage \nSee also Tables XIV. and XV., and the Therapeutic Indica- \ntions at the end of the Section on Ophthalmic Diseases. \n18 \n\n\n\n138 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\nDiet and Regimen. \xe2\x80\x94 Cleanliness, which is of primary \nimportance in every form of contagious ophthalmia, should be \nrigidly enforced in this, especially if but one eye is affected \nsince, should both eyes become involved, the danger to vision \nwill be proportionably increased. For this purpose an abund- \nance of soft clean rags should be kept on hand, which should, \nbe burned, or otherwise destroyed, as fast as used. Care \nshould be taken, also, to supply the patient with clean clothes \nnutritious and easily digestible food, clean and comfortable bed- \nding, and an abundance of fresh pure air. If, as frequently is \nthe rooms are small or over-crowded, a liberal use of Carbolic \nAcid, or other suitable disinfectant, should be made, while at \nthe same time the freest possible ventilation should be secured. \n\n\n\n4.-SCR0FUL0US CONJUNCTIVITIS. \n\nSCROFULOUS OR PHLYCTENULAR OPHTHALMIA. \n\nFig - 6 - Scrofulous ophthalmia, as \n\nits name imports, is an in- \nflammation of the eye occur- \nring in scrofulous subjects. \nIts principal seat is the con- \njunctiva oculi, but it also af- \nfects, the episcleral tissue \nand cornea ; and sometimes, \nscrofulous conjunctivitis. in complicated cases, it ex- \n\ntends to the choroid coat and iris. The disease is almost en- \ntirely confined to childhood ; it is said never to occur in infants \nat the breast, and it is rarely seen after puberty. \n\nSymptoms. \xe2\x80\x94 The disease seldom occurs in a purely \nsimple form, but as already stated, is generally associated \nwith more or less inflammation of the cornea and epis- \ncleral tissue, constituting what is called scrofulo-rheumatic \nophthalmia. It is chiefly characterized by a number of \n\n\n\n\nSCROFULOUS CONJUNCTIVITIS. 1 39 \n\nvessels occupying a circumscribed part of the orbital con- \njunctiva, generally that which borders upon the commissures \nof the eyelids, pursuing nearly a parallel course towards the \ncornea, and forming with each other fasciculi or bundles, which \nterminate abruptly near the edge of the cornea, without going \nbeyond it. (See Fig. 6.) When, however, the disease is com- \nbined with catarrhal inflammation, the vessels may extend be- \nyond the border of the cornea, where they assume the fascicular \nform characteristic of the scrofulous injection. These fasciculi \ngenerally terminate in one or more small vesicles, called phlyc- \ntaena, which, though not belonging exclusively to this affection, \nare nevertheless so characteristic of the disease, as almost to \njustify the term phlyctenular ophthalmia, by which it is some- \ntimes called. The vesicle or phlyctaena generally appears first, \nand afterwards the vessels which run towards it become inject- \ned. The vesicle either dries up and disappears, or else breaks, \nleaving a superficial ulcuscle, which extends itself by ulceration. \nSometimes the cornea, instead of being ulcerated, takes on a \nmammillated nebulous appearance, becoming as it were sanded \nor dotted over with a number of extremely fine points ; (non- \nvascular or diffuse keratitis ;) or a papulous exudation arises, \n(vascular keratitis) whichforms a grayish vascular covering to the \ncornea, giving rise to what is called pannus. \n\nThe external redness, unless the disorder is complicated \nwith catarrhal inflammation, is generally inconsiderable. On \nthe other hand, owing partly to its combination with keratitis, \nand partly to nervous or ciliary irritation, the sensitiveness to \nlight is so extreme as to constitute a distinguishing feature of \nthe disease, under the name of photophobia scrofulosa. The \naccess of light to the eye is so extremely painful as to cause the \nchild to turn its head obstinately from the light, and, in severe \ncases, to hide away in the dark, or bury its face in its mother\'s \nlap, or in the bed. If the lids are forced open \xe2\x80\x94 which, how- \never, need never be done, as both the pain and photophobia \n\n\n\n140 PRACTICE OF MEDICINE. \n\ngenerally abate at dusk, when the child will open its eyes of its \nown accord \xe2\x80\x94 although the cornea is turned up so as to hide the \npupil from view, the orbicularis palpebrarum muscle becomes \nspasmodically contracted on the globe, producing so much \npressure as to cause the child to cry with pain. In uncomplica- \nted cases, neither pain nor tears accompany the disorder ; but, \nas already stated, the complaint is generally associated with \nkeratitis, so that, in addition to the pain \xe2\x80\x94 which, as already \nexplained, depends partly upon inflammation of the cornea, \nand partly upon sympathetic or nervous irritation \xe2\x80\x94 there is \ngenerally a copious flow of tears, especially at the commence- \nment of the disease. These greatly aggravate the complaint, \nby excoriating the parts over which they flow, producing more \nor less soreness and itching of the lids and face. This is still \nfarther augmented by scratching and rubb\'ing, which inflame \nthe skin and sometimes give rise to an eczematous or impetig- \ninous eruption, which not only incrusts the affected parts, but \nmay even extend over the head and body. \n\nOwing to the scrofulous disposition of the patient, the dis- \nease has a natural tendency to become chronic, or at least to \nbe reproduced by every new influence of an exciting cause, so \nthat after one attack has been overcome, another frequently \ntakes its place, either in the same or the other eye, and thus the \ndisease may continue for months and years, and perhaps never \nreach a permanent and satisfactory conclusion. \n\nRESULTS. \xe2\x80\x94 The pustules or phlyctaena which form at the \nextremities of vascular fasciculi, or near the junction of the \ncornea with the sclerotica, frequently ulcerate, the ulcers some 4 \ntimes extending superficially, at others penetrating into the \ncorneal substance ; in the latter case they may open into the \nanterior chamber, and cause prolapsion of the iris. In addition \ntion to these results, we have in some instances, pannus, inter- \namellar effusions into the cornea, onyx, hypopion, leucoma, \nsynechia anterior, and staphyloma. When the inflammation \n\n\n\nSCROFULOUS CONJUNCTIVITIS. 141 \n\nextends to the choroid coat and iris, alterations, more or less \nserious, of those membranes occur. \n\nDIAGNOSIS. \xe2\x80\x94 Scrofulous ophthalmia is generally easily \ndistinguished by the great intolerance of light, the vesicular \nelevations of the conjunctiva, the vascular fasciculi, and the co- \nexistence of scrofulous symptoms in other parts of the body. \nWhen, as frequently happens, the absorbent glands of the neck \nare inflamed and swollen, the alae of the nose red, swollen and \nexcoriated, and the ears sore and excoriated behind ; and when, \nin addition to these symptoms, there is a disordered state \nof the stomach and bowels, generally characterized by a fetid \nbreath, furred tongue, morbid appetite, swollen abdomen and cos- \ntiveness, it is scarcely possible to mistake the affection. Indeed, \nsuch is the severity of the ciliary irritation and consequent pho- \nphobia in these cases, as of itself to constitute an almost certain \nguide to the nature of the complaint. It is well to remember, \nin this connection, that there is a troublesome form of ophthal- \nmic inflammation occurring in strumous children, which is main- \nly dependent upon the state of the primae viae and skin, but \nwhich does not exhibit, in any marked degree, the features of \nordinary scrofulous ophthalmia. There is generally more ex- \nternal redness, especially of the lids, and but little intolerance \nof light ; still the disease is esentially scrofulous in its nature, \nand, like other scrofulous diseases, is extremely obstinate, and \nand continually apt to recur. \n\nPROGNOSIS. \xe2\x80\x94 This, so far as vision is concerned, is gener- \nally favorable, provided the cornea remains clear, or, if opaque, \nthe opacity is merely superficial, or is simply owing to intersti- \ntial deposition. Vascularity and inter-lamellar depositions gen- \nerally disappear soon after the subsidence of the inflammation ; \neven pannus, though it may last a long time, does not endanger \nthe sight. Ulceration produces more or less permanent opacity ; \nand when extreme, especially if attended with prolapsion of the \niris, it generally causes serious injury to vision. Staphyloma \n\n\n\n142 PRACTICE OF MEDICINE. \n\nand bursting of the cornea are of course always attended by \nthe most disastrous consequences. \n\nEtiology. \xe2\x80\x94 The chief predisposing cause of scrofulous \nophthalmia is a strumous condition of the system. The excit- \ning causes are such as, by depressing the vital powers, are cal- \nculated to call into action the scrofulous diathesis, such as cold, \ndamp and variable weather, inadequate clothing, poor and im- \nproper nourishment, dark and unwholesome dwellings, insuffi- \ncient exercise in the open air, disorders of the digestive system, \nand an inactive state of the skin, bowels and uterine organs. \nIt likewise occurs, for the same reason, after any protracted ill- \nness, such as the various exanthemic fevers, whooping cough, \netc. On the other hand, if the strumous disposition be strong, \nthe disease may by provoked by mechanical injuries, excessive \nuse of the eyes, want of cleanliness, and even by a change of \nseason. Not unfrequently the disease alternates with other af- \nfections, such as otorrhcea, cutaneous eruptions, etc. \n\nTteatment. \xe2\x80\x94 This should be general as well as special, \nthat is to say, the treatment should be directed against the gen- \neral unhealthy state of the system \xe2\x80\x94 the scrofulous diathesis \xe2\x80\x94 \nas well as against the attack itself ; this is necessary in order \nboth to remove the local affection and prevent relapse. The \ntreatment should also have relation to the particular form of \nthe attack, whether as simple or complicated ; the former will \nrequire, more especially, the antipsoric remedies, such as Calca- \nrea, Hepar sulph., Sulphur, etc. ; while the latter will require \nthose best adapted to the particular complications, such as Bel- \nladonna, Mercurius, etc. \n\nCold applications are, as a general rule, injurious to scrofu- \nlous sore eyes, and should therefore seldom be employed ; \nnever, indeed, unless the inflammation is combined with some \nother form of ophthalmia ; even in these cases warm applica- \ntions will be more suitable, and will commonly give most relief. \nIt is generally sufficient, so far as local treatment is concerned, \n\n\n\nSCROFULOUS CONJUNCTIVITIS. 1 43 \n\nto bathe the eyes frequently with tepid water, and to shade \nthem with a stiff crescent-shaped screen, which is preferable to \na bandage, as it neither overheats the eyes, nor deprives them \nof the beneficial effects of fresh air. \n\nThe principal remedies for scrofulous ophthalmia are the \nfollowing : \n\nAcidum Nitricum is especially adapted to protracted cases, \nparticularly when the cornea has become nebulous, or clouded \nwith dark spots. \n\nApis mellifica. \xe2\x80\x94 This remedy, though it appears to be indi- \ncated in many cases, is generally of doubtful value. We have \ncommonly found it to prove most useful in the first stage of \npurely scrofulous cases, attended with burning and stinging \npains, redness of the conjunctiva, extreme photophobia and \nlachrymation, a nebulous state of the cornea, and an eczematous \neruption on the lids and face. \n\nArsenicum* \xe2\x80\x94 This remedy is particularly adapted to pro- \ntracted cases, especially such as are subject to frequent relapses, \ncharacterized by photophobia, keratitis, redness of the lids and \nburning, itching and excoriation of the surrounding integuments. \n\nBellado7i7ia.-\\ \xe2\x80\x94 This medicine is indicated in cases compli- \ncated with catarrhal or rheumatic ophthalmia, especially if the \npains are accompanied with acute febrile symptoms. \n\nCalcarea Carb.% \xe2\x80\x94 One of the best antipsoric remedies, \nespecially adapted to purely scrofulous cases of a protracted \ncharacter, and subject to frequent relapses. \n\nCannabis sat. is indicated in chronic cases attended with \ncorneal opacity. \n\nConium mac. \xe2\x80\x94 Chronic cases, attended with photophobia, \n\n* See Am. Horn. Obs.^ vol. vil, pp. 120, 121. (3d and 30th.) \n\nt Ibid. (3d). \n\n% See Am. Horn. Obs., vol. vii. p. 120. {30th and 200th\xc2\xbb) \n\n\n\n144 PRACTICE OF MEDICINE. \n\nspasms of the orbicularis, redness, burning and itching of the \neyes and lids, and an eczematous or impetiginous eruption, \nwith soreness and excoriation of the neighboring parts. \n\nGraphites. \xe2\x80\x94 This remedy is adapted to both acute and \nchronic cases, especially if accompanied with eruptions in the \nface and behind the ears. \n\nHepar sulph* \xe2\x80\x94 This is one of the best anti-scrofulous rem- \nedies, particularly adapted to protracted and relapsing cases, \nespecially if attended with ulceration of the cornea. \n\nMercurius. \xe2\x80\x94 This medicine is well adapted to both acute \nand chronic cases, being equally applicable to the inflammatory, \nexudative and ulcerative stages of the complaint. It is one of \nour most valuable remedies for scrofulous ophthalmia, and \nshould therefore, in most cases, be used early, and not too \nhastily discontinued. \n\nPulsatilla. \xe2\x80\x94 This medicine being well adapted to lym- \nphatic constitutions, is especially suited to those cases depend- \ning on stomachic and uterine derangements, whether acute or \nchronic. \n\nRhus tox/* \xe2\x80\x94 This remedy, notwithstanding its somewhat \ndoubtful indications, has done good service in scrofulous oph- \nthalmia, especially when attended with photophobia, lachryma- \ntion, spasms of the lids, and exanthematous or herpetic erup- \ntions. \n\nSilicea. \xe2\x80\x94 This remedy is well adapted to chronic cases, at- \ntended with ulceration and opacity of the cornea, swelling of \nthe cervical glands, and cutaneous eruptions on the lips and \nface. \n\nStaphysagria. \xe2\x80\x94 This medicine has been found useful in \nscrofulo-rheumatic ophthalmia, accompanied by spasmodic \nclosure of the lids, glandular swellings, and cutaneous eruptions. \n\nSulphur* \xe2\x80\x94 This powerful antipsoric remedy is indicated \n\n* See Am. Horn. Obs., vol. vii., pp. 120. 121. {3d and 30th.) \n\n\n\nPHLYCTENULAR CONJUNCTIVITIS. 145 \n\nin all chronic and relapsing cases, especially when the cornea \nis deeply involved, as in pannus, ulceration, interstitial deposi- \ntion and onyx. \n\nThe remedies above mentioned are those of chief import- \nance in the treatment of the ordinary forms of scrofulous oph- \nthalmia ; but inasmuch as the disease is frequently complicated \nwith other forms of ophthalmic inflammation, the prescriber is \nreferred for additional remedies* and details to Tables XIV. \nand X V. ; and also to the Theraptutic Indications given at the \nend of the Section on Ophthalmic Diseases. \n\nDIET AND REGIMEN. \xe2\x80\x94 The diet should be of the most \nnourishing and digestible character, consisting, for the most \npart, of good home-made wheat bread, graham bread, oat-meal \npudding, fresh butter, tender and juicy beef, good ripe fruit, \ndried fruit, etc. ; while all such articles as pork, sausage, bacon, \nveal, coffee, pickles, pastry, etc., should be rigidly excluded. \n\nSuitable and adequate clothing, with proper attention to \nlight, air and exercise, will do much to ward off the disease from \nthose that are predisposed to the affection, and to mitigate it \nwhen established. \n\n5-PHLYOTENULAR CONJUNCTIVITIS. \n\nAPTHOUS, HERPETIC OR PHLYCTENULAR OPHTHALMIA. \n\nFig. 7 \n\nPhlyctenular Conjunctivitis, \nor, as it is sometimes impro- \nperly called, pustular ophthalmia, \nis a mild form of conjunctivitis, \ncharacterized by an eruption of \nphlyctenular conjunctivitis. vesicles, called phylyctcence ox phly- \nctenules, on or near the margin of the cornea. The eiuption \nfirst makes it appearance in the form of small red, slightly \nelevated points upon the inflamed conjunctiva oculi ; these \npoints as they enlarge develope into vesicles ; and finally, if the \n\n* See Am. Horn. O&s., vol. vi, p. 559. \n*9 \n\n\n\n\n146 PRACTICE OF MEDICINE. \n\ninflammation goes on unchecked, the vesicles burst and form \nulcers, which in mild cases gradually disappear, but in others \nmanifest a disposition to spread. Numerous vessels, or bundles \nof vessels, {vascular fasciculi,) run toward the cornea, but never \npass beyond the borders of the vesicles or ulcers, in which they \nalways terminate. {See Fi%. 7.) The phlyctaenae vary in size \nas well as in number, solitary ones being sometimes nearly as \nlarge as a split pea ; generally, however, they are much smaller, \ntheir relative dimensions being usually in an inverse ratio to \ntheir number. Phlyctaenae are not peculiar to this form of \nophthalmia, being, as we have already seen, sometimes observed \nin other forms of conjunctivitis, especially the catarrhal and \nscrofulous ; indeed, some opthalmologists regard the phlyctenu- \nlar as a modification of strumous conjunctivitis, intermediate in \ncharacter between the catarrhal and scrofulous. Like the latter, \nit is almost entirely confined to children, but unlike it is seldom \nattended with ciliary irritation and photophobia, though gene- \nrally occurring in scrofulous subjects. It is only when the \nvesicles are numerous, and are situated wholly or partly on the \ncornea, that there is much intolerance of light, lachrymation, or \nciliary irritation. \n\nTreatment. \xe2\x80\x94 Many cases are so mild as to require little \nmore, in the way of treatment, than rest and protection of the \norgan. When arising from fatigue, the irritation of dust, or \nother similar causes, hygienic measures alone will generally \nsuffice. This is especially true if the vesicles are solitary, or but \none or two in number, and are situated over the sclerotica. \nSevere cases are benefited by warm fomentations, and by the \nparticular treatment recommended for scrofulous conjunctivitis, \n(which see.) The most efficient remedy for ulceration is Mer- \ncurius, which may be prescribed with as much confidence in \nthis affection as in aphthous stomatitis. Other remedies which \nhave been found most useful for particular conditions, are the \nfollowing : \n\nCiliary Neuralgia : Atrop., Bell., Cham., Spigel. \n\n\n\nERYSIPELATOUS CONJUNCTIVITIS. 147 \n\nPhotophobia : Ant. tart., Ars., Bell, Con., Hepar, Merc, \nSpigel. \n\nUlceration, with or without ciliary irritation and photopho- \nbia : Ars., Merc. \n\nObstinate, the disease appearing to be seated in the sub-con- \njunctival tissue : Ars., Cham., Merc. \n\n6-ERYSIPELATOUS CONJUNCTIVITIS. \n\nThis form of ophthalmic inflammation is seated in the orbi- \ntal conjunctiva, and in the subjacent cellular tissue. The \ninjection of the conjunctival vessels becomes rapidly confluent, \nthe membrane swells, assumes a uniform pale red color, be- \ncomes relaxed and wrinkled, except at the lower part of the \nglobe, where it remains tumefied and presents a more or less \noedematous appearance. As there is neither epiphora nor \nphotophobia, it is reasonable to infer that the deeper structures \nare not involved. This description, however, applies only to \nidiopathic cases ; when secondary to facial erysipelas, the \ninflammation is generally of much greater severity. In these \ncases the episcleral and neighboring tissues sometimes \nparticipate, and then there is a deeper redness, with more or \nless intolerance of light and ciliary irritation. As an idiopathic \naffection, it is mostly confined to persons who have reached the \nperiod of middle life, or beyond, and whose constitutions are \ngenerally more or less debilitated. The chief exciting cause is \ncold, though the disease is sometimes of epidemic origin. \n\nTREATMENT. \xe2\x80\x94 Aconite and Belladonna, with warm fomenta- \ntions, generally constitute all the treatment required. When \nsecondary to facial erysipelas, remedies should be selected \nwith special reference to the primary disease. See Erysipelas \nof the Head and Face. \n\n7-EXANTHEMATOUS CONJUNCTIVITIS. \nThe contagious exanthemata are accompanied by inflam- \nmations of the conjunctiva corresponding in intensity to the \n\n\n\nI48 PRACTICE OF MEDICINE. \n\neruptive inflammations of the skin with which they are asso- \nciated. As they seldom demand special treatment, and are, for \nthe most part, neither sufficiently important nor peculiar to \nrequire minute description, we shall give them but brief con- \nsideration. \n\nA\xe2\x80\x94 Scarlatinous and Rubeolous Conjunctivitis. \n\nOPHTHALMIA SCARLATINOSA AND MORBILLOSA. \n\nIn scarlatina and measles, we have more or less redness and \ninflammation of the external membranes of the eye, with mode- \nrate pain or uneasiness, lachrymation, and sensibility to light. \nSometimes, though rarely, phlyctaenae and ulcers also appear \nupon the cornea, and occasionally interstitial depositions take \nplace between its laminae. The ophthalmic disorder generally \nkeeps pace with the cutaneous affection. It is less frequently \nassociated with scarlatina than with measles, of which it is a \ncommon attendant. \n\nTreatment. \xe2\x80\x94 When the conjunctiva alone is affected, the \ntreatment is the same as required for catarrhal ophthalmia, \n(which see.) Cool and tepid washes are generally agreeable, \nand with protection from light, and the occasional administra- \ntion of Aconite, the inflammation usually runs a satisfactory \ncourse. When the exanthemata are succeeded by severe con- \njunctivitis extending to the submucous tissues, and especially \nwhen attended with ulceration of the cornea, the treatment \nshould be much more active, in order to prevent opacity and \nloss of vision. In these cases, Aconite and Mercurius, with the \ndiligent use of the cold compress, will be required. \n\nB\xe2\x80\x94 Variolous Conjunctivitis. \n\nOPHTHALMIA VARIOLOSA. \n\nThis form of ophthalmia is seated in both the orbital and \npalpebral conjunctiva, and in the cutaneous covering of the lids. \nIt occurs conjointly with, and subsequently to the variolous \ndisease ; and not unfrequently it assumes a chronic form. \n\n\n\nVARIOLOUS CONJUNCTIVITIS. 149 \n\nMost commonly it is confined to the lids, the external surface \nof which, with their ciliary margins, are covered with a greater \nor less number of variolous pustules, which produce extensive \nswelling, and close the eyes. As the eruption declines, the \nswelling abates, and the globe of the eye is found uninjured. \n\nIn a small proportion of cases, however, (stated by some \nauthorities at about four per cent, of the whole number,) the \ninflammation likewise involves the conjunctiva and cornea. \nThis is what constitutes the true variolous ophthalmia, and is \nalways a dangerous disease. The inflammation is so violent, \nand proceeds with such rapidity, as to cause suppuration and \nmore or less sloughing. The results are in proportion to the \nextent and violence of the inflammation. Staphyloma, prolap- \nsion of the iris, synechia anterior, obliteration of the pupil, \nopacity of the cornea, collapse of the globe, and partial or com- \nplete blindness, are not uncommon terminations. \n\nTreatment. \xe2\x80\x94 The suppurative form of variolous ophthal- \nmia, which does not generally set in until after the decline of \nthe cutaneous affection, requires the same treatment as purulent \nconjunctivitis, (which see.) Treatment for the palpebral in- \nflammation will be given in the next article (which see.) \n\nART. II. \xe2\x80\x94 BLEPHARITIS. \n\nThe term blepharitis, signifying inflammation of the eyelids, \nis a general one, and may therefore be properly used to denote \nany variety of inflammation to which the lids are subject ; but \ninasmuch as these inflammations are mostly of a subacute or \nchronic character, as they occur for the most part in scrofulous \nsubjects, and as they are chiefly limited to the tarsal borders ; \nin other words, as they possess many features in common, we \nshall include under it the several conditions known as Ophthal- \nmia Tarsi, Psorophthalmia, Blepharitis Ciliaris, Eczema Pal- \npebrarum, etc., reserving the more acute, but less common forms \nof palpebral inflammation for separate consideration. \n\n\n\n150 PRACTICE OF MEDICINE. \n\nI-BLEPHAEITIS OILIAEIS. \n\nFOLLICULAR INFLAMMATION GF THE LIDS. \n\nBlepharitis ciliaris is an ulcerative inflammation of the edges \nof the eyelids, depending on a psoric or scrofulous condition \nof the system, or occurring as a sequence of measles and other \nexanthemata, styes, etc. \n\nSymptoms. \xe2\x80\x94 The disease commences as an eczematous \ninflammation of the cuticle of the edge of the lid, the epidermis \nof which either desquamates or suffers ulceration. The inflam- \nmation and ulceration produce suppuration, and the purulent \nmatter collecting at the roots of the cilia forms scabs, beneath \nwhich the ulcerative process continues. As the ciliary follicles \nbecome inflamed, the cilia loosen and drop out. The inflam- \nmation also invades the meibomian glands, or follicles, which \nwith the ciliary apertures may become permanently occluded. \nIn this manner the disease may continue until the whole ciliary \nborder becomes ulcerated, the outer surface of the lids, as well \nas the conjunctival lining, inflamed, the cilia destroyed, the \ntarsal edges thickened and indurated, and the puncta lachry- \nmalia everted, so that the tears overflow the lids ; ultimately, \nthe skin contracts so as to cause more or less ectropium. This \nis the state called lippitudo or blear eye. Sometimes, in chronic \ncases, the edges of the lids turn inwards instead of outwards, \nproducing trichiasis and entropium. The cilia by constant \ncontact with the globe may inflame the cornea, causing a super- \nficial vascular keratitis which may result in pannus. \n\nResults. \xe2\x80\x94 These are: loss of cilia, epiphora, lippitudo, \nectropium, entropium, trichiasis, diatrichiasis, opacity of the \ncornea, pannus, and more or less impairment of vision. \n\nETIOLOGY. \xe2\x80\x94 In addition to the causes already enumerated, \nnamely, scrofula, small pox, measles, erysipelas, etc., may be \nmentioned such causes as cold and damp air, smoke, dust, and \nother irritants, especially when acting on a psoric or strumous \nconstitution. \n\n\n\nBlepharitis ciliaris. 151 \n\nPROGNOSIS. \xe2\x80\x94 This disease is always protracted, and subject \nto frequent relapses. In its earlier stages, before ulceration has \ninvolved the entire margin of the lids, destroyed the cilia, and \nproduced hypertrophy of the palpebral tissues, the disease may \nbe cured ; but after these changes have occurred, it only admits \nof palliation. \n\nTREATMENT. \xe2\x80\x94 The edges of the lids should be kept free from \nscabs and purulent accumulations by cleansing them as often \nas may be necessary with tepid water, after which they should \nbe bathed with some mild astringent lotion, such as a weak \nsolution of alumen or muriate of hydrastia. At night, they \nshould be anointed with simple cerate or spermaceti, in order, \nto prevent as far as possible, their becoming glued together \nwith the discharges ; and in the morning the agglutinating mat- \nter should be softened with tepid milk and water, or, what is \nbetter, with warm cream, until the lids can be separated with- \nout the use of force, the employment of which will surely aggra- \nvate the disease. If trichiasis exists, the inverted hairs should \nbe carefully removed, as they are not only a great annoyance \nto the patient, but they keep up such a constant irritation as \ngreatly to aggravate the inflammation, and ultimately produce \nopacity of the cornea. Stimulating ointments without number \nhave been recommended, but the most popular, and, in most \ncases effective, is the red precipitate, of the strength of \nabout fifteen grains tb the ounce of simple cerate, which should \nbe carefully applied to the tarsal edges at night. \n\nThe internal treatment should be similar to that recom- \nmended for scrofulous ophthalmia, (which see.) Consult also, \nthe article Scrofula ; likewise, Tables XIV. and XV. and the \nTherapeutic Indications at the end of the section on Oph- \nthalmic Diseases. \n\nDiet and Regimen. \xe2\x80\x94 The diet should be carefully re- \ngulated ; and should consist of nutritive and easily digestible \nfood, such as milk, soft boiled eggs, and wholesome meats, \nstale bread with fresh butter, and a due admixture of fresh \n\n\n\n152 PRACTICE OF MEDICINE. \n\nvegetables and fruit. The clothing, also, should be carefully \nattended to, so as to protect the patient against the effects of \nsudden atmospheric changes. Special caution should be ob- \nserved against reading at night, or exposing the eyes to dust \nand smoke, or to the glare of the sun, gas and other bright \nlights. Frequent ablutions, exercise and fresh air, are import- \nant adjuvants in the treatment and should not be overlooked. \n\n2-INFLAMMATIO PALPEBRARUM. \n\nSIMPLE INFLAMMATION OF THE LIDS. \n\nSimple inflammation of the eyelids is characterized by red- \nness, swelling and soreness of the tarsal border, whence it \nspreads over the entire lid. It is generally of catarrhal origin, \nand is almost always associated with more or less conjunctivitis. \nWhen severe, the cellular tissue is apt to become involved, \ngiving rise to oedema and in some cases to abscess. \n\nCBd^ma. \xe2\x80\x94 Effusion of serum into the cellular texture of the \neyelid, is a frequent result of ophthalmic inflammation, whether \nsimple or specific. When severe, as in the various forms of \npurulent ophthalmia, the tumefaction of the lids becomes very \ngreat, the upper projecting over the lower, and presenting a \nsmooth convex surface of a bright red color. In other cases, \nthe vascular congestion is such as to cause considerable swelling \nwith little or no external redness. In inflammation of the \nlachrymal sac, the lids are often greatly distended, subsiding \nonly when the cause is removed. CEdema of the lids also \noccurs in cases of hordeolum, or stye, from the bites and stings \nof insects, from erysipelas and anasarca of the face, and from \nother causes. \n\nAbscess, though necessarily dependent upon inflammation, \nis frequently the result of injury. It may form on either side \nof the palpebral cartilage, or it may exist in both situations at \nthe same time; consequently, the matter may approach the \nsurface in either direction. Neglected cases sometimes result \n\n\n\nKERATITIS. 153 \n\nin very great deformity, giving rise to ectropium or lagophthal- \nmus, and sometimes to both. \n\nTREATMENT. \xe2\x80\x94 For simple uncomplicated inflammation of \nthe lids, Aconite, or Aconite and Belladonna in alternation, with \nthe early use of the cold compress, is generally sufficient to effect \na cure. CEdema usually requires Apis, Arsenicum or Rims tox. \nAbscess calls for such additional remedies as Hepar, Silicia \nand Calcarea. In order to prevent deformity, the lancet should \nbe used as soon as fluctuation can be detected, being careful to \nmake the incision in a horizontal direction, so that the cicatrix \nremaining may be concealed by the natural folds of the in- \ntegument. \n\nART. III. \xe2\x80\x94 KERATITIS. \n\nInflammation of the cornea is not only frequently associated, \nas we have seen, with several forms of ophthalmia, but also \noccurs as a primary or idiopathic affection. It is only when \nthe inflammation begins in the cornea, however, that the disease \nis to be classed as keratitis. The affection assumes a great \nvariety of forms, according as it is simple or complicated, vas- \ncular or non-vascular, inflammatory or non-inflammatory, partial \nor total, acute or chronic, active or indolent, fascicular, phlyc- \ntenular, diffuse, suppurative, neuro-paralytic, etc. These and \nvarious other distinctions we shall find it convenient to con- \nsider under the following four heads, namely: (1) diffuse kera- \ntitis ; (2) suppurative keratitis ; (3) vascular keratitis, and (4) \nphlyctenular keratitis. Keratitis punctata being a secondary \nform will be described under iritis. (See Serous Iritis) \n\n1-DIFFUSE KERATITIS. \n\nPARENCHYMATOUS, OR INTERSTITIAL CORNEITIS. \n\nSYMPTOMS. \xe2\x80\x94 Diffuse inflammation of the cornea, when \nfully formed, is characterized by more or less impairment ot \nvision from interstitial deposition. At first the cornea has a \nsomewhat hazy, cloudy, or smoky appearance, which partially \nimpedes the transmission of light. This condition is called \n\n\n\n154 PRACTICE OF MEDICINE. \n\nnebula, and constitutes the slightest form of corneal opacity. \nAs the disease progresses, the opacity increases, and vision \nbecomes less and less distinct ; but owing to inequalities in its \ndevelopement, the sight is less troubled than it would otherwise \nbe. This arises from the fact that clearer, or less affected por- \ntions of the cornea remain scattered among the more opaque, \nas if the infiltration had occurred only in detached points, \nthough as a general rule the opacity first begins at the limbus, \nwhere its density is greatest, and spreads gradually more and \nmore towards the centre, until finally it involves the whole cor- \nnea. Sometimes, however, the reverse of this occurs ; the infil- \ntration beginning at or near the centre, and gradually extend- \ning towards the circumference. The more opaque parts are \nsometimes of a yellowish hue, as though suppuration had oc- \ncurred there, but this is seldom the case in the form of keratitis \nwe are now considering. In addition to these changes, the \nFi s- 8 surface of the cornea loses its usual \n\npolish and becomes unequal, as if sand- \ned or dotted over with fine points. {See \nFig. 8) It is this fine stippled ap- \npearance ol the surface which causes \nnebulous vision, and gives to the eye \nits peculiar dull expression at the be- \nginning of the complaint. \n\nKERATITIS. \n\nThe degree of inflammation and vascular injection, varies \ngreatly in different cases. Sometimes the injection is incon- \nsiderable, and then the disease is called non- vascular. In other \ncases, with a varying amount of conjunctival injection, the \ndisease is marked by a zone of deep parallel vessels running \ntowards the cornea \xe2\x80\x94 the distended trunks of which lie beneath \nthe conjunctiva, in the sub-conjunctival or episcleral tissue, and \nknown as the episcleral or circumcorneal zone \xe2\x80\x94 whose minute \nbranches or extremities passing the border of the cornea, form \nupon the limbus a small circle, or oftener a segment of a circle, \n\n\n\n\nDIFFUSE KERATITIS. 155 \n\nof a dark red tint, which presents a marked contrast with the \nopaque centre of the cornea and the pink-colored zone of the \nborder. {See Fig. 8,) Vascular diffuse keratitis is also charac- \nterized by the presence of delicate vessels in the deeper layers \nof the cornea, extending from the corneal zone to the several \ncentres of exudation. \n\nIn addition to the above symptoms, diffuse keratitis also \ngives rise to more or less ciliary irritation, photophobia and \nlachrymation, especially on exposure to light. Occasionally \nthese symptoms are so slight as scarcely to attract attention ; \nbut in the majority of cases they are quite marked, especially \nat the beginning of the disease, and before exudation has taken \nplace. Afterwards, as the process of infiltration goes on, they \ngenerally become less prominent and sometimes disappear alto- \ngether; in some cases, however, they remain unchanged or \nwith varying degrees of intensity throughout the progress of the \ndisease. Having reached its height, the affection frequently \ncontinues for weeks and months apparently stationary before \nbeginning to decline. The retrograde metamorphosis takes \nplace with great slowness, and several months often elapse \nbefore the cornea fully recovers its transparency. Vascular \ndiffuse keratitis generally runs its course more rapidly than the \nnon-vascular which is extremely indolent. \n\nThe disease is seldom confined to one eye ; the second eye \nis generally attacked soon after the first. This is very dis- \ncouraging to the patient, and it is generally difficult to make \nhim believe that he is not going blind. The affection is fre- \nquently complicated with iritis, irido-choroiditis, cyclitis, or \nwith some other form of keratitis. As the iris is hid from view \nduring the progress of the case, the practitioner should be par- \nticularly on his guard, lest when the cornea becomes clear he \nfind his patient affected with posterior synechia. \n\nETIOLOGY. \xe2\x80\x94 Diffuse keratitis has been called syphilitic, \nunder the mistaken notion that it owes its origin to hereditary \n\n\n\n156 PRACTICE OF MEDICINE. \n\nsyphilis. There is probably no good foundation for this belief, \nany more than there is for referring it to scrofula or tubercu- \nlosis. It is true it is frequently met with in persons affected \nwith hereditary or constitutional syphilis, but it is also true \nthat it occurs just as often in those in whom not a trace of \nsyphilitic taint can be discovered. The disease occurs at all \ntimes and under all conditions of life ; but chiefly in children \nbetween the ages of ten and fifteen years, especially those of a \ndelicate constitution, many of whom are more or less weakly, \nanaemic and scrofulous. It is highly probable, therefore, that \ndelicacy of constitution, defective nutrition, or a broken-down \nstate of the system \xe2\x80\x94 in short, deficient vital action \xe2\x80\x94 contribute \nmore to its production than syphilis, either hereditary or \nacquired. \n\nPROGNOSIS. \xe2\x80\x94 This is generally favorable ; for notwithstand- \ning its chronicity and tendency to relapse, the disease is seldom \nattended with ulceration, and, if properly treated, the cornea \nfinally clears up, leaving little if any trace of its previous dis- \neased condition. Some slight inequality in its curvature may \nremain, however, especially if there has been much bulging \nfrom intra- ocular pressure; but the causes which commonly \ngive rise to this condition generally prove more serious in other \nways. Hence the prognosis will be more or less favorable, \naccording as the inflammation affects the deeper tissues of \nthe eye. \n\nTreatment \xe2\x80\x94 The employment of caustics, or even astrin- \ngent collyria, should be carefully avoided, as such applications \nnot only do no good, but often do much harm. This caution \nis all the more necessary, as the temptation to use them is \noften stimulated by the importunities of the patient, under the \nidea that the long duration of the disease may in this way be \nabridged. The danger lies in their tendency to cause serious \ncomplications, such as iritis, cyclitis, ulceration of the cornea, \netc. Atropine should be instilled as soon as it can be well \n\n\n\nDIFFUSE KERATITIS. 157 \n\nborne, for although it will not be absorbed to any great extent \nuntil the cornea begins to clear, it is important to obtain its \nearly action in dilating the pupil, \' and thereby prevent the \nformation of posterior synechias, (See Iritis}) Paracentesis \nand iridectomy prove useful in accelerating the cure, and some- \ntimes succeed in arresting the disease at an early stage. They \nare especially indicated if symptoms of cyclitis supervene, or if \nthere is continued increase of intra-ocular pressure. (See \nIritis and Cyclitis) In very chronic cases, especially those of \nthe non-vascular variety, Von Graefe recommends the employ- \nment of warm compresses. If used with sufficient care in this \nclass of cases, and discontinued immediately they have fulfilled \ntheir mission, namely, to stimulate the action of the bloodves- \nsels of the cornea, they will doubtless do much good in pro- \nmoting absorption of the exudations ; but it is evident that \nsuch applications cannot be safely left to the judgment of \ninexperienced attendants. The same end may be accomplished \nby applying mild irritants, such as Mercurius dulcis, to the dis- \neased membrane. This may be employed once a day by \ninsufflation with great advantage, being careful to see that the \ncalomel is pure and free from lumps. Wells recommends a \ncollyrium of Kali hydriod, (gr. ij. @ ?j) for the same purpose. \n\nTHERAPEUTIC INDICATIONS. \n\nAconite. \xe2\x80\x94 This remedy is useful whenever the vascular re- \naction is in excess. \n\nArsenicum. \xe2\x80\x94 This is one of the best internal remedies for \nulceration of the cornea, and is also frequently serviceable in a \nweak and impoverished state of the general system. \n\nBelladonna is indicated whenever there is much conjunctival \ninjection and ciliary neuralgia. \n\nCactus frequently relieves nervous and vascular irritation in \nthe ciliary region, and also the accompanying asthenopia. \n\nCimicifuga. \xe2\x80\x94 This remedy is often useful when there is much \nneuralgia and ciliary irritation. \n\n\n\n158 PRACTICE OF MEDICINE. \n\nConium is often a valuable remedy in allaying photophobia, \nespecially when accompanied with much ciliary irritation. \n\nGelseminum is indicated in cases attended with asthenopic \nsymptoms and photophobia, especially when associated with \nmarked hyperemia and hyperesthesia of the retina and ciliary \nnerves. \n\nHepar sulph. \xe2\x80\x94 This remedy is useful in promoting absorp- \ntion of the exudation and clearing the cornea, more particularly \nin indolent and chronic cases. \n\nKali hydriodicum is an important constitutional remedy, \nespecially in syphilitic cases. \n\nMercurius is very servicable in cases attended with ulcera- \ntion, either with or without photophobia, but is more particu- \nlarly useful in promoting interstitial absorption. It may often \nbe advantageously alternated with Hepar sulphuris. \n\nNitric acid is especially indicated when, in addition to \nphotophobia, lachrymation and nervous irritation, the patient is \nlaboring under syphilitic dyscrasia, or a weak and impoverished \nstate of the constitution. \n\nSpigelia. \xe2\x80\x94 This is one of our best remedies for ciliary irrita- \ntion and neuralgia, especially when there is much hyperemia \nof the ciliary vessels, and photophobia. \n\nFor additional remedies, see Tables XIV and XV., and con- \nsult the Therapeutic Indications at the end of the section on \nOphthalmic Diseases. \n\nDiet and Regimen. \xe2\x80\x94 The diet will in most cases require \nto be of the most liberal and nutritious character, consisting \nchiefly of such articles as roast beef, eggs, milk and other kinds \nof nitrogenous food, together with a due proportion of vegeta- \nbles and ripe fruit. In some cases benefit will be derived from \npartaking freely of malt liquors, wine, kumiss, and other like \nstimulants. \n\nCare should be taken, by shading the eyes or otherwise, not \nto expose them while under treatment to any irritating or in- \n\n\n\nSUPPURATIVE KERATITIS. 1 59 \n\njurious influences, such as wind, dust, smoke, heat, bright light, \netc., and at the same time to guard against the debilitating \neffects of confinement and vitiated air, by regular out-door \nexercise, ventilation and the observance of such other hygienic \nregulations as the habits and surroundings of the patient may \ndemand. \n\n2.-SUPPURATIVE KERATITIS. \n\nSYMPTOMS. \xe2\x80\x94 Suppurative Keratitis is characterized by the \ndevelopment of purulent collections in the substance of the \ncornea, and by ulceration and disintegration of its tissues. \nThese changes are generally preceded and accompanied by \nsymptoms denoting high inflammatory action ; while on the \nother hand we sometimes meet with cases in which the symp- \ntoms of inflammation and ciliary irritation are almost entirely \nabsent. \n\nIn the inflammatory form, as it is called, the conjunctival \nand episcleral injections are strongly marked, the corneal zone \nbeing of a bright rose color ; generally, also, there is severe cil- \niary neuralgia, with photophobia and lachrymation. The pupil \nis frequently much contracted, and there is also, in most cases, \nmore or less chemosis. We first notice a small grayish opacity, \ngenerally near the center of the cornea, which afterwards \nbecomes cream-colored or yellow, the infiltrated tissue breaking \ndown into an abcess, which may find its way to the surface, \nforming an ulcer of corresponding depth. Or several small \nabcesses may coalesce and form a corneal abscess of large \ndimensions. Sometimes the pus sinks down between the \nlamellae of the cornea, separating them, and leaving a condi- \ntion called onyx, from its resemblance to the lunula of the \nnail. This may be so small as to be difficult of detection, \nappearing only as a narrow yellow line near the limbus of the \ncornea, or so large as to cover more or less of the pupil, when \nit may be mistaken for an hypopyon. The latter is generally \ndue to the bursting of a corneal abcess, and the precipitation \n\n\n\n160 PRACTICE OF MEDICINE. \n\nof its contents at the bottom of the anterior chamber. It may \nalso arise from inflammation of the iris, as will be explained \nunder iritis. \n\nThe non-inflammatory form of suppurative keratitis is \ndistinguished by the absence, more or less complete, of all the \nusual symptoms of the inflammatory form. Thus, there is \nlittle or no ciliary neuralgia, photophobia or lachrymation ; the \nsensibility of the eye is also greatly diminished, responding \nimperfectly, and as it were with difficulty, to external irritation. \nSometimes the disease sets in with the usual symptoms of \ninflammatory irritation and severe ciliary neuralgia, and then \nthese symptoms suddenly disappear, the cornea rapidly break- \ning down, and forming abcesses of a deeper and more uniform \nyellow color than those of the inflammatory variety. The \ntendency in this form of keratitis, is to rapid suppuration and \nsloughing of the corneal tissue, the suppurative process extend- \ning in circumference rather than in depth, contrary to what \nusually occurs in the other form. The inflammation frequently \nextends to the iris, and then we are apt to have large hypop- \nyon. (See Iritis.) \n\nETIOLOGY. \xe2\x80\x94 Suppurative keratitis sometimes results from \nparalysis of the fifth pair of nerves, and is then called neuropara- \nlytic keratitis. If the paralysis is incomplete, the cornea frequent- \nly escapes, or is but partially and lightly affected ; but when com- \nplete, the entire cornea is generally involved, becoming opaque, \nswollen and discolored from purulent infiltration ; ulceration \nensues, and more or less of the corneal texture is destroyed. \nNeuro-paralytic keratitis is supposed to be due, not to mal-nu- \ntrition of the cornea, but simply to the irritation excited by \nexternal irritants, such as air and dust, the action of which is \nallowed to continue in consequence of the insensibility of the \neye. Meissner and others, however, have shown that this form \nof keratitis is not entirely due to insensibility of the organ, \ndeeming it probable that the integrity of the nerve renders the \neye mor: able to resist the noxious effects of external irritants. \n\n\n\nSUPPURATIVE KERATITIS. l6l \n\nSuppurative keratitis, both inflammatory and non-inflam- \nmatory, is frequently of traumatic origin. This is most \nfrequently the case in the aged and infirm, especially after \noperations upon the cornea, such as cataract ; also after \nmechanical or chemical injuries arising from blows, or from the \nlodgment of foreign bodies, such as bits of steel, in the sub- \nstance of the cornea. The inflammatory form is met with in \nsevere cases of purulent and diphtheritic conjunctivitis ; and \nthe non-inflammatory, after certain very debilitating diseases, \nsuch as cholera, diabetes, typhus fever, etc. \n\nPROGNOSIS. \xe2\x80\x94 From what has been said, it follows that in \nmost cases the cornea suffers irreparable injury, especially in \nthe non-inflammatory form. Perforation of the cornea fre- \nquently occurs, followed by extensive ulceration and sloughing, \nthe formation of anterior senechia and staphyloma, and, when \nthe deeper tissues of the eye are involved, the disease may end \nin panophthalmitis and atrophy of the globe. On the other \nhand, ulcers may heal without permanent opacity, onyces and \nhypopya may be rapidly absorbed, anterior senechiae may be \nbroken through, and in a large proportion of cases, under pro- \nper treatment, the cornea may preserve its continuity, and \nregain to a great extent its transparency and usefulness. \n\nTreatment. \xe2\x80\x94 In the inflammatory form of suppurative \nkeratitis, attended with high vascular and nervous excitement, \nchemosis, etc., frequent instillations of a neutral* solution of \nthe sulphate of atropine, together with the diligent use of cold \ncompresses, will be required. If the abscess is so situated that \nperforation would endanger prolapsion of the iris by dilatation, \nthat is, towards the circumference of the cornea, the atropine \nshould be omitted, and, if necessary, calabar bean substituted \nin its stead. \n\nIn the non-inflammatory form, the protective bandage will \nbe the best local application, unless there should be very severe \n\n* Some chemists are accustomed to add a few drops of sulphuric acid to the solution \nwhich appears to render it highly irritating to some eyes.\xe2\x80\x94 Wells, \n\n\n\nl62 PRACTICE OF MEDICINE. \n\nciliary neuralgia, when it should be combined with the diligent \nuse of atropine. If this fails to relieve, warm water compres- \nses, of a temperature slightly above that of the blood, may be \nused in connection or in alternation with the bandage until the \npain is moderated, when the compresses should be omitted, as \ntheir continued use would aggravate both the conjunctival and \ncorneal inflammation, and also tend to increase the suppurative \nprocess. \n\nIf the case should become indolent, either warm or hot \nfomentations will be required, according to the degree of pas- \nsive congestion or vascular stasis then existing, the object \nbeing to excite just sufficient inflammatory reaction to promote \nresolution, but no more. This, it is evident, will call for the \nexercise of sound judgment, as well as the greatest care, on \nthe part of all to whom their application is intrusted. If too \nlong continued, or if the temperature is too high, the inflam- \nmatory symptoms will be apt to pass the bounds of healthy \nreaction, in which case they will require to be subdued by cold. \n\nUlceration is generally best treated by pressure, after the \ninflammatory process has been regulated by the local measures \nalready recommended. The bandage should be elastic, like \nflannel, and long enough to pass twice round the head, so as \nto exercise the requisite pressure on the cornea. The pressure \nbandage is also frequently useful in limiting the extent of sup- \npuration, but, according to Graefe, is not applicable to those \ncases of rapid suppurative necrosis which sometimes succeed \nthe sudden disappearance of acute symptoms. \n\nIf, in spite of the foregoing treatment, suppuration still \ncontinues, especially if it threatens perforation, benefit will be \nderived from puncturing the cornea, (paracentesis,) not so much \nby the simple removal of the purulent infiltration, as this is \nrarely so fluid as to escape freely from so small an opening \nbut rather, by diminishing intra-ocular tension, to promote \nabsorption of the infiltration, and hasten the restoration and \ncicatrization of the corneal tissue. If the ulcer is compara- \n\n\n\nSUPPURATIVE KERATITIS. 163 \n\ntively small, the operation may be performed with a small \nneedle, such as is represented in Plate I, Fig. 10; but if \nthe ulcer is a large one, or if it has opened into the anterior \nchamber and formed an extensive hypopyon, the incision \nshould be made with a broader instrument, such as the ordinary \nlance-shaped knife, of what is better, Desmarre\'s stop knife, \nrepresented in Plate I, Fig. 15. {See Paracentesis Cornea). In \norder to empty the abscess entirely, it will generally be found \nnecessary to carry the instrument into or through the bottom \nof the ulcer, and also to repeat the operation several times, at \nshort intervals, as the opening made by the incision is usually \nsoon obliterated. \n\nBut paracentesis, as usually performed, is generally less \neffective than iridectomy, especially if the iris is involved, or if \nthe ulcer or hypopyon is of considerable size. This operation \nnot only acts beneficially upon the inflamed iris, but lessens \nmore completely, and for a longer period, the intra-ocular pres- \nsure, and thereby exerts a greater influence in diminishing the \ncorneal suppuration, in promoting absorption of the infiltration, \nand in facilitating the regeneration of the corneal tissue. (See \nIridectomy). \n\nAnother operation, called Saemisches, has more recently \nbeen introduced, which consists in a free transverse section of \nthe cornea, after the manner of operating in cataract. This \noperation is especially suited to the non-inflammatory form, in \nwhich the necrosis takes place superficially, or towards the cir- \ncumference, and which may or may not be complicated with \niritis or hypopyon. The operation consists in laying open the \nbase of the ulcer with a Graefe\'s cataract knife, (PI. II. Fig. 34), \nthe eyelids being separated with the stop speculum, (Fig. 33). \nThe point of the knife is entered on the temporal side, about \none millemetre from the margin of the ulcer, and having \npenetrated the anterior chamber the blade, with its edge turned \ntowards the bottom of the ulcer, is carried through the chamber \n\n\n\n164 PRACTICE OF MEDICINE. \n\nbehind the ulcer, the counter-puncture being made at a cor- \nresponding point on the opposite side of the cornea, and just \nbeyond the margin of the ulcer. The fixing forceps, (PL II., \nFig. 36), with which the globe has been steadied, are now laid \naside, and the knife is made to cut its way out through the bot- \ntom of the ulcer, being so managed as to allow the aqueous \nhumor to escape gently beside the blade, and with it any coex- \nisting hypopyon. The eye is then covered with a light com- \npress, and afterwards treated with Atropine. The success of the \noperation, according to Saemisch, has been of the most gratify- \ning character, the progress of the disease having been imme- \ndiately arrested in almost every instance. \n\nWith respect to the general treatment of corneal ulcers, we \nshould be guided to a considerable extent by general principles. \nThus, if the degree of local inflammation is excessive, we should \naim to subdue it without going to the other extreme, which \nwould favor the disintegrating process, and at the same time \nhinder the filling up of the ulcer. The remedies best adapted \nto fulfill these opposite conditions, can be best selected accord- \ning to the law of similia, choosing such as correspond both to \nthe general constitutional condition and to the pathological \nstate of the cornea. The inflammatory process is so intimately \nrelated to the suppurative, that, so far as medicines are con- \ncerned, the chief aim should be to regulate it, neither attempt- \ning to subdue it altogether, nor on the other hand, allowing it, if \nexcessive, to go on uncontrolled. It follows, therefore, that such \nremedies as Aconite, Belladonna, Cactus, Digitalis, Gelsemi- \nnum, Mercurius, Tartar-emetic, Veratrum, etc., will be of frequent \nbenefit, and may be prescribed agreeably to the indications al- \nready pointed out. The same may be said of the ciliary irri- \ntation and neuralgia, which may be combatted with such reme- \ndies as Atropine, (used topically), Belladonna, Cimicifuga, \nConium, Spigelia, etc., while the suppuration may be meas- \nurably controlled by Arsenicum, Hepar Sulphuris, Kali hydri- \n\n\n\nVascular Keratitis. 165 \n\nodicum, Lycopodium, Mercurius, Sulphur, etc. See Therapeutic \nIndications on page 621, Dec, 1876 ; and consult Tables XIV. \nXV. at the end of the Section on Ophthalmic Diseases. \n\nDiet and Regimen. \xe2\x80\x94 The fact that most cases of suppu- \nrative keratitis occur at the two extremes of life, and in delicate \nand weakly constitutions, will suggest the importance of mak- \ning use, especially in non-inflammatory cases, of a liberal and \nnourishing diet, coupled if necessary with the milder stimulants \nsuch as wine, ale, porter, etc. Too much emphasis can not be \nlaid upon the importance of pure air, cleanliness, and attention \nto the general health. The digestive and assimilative organs \nshould be kept in the best possible condition, the secretions, \nparticularly those of the bowels and skin, should be carefully \nregulated, and in fine every suitable means should be taken to \ncleanse, invigorate and build up the system. \n\n\n\n3.-VASCULAR KERATITIS. \n\nKERATITIS PANNOSA. \n\nSYMPTOMS. \xe2\x80\x94 Vascular keratitis is chiefly characterized \nby a development of vessels on the surface of the cornea. \nThe membrane first becomes more or less opaque, loses its \nbrilliancy and polish, and not unfrequently appears sandy, as if \ndotted over with a multitude of extremely fine points. (See \nFig. 8) Vessels afterwards begin to show themselves upon \nthe surface, advancing towards the centre, and becoming more \nand more numerous as the opacity increases, until finally the \ncornea is over run with a fine vascular net work called pannas, \n(Keratitis pannosa). Occasionally the vascular turgescence is \nso great as to cause a rupture of some of the vessels, giving \nrise here and there to extravasations of blood, which appear as \nsmall ecchymosed spots in the interstices. The deeper por- \ntions of the cornea generally remain unaffected. \n\nVascular keratitis, like other forms of corned inflamma- \n\n\n\n[66 PRACTICE OF MEDICINE. \n\ntion, generally begins with more or less ciliary irritation, which \nproceeds, sometimes for days, the opacity of the cornea. This \nis accompanied with conjunctival and episcleral injection, the \ncorneal and circum-corneal zones being generally well-marked. \n(See Fig. 8.) When the inflammation is severe, the surround- \ning parts participate more or less in the inflammatory process, \nthe conjunctivae and lids becoming red and swollen,and are accom- \npanied in some cases with a marked elevation of temperature. \n\nThe pain is frequently extreme, especially when the nerve \nfibres are exposed by the shedding of epithelium, or by excoria- \ntion. In these cases there is generally severe photophobia, \nwith lachrymation and spasm of the lids ; sometimes, however, \nthere is little or no pain accompanying the photophobia, and \nvice versa, even when associated with spasmodic contraction of \nthe pupil. \n\nThe duration of the disease varies considerably, according \nas the cause is temporary or lasting. In the one case it may \nrun its course in a few days, while in the other, even under the \nbest treatment, it may continue for many weeks. \n\nEtiology. \xe2\x80\x94 The chie/ causes are such as produce mechani- \ncal irritation of the corneal surface, especially trachoma, invert- \ned cilia, dust, cinders and other foreign bodies. Besides these, \nother deleterious external influences, such as heat, smoke, steam, \nirritating collyria, salves, caustic fluids, sudden changes of tem- \nperature, and even long exposure to air 1 itself, as in ectropion, \nsometimes induce it. The vascularity may also result from the \nexcitement of active inflammation in neighboring parts, as in \nthe different forms of conjunctivitis. It is also an accompani- \nment of other forms of keratitis, especially the phlyctenular. \nFinally, it may owe its origin in some cases to internal causes, \neither pathological or functional, especially such as give rise to \nprotrusion of the globe, or to spasmodic pressure of the lids. \n\nPROGNOSIS. \xe2\x80\x94 This is generally favorable, as the causes \nproducing it are such as may be usually, and in many cases, \n\n\n\nVASCULAR KERATITIS. 1 67 \n\nspeedily overcome. When the cause is not removable, of course \nthe prognosis is bad, as then the pannus and opacity are likely to \ncontinue in spite of the very best treatment. On the other \nhand, many cases amenable to treatment are rendered tedious \nand difficult of cure, by reason of the long existence of the in- \nflammation, and the extent and character of the resulting \nopacity. Relapses are also common, and the utmost care is \nrequired on the part of both the surgeon and the patient to \nprevent them. \n\nTREATMENT. \xe2\x80\x94 The first, and in many cases the only treat- \nment required, will be the removal, whenever possible, of the \ncause. Hence, misdirected cilia, or any foreign substance which \nmay have found a lodgment in the conjunctival sac, should be \ncarefully sought for and extracted. For the same reason, \ntrachomatous elevations should be destroyed by caustics, the \nremoval of which generally leads to speedy improvement. \n\nAfter remedying as far as possible the action of external \ncauses, if the inflammation continues unchecked, and especially \nif there is much heat of the neighboring tissues, cold compresses \nshould be applied until the vascular action is sufficiently reduc- \ned, when additional benefit will be derived from the instillation \nof Atropine, and the application of a protective bandage. If \nthese measures, aided by suitable internal treatment, fail to \nrelieve the excessive ciliary neuralgia, photophobia and spasm \nof the lids, and especially if, as is generally the case, the patient \nh delicate or debilitated, such hygienic, dietetic and constitu- \ntional treatment should be adopted as will be best calculated to \ninvigorate the general system. \n\nAfter the inflammatory and nervous symptoms subside, if \nthe cornea still remains cloudy, or if the disease threatens to \nbecome chronic, the vascular stasis may be overcome by dust- \ning the corneal surface once or twice a day with Mercurius \ndulcis. The calomel, which of course should be entirely free \nfrom all impurities or lumps, may be applied by insufflation, or \n\n\n\nl68 PRACTICE OF, MEDICINE. \n\nwhich is better, by means of a short camel\'s hair pencil, by tap- \nping the brush, not too heavily loaded, immediately in front of \nthe cornea. The remedy is generally well borne, but if not, it \nshould be used less frequently, or else entirely omitted. \n\nVascular keratitis, whether arising from trachomatous irri- \ntation, herpes corneae, or pannus, is often greatly benefitted by \nthe operation called canthoplasty. This operation consists in \ndividing the outer canthus with a bistoury or pair of strong scis- \nsors. If the former is employed, the instrument (PL I, Fig. 30) \nis introduced upon a director, behind the external canthus, and \nis made to emerge near the orbital border. The commissure is \nthen divided horizontally, that is, in the direction of the palpe- \nbral fissure. If the scissors are used, one blade should be pass- \ned behind, and the other in front of the outer canthus, and the \ncommissure divided as before. An assistant now causes the in- \ncision to gape by holding the lids widely apart, and the raw \nedge of the conjunctiva is united to that of the skin by means \nof two or three fine sutures, one of which should be at the upper \nand another at the lower angle of the wound. The operation \nas described is a perfectly safe one, and highly serviceable in \nallaying irritation of the cornea, by diminishing the friction be- \ntween it and the palpebral surfaces. \n\nThe internal remedies best adapted to this affection, to- \ngether with their therapeutic indications, will be found on pages \n577 and 578 of this journal for 1876. \n\nConsult, also, Tables XIV and XV, and the TJierapeutic \nIndications at the end of the Section on Ophthalmic Diseases. \n\n\n\nPRACTICE OF MEDICINE. 1 69 \n\n^.-PHLYCTENULAR KERATITIS. \n\nHERPES CORNER. \n\nSYMPTOMS. \xe2\x80\x94 Phlyctenular keratitis is principally charac- \nterized by the development of herpetic vesicles, or phlyctenulae, \non the surface or in the substance of the cornea. The disease \nis frequently associated with phlyctenular ophthalmia, and is of \nthe same nature, differing only in its seat and the consequent \nseverity of the subjective symptoms. (See Phlyctenular Con- \njunctivitis}) \n\nThe vesicles vary considerably in number, size and arrange- \nment. Sometimes they are solitary, or nearly so ; at other times \nthey are numerous, and scattered irregularly over the surface ; \nor they may be arranged in groups at or near the margin of the \ncornea, where they frequently form an arc of considerable ex- \ntent. Occasionally they are very superficial, appearing like \nbeads of sweat just under the epithelium. Most commonly, \nhowever, they are larger and more deeply seated, having at first \nthe appearance of little rounded tubercles, of a grayish or pearly \ncolor, imbedded in the superficial layer of the cornea, with their \napices slightly raised above its surface. The portion of cornea \nimmediately surrounding the tubercle is generally somewhat \nswollen, the puffed appearance being. due to a cloudy border of \ninfiltration, which is most marked in places where the \nphlyctenulae are most closely aggregated. Sometimes a trans- \nparent vesicle forms on the summit of a tubercle, the bursting \nof which gives rise to a small ulcer, with a grayish, or grayish- \nyellow, base and well-defined edges. Occasionally the ulcer ex- \ntends at its circumference, at the expense of the cloudy border \nsurrounding it, constituting what is called the resorption ulcer. \nSometimes no vesicle forms, and then the tubercle becomes \ndenuded of its epithelium, and melts away, as it were, into an \nulcer of corresponding dimensions. The phlyctenulae, and their \nassociated tubercles and ulcers, do not all appear at once, but in \n\n\n\nI70 PRACTICE OF MEDICINE. \n\nsuccessive crops, so that they may be seen in various stages of \ndevelopment at the same time. The ulcers when properly pro- \ntected generally heal readily, gradually filling up and becoming \ncovered with epithelium.without, as a general rule, permanently \nimpairing the transparency of the cornea. \n\nWhen the Phlyctenular are numerous and scattered, the \nconjunctival and episcleral injections are generally strongly \nmarked, especially the rose-colored zone around the cornea ; \nbut when confined to one side of the cornea, the hyperaemia is \nusually limited to the corresponding portion of the ciliary \nregion. In this case the phlycten forms the apex of an irregu- \nlar vascular triangle, whose base is turned towards the circum- \nference of the globe. As the eruption is situated exactly at the \napex, and the vascular net-work extends at first only to the \nborder of the cornea, if the vesicle happens to be seated at a \ndistance from the corneal border, the vascular triangle will be \nincomplete, a clear or non-vascular portion of the cornea inter- \nvening between the eruption and the marginal cut-off. This \nappearance, however, is sometimes only temporary ; after a \nwhile the irritation developes vascular keratitis, and the vacant \nportion of the triangle becomes bridged over with a net-work of \nvessels, constituting what is sometimes called the herpetic bridge. \nWhen the vesicles are much scattered, each group or phlycten \nmay be connected with a separate bundle of vessels, and these \nmay so inter. ningle and overlap each other, as to destroy in a \ngreat measure their individuality. \n\nThe disease is preceded and accompanied with more or less \npain, heat, photophobia, spasm of the lids, and lachrymation. \nThese symptoms vary greatly in different cases, and in different \nstages of the same case, being sometimes so intense as to be al- \nmost intolerable, and at others so light as scarcely to attract at- \ntention. As a general thing, however, they are much more \nprominent and persistent then when the disease is confined to \nthe conjunctiva. \n\n\n\nPHLYCTENULAR KERATITIS. 171 \n\nETIOLOGY. \xe2\x80\x94 The causes of phlyctenular keratis are as \nvaried as they are numerous. Not only is it capable of being \nexcited by external irritants, such as usually give rise to other \nforms of keratitis, but it is so frequently associated with a simi- \nlar eruption occuring in the course of the distribution of the \ntrifacial nerve that many observers refer its origin in such cases \nto irritation of the ophthalmic branch of that nerve, or to ac- \ncompanying branches of the sympathetic. Another supposed \ncause is the scrofulous diathesis, the disease appearing most fre- \nquently in scrofulous children, and in persons of a feeble, irrita- \nble and cachetic habit, (See Scrofulous Conjunctivitis) \n\nPROGNOSIS. \xe2\x80\x94 Notwithstanding the great tendency to re- \nlapses in this disease, and its consequent liability to become \nchronic, it frequently terminates in perfect recovery. When the \nphlyctenular are few and superficial, excoriations or ulcusles \nformed from them soon fill up, and under favorable circum- \nstances leave no trace of their previous existence. But the \nmore deeply-seated tubercles rarely disappear altogether, but \nleave opacities of greater or less size, the effects of ulcers \nthat may have existed for weeks or even months. Occasion- \nally the history of the herpetic tubercle is still less favorable, \nthe resulting ulcer extending deeper and deeper, and finally \nending in perforation. Or it may undergo cartilaginous or \ncalcareous degeneration, forming opacities of a dense and per- \nmanent nature. Finally, the disease sometimes becomes com- \nplicated with iritis, trachomatous conjunctivitis and pannus \nwith their attendant consequences. \n\nTreatment. \xe2\x80\x94 The treatment of phlyctenular keratitis is \nsimilar to that recommended for phlyctenular conjunctivitis and \nvascular keratitis, (which see p 610, 1876). The most important \npoints are, the instillation of Atropine and the application of \na protective bandage. The Atropine acts beneficially by \ndiminishing ciliary irritation, and also by lessening intra-ocular \npressure. The latter is of special consequence in the case of \n\n\n\n172 PRACTICE OF MEDICINE. \n\ndeep ulcers, the floor of which may be so thin and weak as \nto render it unable to sustain the normal amount of pressure \nIn case the Atropine is found to disagree, Belladonna collyrium \nshould be substituted. In a few rare instances, owing to some \npeculiar idiosyncrasy of the patient, neither of these prepara- \ntions will be well borne, in which case their use will have to \nbe abandoned. The protective bandage, however, is of uni- \nversal application. It effectually protects the ulcerated sur- \nface from contact with the air, which is always highly irritat- \ning, not only to corneal ulcers, but to ulceration in every part \nand tissue of the body. It is likewise equally serviceable in \nallaying the ciliary irritation, pain, photophobia, and other \nsympathetic symptoms. The bandage may be made of flannel, \nand of sufficient length to extend twice around the head. The \nbest way of applying it is to place a piece of fine muslin over \nthe closed eye, and then to fill the orbital depression with fine \ncharpie, so that the bandage may exert a uniform pressure \nupon the diseased organ. \n\nOther local measures, as well as the most appropriate \nhygienic and constitutional treatment, will be found under the \ntwo heads above referred to, and therefore need not be repeat- \ned. (See Phlyctenular Conjunctivitis a?id Vascular Keratitis) \n\nART. IV. \xe2\x80\x94 SCLERITIS. \n\nAlthough inflammation of the sclera is a very frequent \naccompaniment of conjunctivitis and keratitis, it is doubtful \nwhether it ever occurs as a primary or idiopathic affection. As \na secondary disease it is quite common, but its symptoms are \nso often masked by those with which they are associated, that \nthey frequently escape observation. The inflammation is gen- \nerally partial, affecting only the anterior and superficial portions \nof the membrane ; but it is sometimes general and deep-seated, \nin which case -it is nearly always associated, perhaps always, \n\n\n\nEPISCLERITIS. 173 \n\nwith general choroiditis. It seldom leads to suppuration ; but \nsometimes portions of it undergo fatty degeneration, breaking \ndown into fatty and purulent products, and nearly destroying \nthe tissue. As commonly met with the disease occurs in two \ndistinct forms, both of which are usually described under the \nhead of \n\nEPISCLERITIS. \n\nSYMPTOMS. \xe2\x80\x94 Episcleritis, properly so called, is a partial or \ncircumscribed inflammation of the anterior portion of the \nepiscleral tissue. It is characterized by the appearance near \nthe cornea of one or more small dusky-red spots, which as the \ndisease progresses generally become more or less elevated and \nnodular, and of a deeper or somewhat purplish hue. These \nelevations are commonly situated near the insertion of the recti \nmuscles ; most frequently near that of the external rectus. The \nconjunctival and episcleral injection, which usually precedes and \naccompanies the formation of the little tumors, is generally \nlimited to their immediate vicinity, at which points the episcleral \ntissue is more or less infiltrated and swollen, the vessels distend- \ned and vein-like, and the affected portion of the membrane of a \ndark, bluish or purplish color. \n\nThe subjective symptoms are not generally very strongly \nmarked, unless the cornea is implicated. As a general rule \nthere is little or no pain, perhaps only a sense of uneasiness, \nthough sometimes there is a dull, heavy, aching feeling in the \neye, which renders the patient quite uncomfortable. Photopho- \nbia and lachrymation are more constant symptoms ; but, \nalthough sometimes considerable, they are often insignificant. \n\nAt first the disease is liable to be mistaken for phlyctenular \nconjunctivitis, but the little tumor or nodule continues to in- \ncrease in size, especially at the base, until it sometimes threatens \nto develope into what is called anterior sclerotic staphyloma ; but \nafter existing for weeks, and perhaps months, it generally \nbegins to diminish in size, and at last gradually dies away and \n\n\n\n174 PRACTICE OF MEDICINE. \n\ndisappears. Or, it may recede only to return in the same or \nsome other spot, and in this way the disease is sometimes pro- \nlonged for an indefinite period. \n\nETIOLOGY. \xe2\x80\x94 Very little is definitely known concerning the \norigin of this affection. Its frequent occurrence in young \nwomen has led some to infer that it is in some way connected \nwith the menstrual function, but this is mere conjecture. It is \nperhaps most frequently met with in persons of a rheumatic or \ngouty habit. Its extreme obstinacy in subjects affected with \nsyphilis, except when treated with anti-syphilitic remedies, \nrenders it probable that it may sometimes owe its origin to that \ndisease, especially when we consider how often syphilis affects \nother similar tissues. When occurring independently of other \nconstitutional causes, it is probably due, in most cases, to over- \nwork, debility, or some other depressing influence. \n\nPROGNOSIS. \xe2\x80\x94 This is almost always favorable. If, how- \never, the disease goes on uncontrolled, or if resolution fails to \noccur, the tumors may suppurate, giving rise to small abscesses \nin the sub-conjunctival tissue ; or they may degenerate, becom- \ning cartilaginous or calcareous ; or, finally, deep-seated ulcera- \ntion may occur, resulting in anterior sclerotic staphyloma, or \nprolapse of the uvea. \n\nTREATMENT. \xe2\x80\x94 Little treatment is generally necessary, \nprovided the patient will abstain from using the eyes, and will \nprotect them from bright light by wearing a shade. The instil- \nlation of Atropine at night, and the use of warm fomentations \nwhen necessary, will generally relieve the ciliary neuralgia, \nwhich is not often very severe. Caustic collyria not only do no \ngood, but frequently do harm by increasing the ciliary irritation. \nWells, however, strongly recommends a weak collyrium of \nchloride of zinc, beginning with one-half grain to the ounce of \nwater, and if well borne, increasing the strength to one or two \ngrains to the ounce. When syphilis is at the bottom of the \ntrouble, Kali hydriodicum is by far the best constitutional \n\n\n\nIRITIS. 175 \n\nremedy, though good results have been obtained in these cases \nfrom Mercurius protoiodatus. Colchicum is generally the best \nremedy for rheumatic and gouty subjects, Bryonia being most \nserviceable for aggravations resulting from fatigue. Sepia is \nparticularly useful when the catamenia are deranged. Nux \nvomica is a good remedy when the disease is induced or aggra- \nvated by over-taxing the eyes, especially when there is debility \nof the digestive organs or constipation. \n\nDiet and Regimen. \xe2\x80\x94 Whatever benefits the general \nhealth is likely to have a salutary influence on the disease. The \ndiet should therefore be liberal, nutritious and easily digestible. \nThe several animal functions, especially those of digestion and \nsecretion, should be carefully regulated ; and the patient should \ntake regular but moderate exercise in the open air. \n\n\xe2\x80\xa2 \xe2\x80\xa2 ART. V. \xe2\x80\x94 IRITIS. \n\nOphthalmic writers have divided iritis into numerous forms \nor varieties, distinguishable for the most part by the special \ncauses which are supposed to give rise to them. Thus, we have \nthe simple or rheumatic, the arthritic, the gonorrhoeal, the \nsyphilitic, the serous or cedematous, the suppurative or \nparenchymatous, the idiopathic, the sympathetic, the traumatic, \netc. We may, however, reduce them all to the following four \ngroups: (1), simple iritis ; (2), serous iritis ; (3), suppurative \niritis ; and (4), syphilitic iritis. \n\nl.-SIMPLE ACUTE IRITIS. \n\nSYMPTOMS. \xe2\x80\x94 The principal symptoms of simple acute iritis \nare : Episcleral redness, pain, Iachrymation, photophobia, \nchemosis, structural changes lin the iris, sluggishness or immo- \nbility of the pupil, and more or less febrile disturbance of the \nsystem. \n\nThe characteristic redness is due to sub-conjunctival or \nepiscleral injection, in the form of a narrow band or zone, \n\n\n\n176 PRACTICE OF MEDICINE. \n\nimmediately around the cornea. This zone, commonly called \nthe corneal zone or circle, is composed chiefly of deep-seated \narterial twigs, of a rose-red, or violaceous hue, straight and \narranged parallel to each other, commencing at the junction of \nthe sclerotica with the cornea, becoming finer and finer as they \nradiate from the latter, and terminating about a line from the \ncorneal border. The vascularity of the conjunctiva is in some \ncases confined to the palpebral portion of the membrane ; in \nothers the ocular conjunctiva is involved, the distended vessels \nproceeding from the circumference of the globe, following an \nirregular but nearly parallel course towards the cornea, and \ndividing into numerous branches, are at length lost in the nar- \nrow, but deeper-seated, more constant and characteristic circle \nof vessels situated immediately around the cornea. The con- \njunctival vessels are readily distinguishable from those compos- \ning the corneal zone, by being of a deeper red color and of \nlarger calibre, by being displaced by the movement of the con- \njunctiva, by their more or less irregular distribution, and by \ntheir connection with other similar vessels coming from the \npalpebral surface. The episcleral redness is much more evenly \ndiffused than the conjunctival, owing to the fineness, closeness \nand parallelism of the vascular injection. It is generally limit- \ned, at first, to the corneal border ; but as the disease progress- \nes, the injection frequently becomes deeper and more general, \nuntil, in some cases, the entire surface of the subjacent sclera \npresents a reddish or rose-carmine appearance. Occasionally, \nhowever, we meet with severe cases in which the subconjunc- \ntival injection is but feebly developed, as in pyaemia, typhus, \npuerperal, and other low forms of fever. \n\nSome degree of chemosis of the ocular conjunctiva is gen- \nerally present, and this may be so great as to cause considerable \nbulging of the conjunctiva around the cornea. The eyelids also \nparticipate in the affection, especially the upper lid, which fre- \nquently becomes more or less inflamed and cedematous, when- \n\n\n\nSIMPLE ACUTE IRITIS. 1 77 \n\never the attack is severe. These complications, however, are \nfrequently absent. \n\nThe pain, also, which is occasionally throbbing, and ac- \ncompanied with a feeling of distension or pressure, is sometimes \nalmost entirely wanting ; but in most cases it is severe, often \nextremely so, and of a lancinating, burning or aching character. \nWhen confined to the eye it is generally superficial, but as the \ninflammation spreads the pain augments, and extends to the \norbit, temple and side of the head. It undergoes frequent exa- \ncerbations and remissions, chiefly of a periodical character, and \nis always most severe during the night. So long as the inflam- \nmation is confined to the iris, the globe is not particularly pain- \nful to the touch ; but when it extends to the ciliary body, con- \nstituting cyclitis, there is more or less tenderness and pain in \nthe ciliary region. \n\nAt first the eye is preternaturally dry, but soon the lachry- \nmal secretion is re-established, and becoming excessive, consti- \ntutes the condition called epiphora. This hyper-secretion,which \nis due to the sympathetic influence of the inflammation on the \nlachrymal gland, sometimes becomes so great as to overflow \nthe lids. The tears are frequently hot and burning, particularly \nif there is much co-existing inflammation of the neighboring \nparts, and so irritating as sometimes to inflame the skin over \nwhich they flow. \n\nPhotophobia is another prominent symptom of acute iritis, \nespecially if the cornea is implicated, and is generally in propor- \ntion to the violence of the inflammation. The eye is unable-to \nbear the full light of day, and suffers more or less when expos- \ned to a diffused light ; hence the patient generally keeps the \neyes closed or deeply shaded. \n\nThe constitutional disturbance, though modified to some \nextent by the age and health of the patient, commonly varies \nin proportion to the amount of local disorder. When severe \nthere is generally considerable febrile excitement, which is \n\n23 \n\n\n\n178 PRACTICE OF MEDICINE. \n\nsometimes accompanied by more or less derangement of the \ndigestive organs. \n\nVision is always more or less impaired, and in mild cases \nthis is sometimes the only symptom that attracts attention. \nMany causes contribute to this result. Sometimes it is chiefly \ndue to haziness or opacity of the cornea, the membrane appear- \ning as if dotted over with fine points of opaque matter, as rep- \nresented in Fig. 8. In most cases of simple iritis, however, \nthe cornea remains unaffected, or at most is rendered only \nslightly hazy. Vision may also be affected by cloudiness of \nthe aqueous humor, or by diffuse opacity of the vitreous, due \nto co-existent inflammation of the ciliary body, in which case \nthe power of accommodation is also impaired. But the chief, \nor rather the most constant causes of impaired vision in iritis, \nare such as result from paralysis of the muscles caused by \nproliferation of tissue, from immobility of the iris, or from a \ngreater or less amount of occlusion or obstruction of the \npupil by inflammatory products. \n\nIn all cases the pupil is rendered more or less sluggish. \nThis is owing partly to hyperaemia of the vessels, but chiefly \nto plastic or serous exudations into, or upon the surface of \nthe iris, whereby its motions are mechanically hindered. \n\nContraction and irregularity of the pupil are characteris- \ntic symptoms, dependent upon exudations between the iris and \ncapsule of the lens, giving rise to a greater or less amount of \nadhesion between them. These exudations may be so situated, \nor so minute, as to escape detection until the pupil is arti- \nficially dilated, or is examined by lateral illumination, when \nwe may discover the beads of lymph which tie it to the anter- \nior capsule. The exudations coalesce as they increase in size, \nuntil in some cases the entire pupillary margin becomes \nadherent, constituting what is called annular synechia. This \ncondition does not materially interfere with vision, as the \ncentre of the pupil still remains clear ; but when the exuda- \n\n\n\nSIMPLE ACUTE IRITIS. 179 \n\ntions invade the pupillary opening, a greater or less portion of \nits area is covered with lymph, and then, of course, vision is \nproportionally obstructed. \n\nThe contraction and immobility of the pupil are always \nassociated with more or less dullness and discoloration of the \niris. These symptoms are all due to the same causes, namely, \nto hyperaemia and effusion, and are among the earliest signs \nof the disease. The iris in its natural state has a more or \nless bright, glistening appearance, which is changed by inflam- \nmation to a dull, lustreless aspect, as though the membrane had \nlost its vitality. In addition to this the color itself changes. Blue \nand gray irides become slate-colored or greenish, while brown \nand black irides change to a reddish-brown or cinnamon color. \nAs such changes are sometimes only apparent, the affected \niris should always be carefully compared with that of the sound \neye, remembering at the same time that dullness and discolora- \ntion of the iris may be caused by cloudiness of the cornea and \nof the aqueous humor. \n\nETIOLOGY. \xe2\x80\x94 The chief predisposing cause of simple iritis \nis the rheumatic or gouty diathesis. But the same form of \niritis may occur independently of rheumatism in other parts of \nthe body, and unassociated with the gouty or rheumatic consti- \ntution. In such cases, however, the same exciting causes gener- \nally give rise to it, namely, exposure to sudden atmospheric \nchanges, dampness, wind, cold draughts of air, etc., and hence, \nas there are no characteristic symptoms by which to distinguish \none form from the other, it has been customary to call them both \nrheumatic. Simple acute iritis, though frequently of traumatic \norigin, is most generally \'secondary, inflammation originating in \nother parts being transmitted to it in consequence of the close \nanatomical or functional relation they sustain to each other. \nHence we have found it to be frequently associated with various \nforms of ophthalmia, especially the purulent. On the other \nhand, also, as we have seen, acute iritis is frequently complicated \n\n\n\n180 PRACTICE OF MEDICINE. \n\nwith inflammation of the neighboring parts, constituting what is \nfrequently called rheumatic ophthalmia. \n\nPrognosis. \xe2\x80\x94 The prognosis in the great majority of cases \nis favorable. The disorder is often obstinate, owing to its fre- \nquent complication with other forms of ophthalmic inflamma- \ntion, the diathesis of the patient, atmospheric influences, etc. ; \nbut sooner or later the inflammation undergoes resolution, and, \nunless complicated with more serious affections, such as unyield- \ning posterior synechiae, the organ fully recovers. Of course, in \ntraumatic iritis the prognosis will have to depend, in a great \nmeasure, upon the nature, extent and precise seat of the injury, \nand should therefore always be particularly guarded. \n\nDIAGNOSIS. \xe2\x80\x94 The diagnosis has already been given with \nsufficient accuracy. Iritis is distinguished from simple inflam- \nmation of the conjunctiva, with which it is sometimes \nconfounded, by the injection being originally confined \nto the episcleral tissue ; by its pinkish or violaceous hue ; \nby its forming a narrow zone about the cornea \ncomposed of straight, deep-seated, parallel vessels, disconnected \nwith those of the conjunctiva; by the epiphora, photophobia, \nand orbital and circumorbital pain ; by the dullness and dis- \ncoloration of the iris by exudations of plastic lymph upon its \nsurface or margin ; and by the contracted, irregular and slug- \ngish state of the pupil. Not unfrequently the points of some \nof the vessels constituting the corneal zone encroach upon the \nedge of the cornea, forming upon its border a small vascular \ncircle, or segment, varying in breadth from one-eighth to three- \neighths of a line ; this is supposed to constitute one of the \ndifferential signs of rheumatic iritis. \n\nRESULTS. \xe2\x80\x94 The chief results attending this form of iritis \nare : exudations upon the surface of the iris, or upon its margin, \nand in the pupillary aperture ; adhesions to the anterior capsule ; \n{posterior synechia) ; occlusion of the pupil ; and, when compli- \ncated with keratitis, the development of phlyctaena on the cor- \n\n\n\nSEROUS IRITIS. l8l \n\nnea : superficial ulceration resulting from their rupture ; \nand more or less opacity of the cornea arising from depositions \nupon the inner surface or between its laminae. (See Fig. 8.) \nTreatment. \xe2\x80\x94 The medical and surgical treatment of iritis \nis so varied, and at the same time is of such great importance, \nthat we deem it best to defer its consideration until after the \nother forms of iritis have been described. \n\n\n\n2 -SEROUS IRITIS. \n\nDESCEMETITIS. KERATITIS PUNCTATA. \n\nSYMPTOMS. \xe2\x80\x94 This form of iritis is chiefly characterized by \nan increase of the aqueous humor, and by the absence of plastic \nexudations. Instead of the usually contracted state of the \npupil, this aperture is generally more or less dilated, in conse- \nquence of the increased intra-ocular pressure. Discoloration of \nthe iris is not very perceptible, nor are the other symptoms of \nacute iritis sufficiently marked to attract attention. Pain and \nphotophobia are generally absent, and the injection is usually \nlimited to the vessels composing the narrow circum-corneal \nzone of the episcleral tissue. The aqueous humor is more or \nless turbid, the cloudiness arising from minute particles of float- \ning lymph in the anterior chamber. Similar particles are de- \nposited in the form of points upon the posterior surface of \nthe cornea, from which they occasionally project, giving to that \nmembrane a punctated appearance, (keratitis punctata). Inter- \nstitial opacities also occur in the different layers of the cornea, \nespecially of the posterior laminae, similar in appearance to \nthose observed on the posterior wall of Descemet\'s membrane. \nThese, however, are supposed to be caused by inflammatory \nchanges, and not by deposits from the aqueous humor. Vision \nis always more or less impaired, owing partly to cloudiness of \nthe cornea and aqueous humor, partly to intra-ocular tension \ncaused by hypersecretion of the aqueous, and sometimes of the \n\n\n\n1 82 PRACTICE OF MEDICINE. \n\nvitreous humor, and partly to deeper seated inflammation, es \npecially cyclitis and choroiditis, with which it is frequently as- \nsociated. \n\nETIOLOGY. \xe2\x80\x94 Anaemia, chlorosis, scrofula, and especially \nsyphilis, both constitutional and hereditary, have all been re- \ngarded as predisposing causes. It is often observed in children \naffected with the peculiar notching of the central incisors, of the \nsecond dentition, which indicates congenital syphilis. It also \nconstitutes one of the forms of sympathetic ophthalmia. \n\nPROGNOSIS. \xe2\x80\x94 Serous iritis is usually very chronic, but is \ngenerally less serious than either the suppurative or the syphili- \ntic. When timely recognized, if the affection which causes it \ncan be overcome, the disease will generally soon disappear. On \nthe contrary, if the deep structures of the eye have become im- \nplicated, and especially if there is at the same time a syphilitic \ndyscrasia to contend with, the prognosis is particularly bad. \n\nTreatment. \xe2\x80\x94 This we shall defer until we come to con- \nsider the treatment of the other forms of iritis. \n\n\n\n3-SUPPURATIVE IRITIS. \n\n\n\nSYMPTOMS. \xe2\x80\x94 Suppurative or parenchymatous iritis is \ncharacterized by the presence of pus-cells in the stroma or \ntissue of the membrane. In some cases their situation corres- \nponds to the course of the vessels ; in others they coalesce and \nform small collections, constituting true abscesses. These find \ntheir way to the surface, either by ulceration or rupture, and \nsinking to the bottom of the anterior chamber, form an hypopyon. \nGenerally, however, the exudation takes place on the surface of \nthe iris, either in the form of a thin gray secretion, covering the \niris like a veil, or else thick and puriform, interpersed here and \nthere with minute patches of extravasated blood. The tissues \nof the iris swell and impede the circulation, and soon large \nvaricose veins become visible on its surface. \n\nNeoplastic exudations also take place along the edge and \n\n\n\nSUPPURATIVE IRITIS. 1 83 \n\ninto the area of the pupil, as well as upon the posterior surface \nof the iris, giving rise to extensive adhesions between it and the \nanterior capsule. Frequently the deposits assume the form of \nirregular masses, or nodules, especially around the pupillary \nopening, where they sometimes give rise to annular synechias, \nor by extending into the area, fill up and completely occlude \nthe pupil. Occasionally some of these nodular masses become \ndetached, and melting down become mixed with the aqueous \nhumor, and render it more or less turbid. The particles of \ndisintegrated lymph and the pus globules, thus liberated, \ngradually settle to the bottom of the anterior chamber. The \nhypopyon thus formed is sometimes so small as to be seen \nwith difficulty, appearing only as a narrow, yellow line along \nthe floor of the anterior chamber ; in other cases it reaches \nthe level of the pupil; and in some rare instances it fills the \nwhole chamber of the aqueous humor. \n\nAccording to Von Graefe and other authorities, these col- \nlections of puriform matter are not always entirely due to in- \nflammation of the iris, some portions of them being derived \nfrom the membrane of Descemet, and some from the ciliary \nmuscle, which is occasionally affected with the same form of \ninflammation. Suppurative iritis may also be complicated with \nchoroiditis, constituting irido-choroiditis, one of the forms of \nsympathetic ophthalmia, (which see). \n\nETIOLOGY. \xe2\x80\x94 As suppurative iritis is generally the result of \na higher grade of inflammation than the simple, it follows that \nthe same causes in some instances give rise to it. It is rarely \nthe case, however, that catarrhal and traumatic iritis take on the \nsuppurative form ; and when they do, it is generally by the ex- \ntension of the disease from other parts. On the other hand, it \nis not unfrequentlythe result of the continuation of the suppura- \ntive process from parts which are in anatomical or functional \nrelation with it, as in keratitis and choroiditis. In other cases, \nagain, it seems to depend upon certain constitutional affections, \n\n\n\n1 84 PRACTICE OF MEDICINE. \n\nespecially syphilis. According to some authorities, it is occa- \nsionally due to a neurotic condition caused by malaria, in which \ncase it assumes the intermittent form. That it may be caused \nby an irritative condition transmitted through the nervous \nsystem, has been established by the testimony of many recent \nobservers. In this case it generally assumes the form of an \nirido-choroiditis. (See Sympathetic Ophthalmia}) \n\nPROGNOSIS. \xe2\x80\x94 Suppurative iritis is generally a much more \nserious affection than either simple or serous iritis, in conse- \nquence of the greater amount of neoplastic formations associat- \ned with it, and which frequently give rise to extensive posterior \nsynechias that effectually resist the action of Atropine. More- \nover, the disease is much more apt to be complicated with de- \nstructive changes in the cornea, and also in the deeper-seated \ntissues of the eye. In these cases, of course, it is the complica- \ntions and sequelae, rather than the iritis, which often renders the \nprognosis doubtful, as the tissue of the iris may recover its \nnormal condition, and yet its function, as well as that of the \neye itself, may remain greatly impaired, or even be entirely de- \nstroyed. \n\nTreatment. \xe2\x80\x94 This will be given in connection with that \nof syphilitic iritis, (which see). \n\n\n\n4.-SYPHILITI0 IRITIS. \n\n\n\nSYMPTOMS: \xe2\x80\x94 Syphilitic iritis is characterized by the pro- \nduction of true gummy tubercles {gummata syphilitica), originat- \ning in the stroma of the iris, and projecting above its surface in the \nform of condylomata or warts. They are often solitary, or nearly \nso; but occasionally they are more numerous, and either scat- \ntered about over the surface of the iris, or collected into a ring \nupon its pupillary or ciliary border. The tubercles vary in size \nfrom that of a millet seed to a split pea, their apices sometimes \nextending to the posterior surface of the cornea. They are \n\n\n\nSYPHILITIC IRITIS. 1 85 \n\nmostly of a reddish or copper-colored tint, suggestive if not \ncharacteristic of their syphilitic origin. In this respect, how- \never, they vary considerably, according to the natural hue of \nthe iris. Thus, in light irides, they are generally of a yellowish- \nred or cinnamon color, while in dark irides they are commonly \nof a dull reddish or muddy brown. They also become darker by \nage. \n\nThe subsequent condition of the tumors varies according \nto circumstances. Sometimes they are rapidly absorbed ; at \nother times they undergo fatty degeneration and purulent solu- \ntion, the detritus mixing with the aqueous humor. Occasion- \nally, on the other hand, after passing through certain \nmetamorphic processes, they assume a more or less permanent \nform, as we shall see hereafter. \n\nThe inflammatory changes in the iris are most marked in \nthe vicinity of the tuberculous nodules, and as these are often \nconfined to a particular portion of the membrane, the thicken- \ning and vascularity of the iris are greatest at that point. This \nfeature of the disease, like that of the gummy tumors on which \nit depends, is a peculiarity of syphilitic iritis. \n\nAlthough the appearance of gummy tubercles in the iris is \nan almost certain indication of their syphilitic origin, yet it \nis generally conceded that their presence is not necessarily \nconnected with secondary syphilis ; nor, on the other hand, \ndoes their absence establish the non-syphilitic character of the \naffection. It is well to remember, therefore, that while the \nexistence of gummy tubercles may be regarded as satisfactory \nevidence of the syphilitic nature of the inflammation, the dis- \nease may have an undoubted syphilitic basis, and yet appear \nin the simple idiopathic or suppurative form. \n\nDiagnosis. \xe2\x80\x94 As there are no local symptoms sufficiently \ncharacteristic to establish beyond a doubt the syphilitic nature \nof the affection, it follows that it can only be positively de- \ntermined by the existence of constitutional syphilis. Thus, \n\n\n\n1 86 PRACTICE OF MEDICINE. \n\nthe specific character of the disease may reveal itself by a \nco-existent papalar eruption, by the presence of syphilitic \nulcers in the pharynx, by enlargement of the lymphatic \nglands, or by the cicatrix of a chancre. In the absence of any \nof the peculiar evidences of constitutional syphilis, the history \nof the case, though it may not supply positive proof, may serve \nto elucidate the nature of the disease, or at least furnish prob- \nable grounds for suspicion. \n\nPROGNOSIS. \xe2\x80\x94 The prognosis in many cases of syphilitic \niritis is most grave. Although the gummy tubercles are often \nquickly absorbed, they sometimes undergo permanent degener- \nation, shrinking into hard nodules, or changing into tough, \ntendon-like masses, which either lie upon the surface or are \nburied in the stroma of the iris. In other cases, as we have \nseen, the suppurative process gives rise to formidable hypopya, \nmany of which never entirely disappear, but leave behind per- \nmanent products, which in some cases undergo fatty and cal- \ncareous degeneration. In other cases, again, the deeper \nstructures of the eye become involved, the disease finally ter- \nminating, it may be, either in atrophy of the globe or in \npanophthalmitis. \n\nTREATMENT OF IRITIS. \n\nThe leading indications in the treatment of iritis are, first, \nto prevent, and afterwards, if necessary, to destroy or break up \nany adhesions of the iris to the anterior capsule ; (posterior \nsynechia) ; to relieve ciliary irritation and neuralgia ; to lessen \nintra-ocular tension ; and to quiet the muscular action of the \ninflamed tissue. These indications are best met by the instil- \nlation of a strong neutral solution of Atropine (grs. ij \xe2\x80\x94 v. ad \nwater gj), the free application of which produces complete \ndilatation of the pupil, sets the muscular fibres of the iris at \nrest by paralyzing the constrictor pupillae, and relieves the \ninterior circulation of the eye, thereby diminishing congestion \n\n\n\nSYPHILITIC IRITIS. 1 87 \n\nof both the ciliary body and iris. These results, however, can \nonly be accomplished by the free and judicious use of the \nAtropine, as the inflamed, swollen and infiltrated state of the \niris prevents, to* a great degree, its absorption, and also dimin- \nishes its mydriatic effect, by producing stiffness and want of \nfreedom of the muscular fibres of the membrane. It is there- \nfore advisable, and in most cases necessary, to apply the \nAtropine fifteen or twenty times during the day,or which is bet- \nter, at intervals of only a few minutes, until it affects the pupil, \nso as to produce at once, if possible, sufficient dilatation to pre- \nvent adhesions and to set the membrane at rest. And should \nadhesions have already formed, the synechias if recent, narrow, \nor easily ruptured, may also by this means be broken through, \nand their reunion prevented, by keeping the pupil completely \ndilated. But this is not all ; the ciliary irritation and pain are \ngenerally greatly lessened, and in many cases entirely overcome, \nby the instillations, in which case nothing remains to hinder \nspeedy recovery. \n\nBut sometimes, owing to the peculiar state of the eye or \nthe idiosyncrasy of the patient, the Atropine does not agree ; \ninstead of lessening the ciliary irritation it seems to increase it. \nThis result is most apt to occur when its influence upon the iris \nis resisted, the remedy not appearing to be absorbed sufficiently \nto produce its mydriatic affect, but, spending its action chiefly \nupon the ciliary region, greatly increases the hypersemia and \nirritability of the eye. In such cases the difficulty may often be \novercome, and the best results obtained, by simply applying \nwarm fomentations, the effect of which seems to be to relax \nthe affected tissues and thereby favor the absorption of the \nremedy. In some of these cases the irritability may be allayed \nby substituting a collyrium of Belladonna in place of Atropine. \nat the same time rubbing in Belladonna ointment around the \neye. \n\nShould the foregoing treatment fail in producing sufficient \n\n\n\n1 88 PRACTICE OF MEDICINE. \n\ndilatation of the pupil, a precious resource remains to us in \nparacentesis cornea. This operation not only favors absorption \nof the Atropine,but also lessens irritability of the eye, by dimin- \nishing intra-ocular tension and relieving the internal circulation. \nThe mydriatics will now be almost certain to act f ivorably, \neven in cases in which they had previously seemed to have lost \ntheir power. \n\nWhen extensive adhesions exist, it is well to bear in mind \nthat if the Atropine does not quickly succeed in breaking them \nup, it is better to use them simply with the viewof allaying irri- \ntation and lessening intra-ocular tension, as a too energetic use \nof them under such circumstances serves only to fret the im- \nprisoned iris, and consequently to augment the inflammation. \nShould any doubt exist as to the inability of the iris to over- \ncome the synechia, Calabar bean, which sometimes proves \neffective after Atropine has failed, may be tried. \n\nWe have already suggested the use of warm fomentations, \nin case the Atropine fails to act on the pupil. Similar applica- \ntions, used as hot as they can be borne, and frequently changed, \nare equally beneficial in promoting absorption of recently \neffused lymph, and also of hypopyon. This remedy, simple as \nit appears, is invaluable in the treatment of both suppurative \nand syphilitic iritis. To be effective, however, the applications \nwill require to be faithfully followed up. If for any reason this \nis found to be impracticable, heat and moisture may be applied, \nand the same end attained, by the use of hot emollient poultices, \nwhich should be changed every half hour or so, according to the \nseverity of the case. These measures will not, of course, be \nrequired after the acute symptoms have subsided ; but the use \nof Atropine should be continued for several weeks, the object \nbeing to keep the pupil dilated and at rest. Unabsorbed \nhypopya will require to be removed by paracentesis. (See \nParacentesis Cornea.) Other operative procedures will be con- \nsidered after we have given the \n\n\n\nSYPHILITIC IRITIS. 1 89 \n\nTHERAPEUTIC INDICATIONS. \n\nAconite. \xe2\x80\x94 In the first stage of iritis, especially when the \npupil is greatly contracted. Its usefulness is generally measur- \ned by the acuteness of the symptoms and the earliness at which \nit is given. \n\nArnica is most serviceable for nervous and plethoric \npatients, and when the iritis is of traumatic origin. \xe2\x80\xa2 \n\nArsenicum is one of our best remedies in serous iritis, \nespecially in scrofulous subjects. It may sometimes be advan- \ntageously alternated with Kali hydriodicum. \n\nBelladonna is best adapted to cases attended with much \nconjunctival injection and swelling, especially when there is \nconsiderable ciliary neuralgia and photophobia. It is often \nalternated with Aconite, particularly at the commencement of \nthe disease. \n\nBryonia is especially suited to rheumatic cases, or when the \neyeballs are sensitive to the touch or. on motion. It may be \ngiven in alternation with Aconite or Mercurius whenever these \nremedies are indicated. \n\nChamomilla is useful in the iritis of scrofulous children, \nespecially when characterized by severe ciliary neuralgia. \n\nCimicifnga** is indicated when there is much pain and in- \ntraocular tension. It is especially adapted to rheumatic cases. \n\nColchicum is also indicated in rheumatic cases, especially \nwhen there is very great soreness of the eyeballs. \n\nDigitalis is another useful remedy in rheumatic iritis, es- \npecially in the early stages, when there is contraction of the \npupil and great tenderness of the globe, with more or less ach- \ning in and around the eye. \n\nKali hydriod. \xe2\x80\x94 This remedy is adapted to nearly every \nform of iritis, especially the serous and syphilitic. \n\nMercurius. \xe2\x80\x94 This is, without exception, the most reliable \ngeneral remedy for iritis, especially after exudation has taken \n\n* See Am. Horn. Obs., vol. 4, p. 229. \n\n\n\n190 PRACTICE OF MEDICINE. \n\nplace. It is adapted to acute, sub-acute and relapsing cases ; \nalso to those which become complicated with inflammation of \nother parts of the eye, particularly the cornea, ciliary body and \nchoroid. \n\nSpigelia. \xe2\x80\x94 This is generally the best internal remedy with \nwhich to relieve ciliary neuralgia and photophobia. It is par- \nticularly adapted to children, especially those of scrofulous con- \nstitutions. See " Additio7ial Therapeutic Indications" at the end \nof section on Ophthalmic Diseases. \n\nDiet and Regimen. \xe2\x80\x94 The diet should be simple and \nunstimulating. If the disease is chronic, or subject to frequent \nrelapses, the patient will need to be particularly on his guard \nagainst everything calculated to favor hyperaemia and conges- \ntion, such as exposure of the eyes to bright light, wind, draughts \nof air, etc., or to straining them with reading, sewing, or any \nfine work. If necessary he should wear blue or smoke-colored \nglasses. (See NOTE, on page 129. \n\nOPERATIONS FOR ARTIFICIAL PUPIL. \n\nWe have already passed in review the following circum- \nstances and conditions in which the operation for the formation \nof an artificial pupil is recommended : (1), permanent opacity \nof the cornea interfering with normal vision ; (2), permanent \nclosure of the pupil, {atresia pupillce), either by contraction, \nocclusion, or complete posterior synechias of the pupillary mar- \ngin ; (3), suppurative keratitis, threatening extensive perfora- \ntion of the cornea ; (4), corneal perforation, and prolapse of the \niris ; (5), to diminish intra-ocular tension ; and (6), to lessen in- \nflammatory symptoms. We shall also have occasion to recom- \nmend it in (7), glaucoma ; (8), staphylomata ; (9), cataract ; and \n(10), to facilitate the removal of foreign bodies from the \naqueous chamber or iris. \n\n{a.) Iridectomy. \xe2\x80\x94 Of the numerous operations daily per- \nformed on the eye, this is both the most frequent and the most \nimportant. Being the safest and most successful operation for \n\n\n\nARTIFICIAL PUPIL. I9I \n\nthe formation of an artificial pupil, it has almost entirely super- \nceded every other method. It consists in excising a small por- \ntion of the iris, after it has been drawn through an opening in \nthe cornea made for that purpose. The instrument generally \nmade use of for dividing the cornea is called a keratome. The \nblade is of a triangular or lance shape, and when the iridectomy \nis made on the temporal side, is set straight with the shaft ; \n(See PL I., Fig. 24) ; but when it is required to be made in- \nwards or upwards, the blade is bent to suit the plane of the \nnose and orbit. (Fig. 26). The forceps should for the same \nreason be straight, as in PL II., Fig. 36, or bent at an acute \nangle, as shown in Fig. 37. They should be so constructed that \nwhen closed the extremity will be perfectly smooth, so that \nthey may be passed through the lips of the incision without \nlacerating them, or doing any injury to the iris. \n\nThe operation is most conveniently performed as follows : \xe2\x80\x94 \nThe patient having been placed upon a couch or bed, in a \ngood light, with his head slightly raised, and chloroform ad- \nministered to him by an experienced assistant, the operator \nplaces himself either behind or in Iront of the patient, as may \nbe found most convenient, and having separated the lids to \nthe desired extent by means of the stop speculum, (PL II., \nFig"- 33)> an< 3 having fixed the globe by seizing the ocular \nconjunctiva with the fixing forceps, (Fig. 36), at a point exactly \nopposite where the incision is to be made, he takes either the \nstraight or angular keratome, (PL I., Figs. 24, 26), as the case \nmay require, and forces it in at the desired point, parallel \nwith, and generally near to, the sclero-corneal junction, being \ncareful to lay the handle of the instrument well back, so as to \nguide the point of the keratome into the anterior chamber in \nsuch a manner as to permit of its being safely pushed forward \nbetween the iris and cornea until the incision is of the requisite \nlength. \n\nWhen the iridectomy is performed with the view of lessen- \n\n\n\n192 PRACTICE OF MEDICINE. \n\ning intra-ocular tension, or for the purpose of relieving the in- \nterior circulation, as in iritis or glaucoma, or when there is but \na limited space for the pupil on the margin of the cornea, the \nincision should be made in the sclerotica, about half a line from \nthe corneal border, so as to penetrate the chamber exactly at \nthe ciliary edge of the iris. But when it is intended for optical \npurposes only, the incision should be made through the cornea ; \nthe preferable point being a little to the inner side of the centre, \nthat being the direction of the visual ray. Other things being \nequal, however, the corneal opening should if possible be made \nnear the superior border of the cornea, so that the upper lid will \nconceal to some extent the obliquity of the pupil, and at the \nsame time reduce the amount of irregular refraction resulting \nfrom it: \n\nIn withdrawing the keratome, care should be taken not to \nallow the aqueous humor to flow off too rapidly, otherwise the \nsudden reduction of the intra-ocular tension will cause conges- \ntion of the interior vessels, which may result in a greater or less \namount of hemorrhage from rupture of the choroidal and \nretinal capillaries. In ^ase the incision made by the keratome \nis not sufficiently broad, or if, for any reason, it becomes neces- \nsary to widen it, it may readily be enlarged in either direction \nby an instrument designed for that purpose, represented in PL \nI., Fig. 20. \n\nOn completing the section of the cornea as above describ- \ned, if the iris does not protrude into the wound, the surgeon \nshould pass the iris forceps, closed, through the lips of the \nincision, and having seized a fold of the iris, should draw it \ngently through the opening; and when a sufficient portion of it \nprotrudes, the prolapsed part should be divided, either with a \nscalpel or bistoury, (PI. I., Fig. 22), or what is better a pair of \niris scissors, (Fig\'s. 1, 18, 19). If on withdrawing the keratome \nthe iris prolapses, there will of course be no necessity of enter- \ning the anterior chamber with the forceps, but the protruding \n\n\n\nSYPHILITIC IRITIS. 1 93 \n\nportion should be immediately seized, drawn out to the required \nextent, and then excised. \n\n(b.) Iriodesis. \xe2\x80\x94 This operation, consisting of an artificial \nprolapse of a portion of the pupillary margin of the iris, is \noften substituted for iridectomy in cases requiring simple dis- \nplacement of the pupil. The general management of the \npatient, and the method of making the corneal incision, are \nthe same as in iridectomy, except that the incision is always \nmade near the border of the cornea. Sometimes the stop \nneedle (PI. I., Fig. 15.) is used in making the corneal incision \ninstead ot the keratome, in order to prevent the too sudden \nevacuation of the aqueous humor. After withdrawing the \nneedle, a small loop of fine silk thread is placed directly over \nthe opening in the cornea, and then a small blunt iris hook, \nbent at the proper angle, (PL I., Fig. 35, b.), is introduced \nthrough the loop into the anterior chamber, pushed forward \nuntil it catches in the proximal side of the pupil, which is then \ngently pulled out through the loop and tied by an assistant. \nThe ends of the loop should cut off; but if the corneal \nincision has been made so large as to render the position of \nthe prolapsed portion of the iris insecure, they should be \ncut long enough to be attached to the integument by means of \na narrow adhesive slip. The loop will fall off in two or three \ndays; if not it may be removed. If the operator chooses, he can \nmake use of the canula forceps, (PI. I., Fig. 3.) instead of \nthe hook for seizing the iris, and in many cases it is to be pre- \nferred, especially when the pupil is required to be only slightly \ndisplaced. The operation, it is seen, is quite simple, but \nrequires care in order to avoid separating the opposite border \nof the iris from its ciliary attachment. \n\n(c.) Iridenkleisis . \xe2\x80\x94 This operation is similar to the last. \nIt consists in strangulating a portion of the pupillary margin \nof the iris in a long narrow opening made in the corneal bor- \nder of the sclerotica. The incision is generally made with a \n\n25 \n\n\n\n194 PRACTICE OF MEtUCINE. \n\nkeratome or lance-shaped knife (PI. I., Fig. 24.) precisely as \nin iridectomy, except that the instrument is entered very obli- \nquely three-fourths of a line from the corneal border, and \nonly far enough to admit of the easy entrance of the canula \nforceps, (PL I., Fig. 3.) by means of which the iris is pulled \nout of the opening in the sclerotica, and there left. The stran- \ngulated portion generally drops off in a few days ; if it should \nnot it may be removed. \n\n(d.) Iridotomy. \xe2\x80\x94 This operation consists in simply making \nan opening in the iris with a knife in cases in which, the lens \nbeing absent, the pupil closed, and the cornea clear, or if par- \ntially opaque, the opacity not interfering with the formation of \nan artificial pupil, one may be made by simply dividing the \nmembrane. The operation may be performed either with a \nstraight, spear-pointed, or lance-shaped knife, by passing the \ninstrument through the cornea perpendicular to its surface, and \nafter incising the iris to the required extent, immediately \nwithdrawing it. The edges of the incision generally retract \nsufficiently to form a useful pupil ; but in case they do not, one \nof them may be drawn out with a blunt iris hook (PL I., Fig, 35) \nand excised. \n\n(e.) I rido dialysis. \xe2\x80\x94 This is a convenient method of forming \nan artificial pupil in cases where the central part of the cornea \nis opaque, or in which the only transparent portion is a narrow \nline at the circumference. The operation consists in entering \nthe anterior chamber with the canula forceps, (PL I., Fig. 3), \nand separating a portion of the iris from its ciliary attachment. \nA better pupil may generally be obtained by first incising the \ncornea as in iridectomy, and then with the iris forceps or hook \ngently separating a small portion of the iris from its insertion, \nwhich is afterwards drawn out of the wound and cut off. \n\n(/.) Corelysis. \xe2\x80\x94 The object sought to be accomplished by \nthis operation is the detachment of adhesions between the edge \nof the pupil and the anterior capsule of the lens, (posterior \n\n\n\nCYCLITIS. 195 \n\nsynechia). The latest and best method of operating is that \ndevised by Passavant. which consists in introducing a pair of \nblunt-pointed iridectomy forceps through an incision in the \ncornea, ( See Iridectomy), seizing the iris between the senechia \nand the corneal opening, and gently drawing it towards the \nlatter far enough to detach the adhesion. The operation should \nbe repeated every two or three days until the entire pupillary \nmargin is relieved. \n\nAFTER Treatment. \xe2\x80\x94 For several days after an operation \nfor artificial pupil, the patient should be kept in bed, or re- \nclining quietly on a sofa, in a darkened room. All noise and \nexcitement of every kind should be suppressed, and the patient \nkept in a state of complete mental and bodily repose. A pres- \nsure bandage should be immediately applied to both eyes, and \ndrawn sufficientlytight to guard against intra-ocular hemorrhage. \nIn a few hours the bandage may be loosened, but it should not \nbe entirely removed for several days. After the operation of \ncorelysis a strong solution of Atropine should be immediately \napplied, and the instillation repeated from hour to hour until \nthe pupil is well dilated, after which the protective bandage \nshould be applied, and so adjusted as to exercise just enough \npressure to prevent winking. The diet for the first few days \nshould be such as to require little or no mastication, consisting \nof such articles as milk, soft-boiled eggs, soups, etc. If much \ninflammation or ciliary irritation should set in, the treatment \npreviously recommended should be rigidly enforced. \n\nART. VI. \xe2\x80\x94 CYCLITIS. \n\nInflammation of the ciliary body is seldom idiopathic. It \nis generally associated with its forerunner, iritis, constituting \nirido-cyclitis, or with iritis and choroiditis, forming irido- \nchoroiditis. Sometimes the inflammation is transmitted to the \nciliary body and iris from the choroid, and then we have what \nis called choroido-cyclitis or choroido -iritis. These combinations \n\n\n\nI96 PRACTICE OF MEDICINE. \n\nare readily understood, when we consider the similarity of \nstructure and close anatomical relations of the parts involved, \nthe iris, corpus ciliare and choroid constituting one continuous \ntissue, or tract, namely the uveal. Hence, inflammation \nbeginning in one of these parts, is very apt to extend to the \nothers, and vice versa. The disease presents two principal \nforms, or varieties, namely : (1) the serous, and (2) the purulent. \n\n1.-SEB0US CYCLITIS. \n\nSYMPTOMS. \xe2\x80\x94 Serous cyclitis is chiefly characterized by \ntenderness to the touch in the ciliary region, and by more or \nless intra-ocular tension, and impairment of vision. It is \ngenerally combined with serous iritis, the leading symptoms of \nwhich are : episcleral injection, ciliary irritation and neuralgia, \nincreased tension, exudation of lymph upon the posterior \nsurface of the iris, the veins of which are dilated and tortuous, \nenlargement of the pupil, and a greater or less degree of \nhypersecretion and cloudiness of the aqueous humor. In \naddition to these symptoms, irido-cyclitis is distinguished by an \nactual shallowness of the anterior chamber, due to a bulging \nfroward of the floating portion of the iris, combined with an \nappearance of unusual depth, arising from a retraction of its \nciliary margin, which is fastened by lymph to the ciliary body ; \nand the ophthalmoscope reveals large opaque spots scattered \nthrough it. Vision is always much impaired, and the field \nlimited. The power of accommodation is also more or less \naffected. If the disease continues unchecked, it soon spreads \nto the choroid ; the aqueous humor, which at first was in \nexcess, diminishes and becomes less than normal ; the tension \nalso diminishes, so that the globe becomes soft ; and finally a \ncondition of general atrophy ensues. \n\nThe etiology, prognosis and treatment will be given under \nthe head of \n\n\n\nPRACTICE OF MEDICINE. 1 97 \n\n2.-PUBULENT CYCLITIS. \n\nSYMPTOMS. \xe2\x80\x94 The chief characteristic symptoms of purulent \nor suppurative cyclitis are : intense episcleral injection, severe \nciliary neuralgia, photophobia and lachrymation, associated with \npain and tenderness in the ciliary region ; occasionally, also, \nthere is more or less cedema of the conjunctiva and lids. The \niris is generally discolored, its ciliary margin retracted, and its \nveins dilated and varicose. Abscesses form in the ciliary body, \nand sooner or later purulent exudations take place from them \ninto the anterior chamber, sometimes forming an hypopyon of \nvery great size. \n\nETIOLOGY. \xe2\x80\x94 The causes of cyclitis are : extension of \ninflammation from the neighboring tissues ; traumatic injuries \nof the ciliary body, especially those arising from operations on \nthe eye. as in cataract ; and irritation resulting from adhesions \nof the pupillary margin to the anterior capsule. It also occurs \nin the form of "sympathetic ophthalmia," (which see.) \n\nPROGNOSIS. \xe2\x80\x94 Inflammation of the ciliary body, whether \nacute or chronic is always a very serious affection, especially \nthe purulent form of it. Few cases, except the most recent, \nfully recover ; the tendency being to suppuration, atrophy, or \nchronic degeneration. \n\nTreatment. The indications being the same, irido-cyclitis \ncalls for similar treatment to that already given under the head \nof iritis. If used early, hot fomentations, faithfully applied, \nwill often give great relief, especially when the symptoms are \nacute; but to be effective they must be used early and \nassiduously, and even then they will sometimes fail in arresting \nthe disorder. As soon as the fomentations have produced \nsufficient relaxation, atropine should be instilled, with the view \nof producing immediate dilatation. If, however, there is closure \nof the pupil, and especially if the deeper structures of the eye \nhave become involved, no time should be lost in making an \nextensive iridectomy, provided there is no purulent exudation, \n\n\n\n198 PRACTICE OF MEDICINE. \n\nbut it will not do to resort to this measure if there are any \nindications of suppuration. \n\nSo far as internal treatment is concerned, the chief reliance \nmust be on Merc, and Kali iod., with such other remedies as \nspecial symptoms may from time to time indicate. See \nSympathetic Ophthalmia, Iritis, and Choroiditis. \n\nART. VII. \xe2\x80\x94 IRIDO-CHOROIDITIS. \n\nThe preliminary remarks made under the head of cyclitis, \napply with equal force to irido-choroiditis, to-wit, that inflam- \nmation of any portion of the uveal tract \' may originate in the \nsame, or in any other portion of it, and gradually spread \nthrough contiguous parts until the whole tract becomes involved. \nThe same is likewise true respecting the various forms of \ninflammation to which each particular part is subject ; but we \nshall confine our attention at present to the consideration of \nthe two principal varieties commonly met with in practice, \nnamely : (1) simple or serous, and (2) pseudo-membranous irido- \nchoroiditis. \n\nl.-SIMPLE IRID0-CH0B0IDITI3. \n\nSYMPTOMS. \xe2\x80\x94 This form of irido-choroiditis generally sets \nin with the usual symptoms of simple iritis, such as ciliary \nirritation and episcleral injection, abnormal appearance and \ndiscoloration of the iris, distension and varicose condition of its \nveins, sluggishness of the pupil, etc., to which is added, unless \nprevented by treatment, complete adhesion of the pupillary \nmargin to the anterior capsule, {annular synechia), thus cutting \noff all communication between the anterior and posterior \nchambers of the aqueous humor. This closure of the posterior \nchamber necessarily destroys the balance of intra-ocular tension \nbefore and behind the iris, causing the latter to be pressed \nforward into the anterior chamber, either in the form of a \ncircular cushion, or, as is more frequently the case, in the shape \n\n\n\nSIMPLE IRIDOCHOROIDITIS. 199 \n\nof irregular knobs or, protuberances, due to the unequal resist- \nance offered by different portions of its tissue. These knob- \nlike projections are sometimes so extensive as to reach the \nposterior surface of the cornea, from which the pupillary margin \nof the iris suddenly recedes, giving to the central portion of the \nmembrane a cup-like appearance, while the outer portion slopes \ngradually towards the circumference. If, now, an artificial \ncommunication be made between the two chambers, a yellowish \nwatery fluid will flow out from behind the iris, the pressure \nupon the two surfaces will be equalized, the knob-like projec- \ntions will recede, and the membrane again resume its normal \nposition. And since this will occur in whatever portion of the \niris the iridectomy is done, it is plain that fhe irregularities are \nnot due to plastic exudations on the posterior surface of the \niris, but to an unequal distension of portions of its tissue, in \nconsequence of an increase of intra-ocular pressure behind it \narising from exclusion of the pupil. This exclusion, it will be \nremembered, may exist either with or without an open pupil, \nthe only essential condition necessary to constitute it being an \nadhesion of the entire circumference of the pupil to the posterior \ncapsule, so as to shut off all communication between the two \nchambers. (See Iritis) \n\nThe tension of the globe varies greatly at different periods. \nAt first it is generally normal, or nearly so ; then it is more or \nless increased ; afterwards, as the disease progresses and the \ninner structures become atrophied, the tension diminishes, until \nfinally the globe becomes quite soft. \n\nIf the pupil is in a condition to admit of an ophthalmoscopic \nview of the interior of the eye, the vitreous humor will generally \nbe found to exhibit more or less cloudiness, mostly of a diffuse \ncharacter, but here and there interspersed with flocculent tufts, \nand delicate leaf-like or moss-like opacities. Sometimes the \ncloudiness is most marked in the vicinity of the ciliary body, \nespecially when there is extreme tenderness in the ciliary region ; \n\n\n\n200 PRACTICE OF MEDICINE. \n\nbut usually the opacity is general, showing that the inflamma- \ntion has extended to both the ciliary body and choroid. \n\nThe vision always becomes greatly impaired, even when \nthe pupil remains unobstructed. At first there is a mere hazi- \nness, which gradually deepens until the patient appears to be \nlooking through a dense cloud. As the disease progresses, \nobjects are seen with more and more difficulty, until finally the \npatient may be wholly unable to recognize them. \n\nThe etiology, prognosis and treatment will be considered \nin connection with \n\n2.-PSEUD0-MEMBKAN0US IRIDO-OHOROIDITIS. \n\nSYMPTOMS. \xe2\x80\x94 This form of irido-choroiditis is characterized \nby the development of thick, tough masses of false membrane \nand plastic lymph upon the posterior wall of the iris and the \nanterior capsule, to the latter of which they adhere. The com- \nmunication between the two chambers being thus cut off, the \niris, and with it the lens to which it is attached, yielding to the \nintra-ocular pressure, is pushed forward into the anterior \nchamber, rendering it more and more shallow, until the pupil, \nwhich in these cases is not retracted, appears just behind the \ncornea. The iris is generally very much discolored, its fibrillar \nobscured, its tissue stretched, and its surface covered with large \ntortuous vessels, due to venous engorgement, the latter arising \nfrom obstruction of the circulation caused by inflammation of \nthe ciliary body and choroid. \n\nThe course of the disease varies according as the inflamma- \ntion begins in the iris or choroid. In the former case, the \nsymptoms of iritis predominate. The episcleral injection of the \ncorneal zone is generally well developed, and there is also more \nor less ciliary irritation and pain. The ocular conjunctiva \nfrequently participates in the congestion, which is mostly of a \nvenous character ; and, as in other cases of acute iritis, the \npalpebral conjunctiva and lids are apt to be more or less \n\n\n\nPRACTICE OF MEDICINE. 201 \n\nswollen and inflamed. The iris is generally somewhat dis- \ncolored, the pupil sluggish or immovable, and the aqueous \nhumor sometimes cloudy or turbid. At a later period, the \nciliary region becomes sensitive, and the vitreous humor more \nor less opaque, showing that the inflammation has reached \nthe ciliary body. On the other hand, when the inflammation \nbegins in the choroid, the first and most marked symptom is, a \nsudden and often very great loss of the power of vision, arising \nchiefly from diffuse opacity of the vitreous humor. Pain if \npresent is not usually very great, nor is there generally much \nphotophobia. The vascular injection of the superficial tissues \nis also very slight, and occasionally it is entirely absent. The \nretina generally becomes detached, in consequence of which the \nfield of vision is more or less contracted. As the disease pro- \ngresses, the posterior portion of the lens frequently loses its \ntransparency, and the ciliary region becomes sensitive and \npainful. Subsequently, as a general rule, the iris becomes \ndiscolored, and its veins tortuous and enlarged ; the pupil con- \ntracted, adherent, and more or less obstructed ; the aqueous \nhumor cloudy and perhaps flocculent ; the anterior chamber \ngreatly diminished by the bulging forward of the iris ; and the \nciliary injection and neuralgia frequently augmented. The \ntension of the globe, which at first was somewhat increased, \nnow begins to diminish, and unless the disease is speedily \narrested, symptoms of atrophy and degeneration set in, the \nglobe ultimately becoming soft, and vision extinct. These \nchanges, though progressive, are often interrupted and irregular, \nbeing sometimes acute and rapid, at others slow, insidious and \nvariable. \n\nETIOLOGY. \xe2\x80\x94 The causes of irido-choroiditis are in many \ncases the same as those of iritis, the extension of the inflamma- \ntion to the ciliary body and choroid depending, in most \ninstances, upon the location, extent, severity and duration of \nthe irritation or injury ; and especially upon the presence of \nextensive posterior synechias, which, when complete or nearly \n\n86 \n\n\n\n202 PRACTICE OF MEDICINE. \n\nso, lead to the frequent renewal of iritis, and to a gradual ex- \ntension of the inflammation to the other portion of the uveal \ntract. Sympathetic irritation may also give rise to it, as we \nshall find when we come to treat of " sympathetic ophthalmia." \n\nPROGNOSIS. \xe2\x80\x94 The prognosis differs very much, according \nto the character and extent of the pathological changes. It is \nonly in recent and uncomplicated cases that we may reasonably \nexpect to effect a satisfactory cure, or even to restore the vision \nto anything like a normal standard. On the other hand, if the \ndisease is already of some standing, if there is complete \nadhesion of the pupillary margin to the anterior capsule, if \nlarge masses of false membrane exist between the iris and lens, \nand especially if extensive lesions of the choroid, opacity of the \nlens, or detachment of the retina has occurred, the prospect of \ncure is so slight as to render the prognosis very unfavorable. \nSome of these conditions, however, may be relieved ; and so \nlong as the field of vision is good, and the sight but little \nimpaired, the case cannot be considered altogether hopeless, \neven though a certain amount of atrophy has already taken \nplace. \n\nTreatment. \xe2\x80\x94 Recent cases require no other treatment \nthan that given under the heads of iritis, cyclitis and choroiditis, \n(which see). Those of longer standing will require that the \noperation of iridectomy shall be performed, perhaps repeatedly, \nboth for the purpose of relieving intra-ocular tension, and of \nbreaking up adhesions between the iris and anterior capsule. \nIn pseudo-membranous irido-choroiditis this is extremely \ndifficult to accomplish, partly in consequence of the shallow- \nness of the anterior chamber and the rotten condition of the \niris, but chiefly on account of the extent and firmness of the \nadhesions, which generally require the sacrifice of the lens. \nThis, however, is of but little consequence in these cases, as \nboth the lens and capsule are generally opaque. Von Graefe, in \norder to facilitate the operation, recommends the previous \n\n\n\nPOST-FEBRILE OPHTHALMIA. 203 \n\nextraction of the lens ; while Bowman performs what he calls \n"excision of the pupil," by cutting out with scissors a square \nportion of the iris, including the pupil, and afterwards removing \nit, along with the attached membrane, with forceps. If the lens \nis opaque, or if it is dislocated or wounded in the operation, it \nshould be removed at the same time. These operations are \nvery apt to excite fresh attacks of inflammation ; but neverthe- \nless it is necessary, in order to relieve the undue tension and \nprevent subsequent attacks of recurrent iritis, to re-establish \ncommunication between the two chambers at the earliest \npracticable moment. When this is satisfactorily accomplished, \nthe vision often clears up in a remarkable manner, and even \natropic symptoms, when not too far confirmed, are sometimes \narrested ; the eye frequently regaining to some extent its normal \ncondition and fullness. \n\nART. VIII. \xe2\x80\x94 OPHTHALMIA POST-FEBRILIS. \n\nA peculiar form of irido-choroiditis, occurring in connec- \ntion with the so-called recurrent typhoid fever, and which has \nbeen referred to mal-nutrition and starvation, has been describ- \ned by Mackenzie and other writers. We shall notice it briefly \nunder the head of \n\nPOST-FEBEILE OPHTHALMIA. \n\nSYMPTOMS. \xe2\x80\x94 This form of ophthalmia, which is generally \nconfined to one eye, is characterized by inflammation of the \niris and opacities of the vitreous humor. The disease does not \nusually manifest itself until several weeks after the last attack \nof fever has been subdued. The iritis is not generally very \nsevere, seldom resulting in entire closure of the pupil, though \nfrequently giving rise to scattered posterior synechias, and \nsometimes to hypopium. The adhesions are limited to the \npupillary margin, and are generally easily overcome by the \n\n\n\n204 PRACTICE OF MEDICINE. \n\nenergetic use of Atropine ; but the disturbances of vision, which \nin the latter stages arc chiefly due to purulent and flocculent \nopacities of the vitreous, frequently remain long after the more \nacute symptoms have been subdued. The disease, however, \ngenerally pursues a comparatively mild course; and, after lasting \nten or twelve weeks, usually ends in entire recovery. It seldom \nattacks children under ten years of age ; but when it does, it is \nsaid to run a shorter, and in most cases a milder course, than \nwhen the patient is more mature. \n\nETIOLOGY. \xe2\x80\x94 The chief cause is supposed to be an impov- \nerished state of the blood, resulting from mal-nutrition ; but the \ntrue nature of its connection with recurrent fever is not known. \nSome authorities attribute it to leucocythaemia, or an excess of \nwhite cells in the blood ; but, as Stellwag observes, this assump- \ntion is rendered very doubtful by the fact that the ophthalmia \nusually makes its appearance long after the last febrile attack, \nand, therefore, after the quality of the blood has become \nessentially improved. \n\nPROGNOSIS. \xe2\x80\x94 As already stated, the disease is seldom fol- \nlowed by any very serious consequences to vision, as the \nopacities are generally soon absorbed, and the synechiae can \ncommonly be broken up. Cases complicated with hypopium \nare, however, more serious, and sometimes terminate in atrophy \nof the globe. \n\nTreatment. \xe2\x80\x94 We have already treated so fully of the \nremedial measures required in this disease, that to give them \nhere would only be to repeat what we have said as to the \ntherapeutic indications and local treatment of iritis, (which see). \n\nART. IX. \xe2\x80\x94 OPHTHALMIA SYMPATHETICA. \n\nIt has long been known that when one eye has become \ndiseased, or has been severely injured, the other eye is liable to \nbecome sympathetically affected, especially if the causes or cir- \ncumstances which first give rise to the disorder are continued ; \n\n\n\nSYMPATHETIC OPHTHALMIA. 205 \n\nbut it has only been within a few years that sympathetic \ninflammation of the eye has attracted the attention which its \nimportance demands. This form of inflammation is peculiar, \nsince it does not follow operations for cataract or iridectomy, \nnor the loss of an eye from suppurative inflammation. The \nliability to the sympathetic affection appears to be greatest in \ncases in which the injured eye remains irritable and sensitive \nafter recovery from the immediate effects of the accident ; as \nwhen a foreign body penetrates the eye, and, by remaining \nwithin it, keeps up a constant irritation, and finally excites \nsympathetic inflammation in the other eye. The affection thus \nexcited is denominated \n\nSYMPATHETIC OPHTHALMIA. \n\nBy " sympathetic ophthalmia " is understood a peculiar \nform of inflammation set up in a previously sound eye by an \ninjury inflicted upon the other eye. It generally assumes the \ncharacter of an insidious but malignant irido-cyclitis. In some \ncases the symptoms supervene within a short time of the inflic- \ntion of the injury; but in others the wounded eye appears to \nrecover from the inflammation caused by the accident, and may \ncontinue in this condition for months without exciting any \napprehensions of approaching danger, when fresh symptoms \nunexpectedly arise, the injured eye again becomes injected and \npainful, and soon the sound eye becomes sympathetically \naffected. This is especially apt to occur where the injury is \ncaused by a bit of steel, or other metal, which, by remaining \nin the eye, afterwards sets up the usual suppurative process of \nelimination about the offending substance. In other instances, \nagain, the wounded eye, especially if the injury happens to be \nin the ciliary region, instead of becoming quiescent, never fully \nrecovers, but remains in a state of low inflammation, which \ngreatly impairs the safety of the other eye. \n\nSYMPTOMS. \xe2\x80\x94 The symptoms vary considerably in different \n\n\n\n206 PRACTICE OF MEDICINE. \n\ncases. The most constant are : temporary disturbances of \nvision, accompanied with a gradual diminution of sight in the \nsound eye ; discoloration of the iris ; effusion of lymph upon \nits posterior surface and in the pupillary area ; adhesion of the \niris to the anterior capsule ; exclusion of the pupil ; increased \nintra-ocular tension ; and, if not arrested, partial atrophy fol- \nlowed by softening of the globe. These symptoms are generally \naccompanied by more or less ciliary neuralgia, photophobia and \nlachrymation ; but in some cases there is neither orbital nor \ncircum-orbital pain sufficient to attract attention, though the \nciliary region is almost always sensitive to pressure. \nOccasionally, the disease manifests itself chiefly by amblyopic \nsymptoms, either with or without photophobia ; and Von \nGraefe describes a rare form of the affection in which the retina \nis implicated. In these cases there is little or no pain ; the \nvision is greatly impaired, and the power of accommodation is \nalmost wholly lost. The ophthalmoscope reveals congestion of \nthe optic nerve ; the retinal veins are sometimes found to be \ndilated and tortuous ; and, in cases connected with increased \nhardness of the globe, especially such as occur in advanced life, \nthere is frequently exhibited a glaucomatous excavation of the \noptic disc. \n\nETIOLOGY. \xe2\x80\x94 The most frequent causes of sympathetic \nophthalmia are : penetrating wounds in the ciliary region, \nespecially such as are accompanied with loss of vitreous or \nwounding of the lens ; severe laceration or bruising of the eye, \nfollowed by ciliary irritation and unattended with general \nsuppuration ; foreign bodies, such as chips of metal, glass, stone, \netc., lodged within the eye ; intra-ocular hemorrhages ; con- \ntraction, degeneration, or calcification of extensive fibrous \ndeposits within the eye, especially when implicating the ciliary \nbody ; and, when the stump remains irritable, the wearing of \nartificial eyes. In short, any injury which is capable of excit- \ning prolonged irritation of the ciliary nerves, may give rise to \n\n\n\nSYMPATHETIC OPHTHALMIA. 20*J \n\nsympathetic irritation or inflammation of the other eye ; and, \nas stated by Wells, this is frequently found to occur at a spot \nof the ciliary region which corresponds symmetrically to that \nat which the injured eye was hurt, or at which the ciliary \nregion still retains its sensibility to the touch. \n\nPROGNOSIS. \xe2\x80\x94 This is so unfavorable as to afford very \nlittle ground for hope after the disease has become fully estab- \nlished. It therefore becomes the imperative duty of the sur- \ngeon to warn the patient in time of the very serious nature of \nhis complaint, impressing upon him the fact that, notwith- \nstanding the long period which may have elapsed since the \noriginal injury was received, and the apparently trivial character \nof his present symptoms, their presence constitutes an insidious \nsource of mischief to the other eye, and that unless he speedily \navails himself of the only effective treatment known to the \nprofession, even that will prove unavailing, and vision will be \nsurely and irretrievably lost. \n\nTreatment. \xe2\x80\x94 The most efficient, and, in the vast majority \nof cases, the only efficient treatment, either preventive or \ncurative, consists in the early removal of the injured eye. Not \nthat every considerable injury, even when involving the ciliary \nregion, requires the loss of the injured eye in order to insure \nthe safety of its fellow, for the observance of such a rule \nwould cause many an eye to be needlessly sacrificed. But \nsince no case of sympathetic ophthalmia is known to have \noriginated after the injured eye has been removed, and since \nits removal generally arrests the disease in the other eye, when \nthe operation is performed immediately after the latter becomes \naffected, it follows that if the power of vision is lost in the \ninjured eye, and there is no prospect of its restoration, there \ncan be no question as to the propriety of immediately enucleat- \ning it. But the case is different if the sight continues tolerably \ngood in the injured eye, or even if only a limited degree of it \nremains, especially if the sympathetic disease has already \n\n\n\n208 PRACTICE OF MEDICINE. \n\nmade considerable progress, since the chances are that in these \ncases the injured eye will finally prove more serviceable to the \npatient than the other. Again, it may be regarded as an \nestablished fact, that the performance of any operation upon \nthe affected eye during the height of the sympathetic disease \nnot only fails in arresting its progress, but actually tends to \nincrease it. No benefit, therefore, can be expected from \niridectomy, unless it be performed at the very outset of the \ndisease, before active inflammatory symptoms have set in, or is \npostponed until by treatment or otherwise they shall have \nmeasurably subsided. In the latter case, the operative \nmeasures indicated will consist in the performance of an \nextensive iridectomy, together with the removal of the lens, \ncapsule, and adherent masses of exudation. Such an extensive \noperation will necessarily be attended with considerable \ndanger, not only by directly increasing the inflammatory \nprocess, but by giving rise, in many cases, to profuse intra- \nocular hemorrhage. " The weight of authority, therefore, \nespecially in this country, is in favor of immediate enucleation, \nin preference to iridectomy or any other operative procedure, \nin all cases in which there is any doubt of a favorable \ntermination. \n\nENUCLEATION OF THE EYE-BALL. \n\nThe removal of the eye-ball, which before the introduction \nof anaesthetics was regarded, even by the profession, as an \noperation of the most formidable character, has since been \ndivested of all its terrors, and, under the improved method of \ndoing it, will hereafter be considered as one of the most simple \nand trivial nature. \n\nThe patient having been fully anaesthetized, the eyelids \nwidely separated by the stop-speculum, (PL II. Fig. 33), and the \nglobe steadied with a pair of fixing forceps, (Figs. 36, 37), the \nsurgeon divides the conjunctival and sub-conjunctival tissues \nclose to the edge of the cornea. He then introduces a stra- \n\n\n\nGLAUCOMATOUS IRIDO-CHOROIDITIS. 200, \n\nbismus hook (PI. I. Fig. 17) beneath the recti-muscles, one \nafter the other, and divides them close to their insertion ; after \nwhich he carries a pair of curved scissors behind the globe and \nsevers the optic nerve as far back as possible. The eye now \nsprings forward from beneath the lids, and may be easily \nseized with the fingers and lifted from the socket, when the \nremaining muscles and conjunctival attachments are to be cut \naway, and the operation is finished. \n\nThe hemorrhage, which ensues when the optic nerve and \nophthalmic artery are divided, is generally soon arrested by \ninjections of cold water ; if not, it may be readily controlled \nby placing a piece of sponge in the orbital cavity and apply- \ning a compress and bandage. In the course of twenty-four \nhours, or sooner if the dressings are very painful, the sponge \nshould be removed, and the orbit cleansed with a little tepid \nwater, after which cold wet compresses should be applied for a \nfew days, or until the discharges cease. The extremities of \nthe severed muscles and optic nerve soon become covered over \nwith a cicatrix composed of the contracted edges of the con- \njunctiva, and the stump thus formed is found to be well adapted \nfor the adjustment of an artificial eye, the insertion of which \nneed not generally be delayed more than two or three weeks \nafter the performance of the operation. \n\n\n\nART. X. \xe2\x80\x94 GLAUCOMATOUS IRIDO-CHOROIDITIS. \n\nThe terms glaucoma and glaucomatous, signifying of a sea- \ngreen color, have been in use ever since the days of Hippocra- \ntes, by whom they were used to designate every form of deep- \nseated opacity. Afterwards they were limited to vitreous \nopacities and cataracts, which, occurring for the most part in \nadvanced life, present a greyish or greenish appearance. Still \nlater, the terms were applied to a particular form of oph- \nthalmia, which, as it occurs chiefly in gouty subjects, is some- \ntimes denominated arthritic. But since the invention of the \nophthalmoscope, in 185 1, our knowledge of the internal \ndiseases of the eye has been greatly advanced, the various \npathological changes occuring in the choroid, vitreous, retina \nand optic nerve disc have been carefully studied and described, \nand as a consequence, the above terms are now used with much \ngreater precision than ever before. By glaucoma, therefore, \nwe no longer mean simply that condition of the globe which \nis marked by stony hardness with its associated symptoms, \n\n\n\n2IO PRACTICE OF MEDICINE. \n\nbut also the previous abnormal conditions or diseases which \ngive rise to it. We shall here treat only of the primary forms ; \nthe secondary will be considered in connection with the \ndiseases with which they are associated. \n\n1 -ACUTE INFLAMMATORY GLAUCOMA, \n\nARTHRITIC OR VENOUS OPHTHALMIA. \n\nSYMPTOMS. \xe2\x80\x94 Premonitory Stage. \xe2\x80\x94 In by far the larger \nnumber of cases, the disease is preceded by certain premon- \nitory symptoms, such as repeated attacks of cephalalgia; \nneuralgia pains in the forehead and temples ; more or less \nvenous congestion, which, however, is always slight during the \npremonitory stage ; indistinctness of vision, arising chiefly \nfrom disturbances in the circulation, and coming on periodi- \ncally ; the appearance of a colored halo, like a rainbow, around \na flame, due probably to congestion ; dilatation and sluggish- \nness of the pupil ; more or less cloudiness of the aqueous and \nvitreous humors ; and, occasionally, a slight variation in the \nfield of vision. But the chief characteristic symptom, and \nthat on which most of the above-mentioned signs depend, is a \ngradual increase in the tension of the globe, which, however, \nnever becomes very considerable during this stage, and is some- \ntimes said to be entirely wanting. But this symptom is of \nsuch high importance, that whenever observed it should always \nexcite our suspicions, especially if any of the before-mentioned \nsigns co-exist. At the same time we should be on our guard \nagainst mistaking the subjective sense of tension or fullness \nwithin the eye for the objective sense of hardness, which may \nand often does exist without any real increase of tension. \n\nAt first, and during the premonitory stage, these symptoms \nare more or less periodic, that is, they occur at intervals of \nlonger or shorter duration, with a period of complete intermis- \nsion between them ; but sooner or later the intermissions cease, \nor are superceded by remissions only, certain symptoms belong- \n\n\n\nACUTE INFLAMMATORY GLAUCOMA. 211 \n\ning to the disease remaining permanently, and constituting \nwhat is called \n\nConfirmed Glaucoma. \xe2\x80\x94 Glaucoma Evolutum or Con- \nfirmatum. \xe2\x80\x94 After a longer or shorter duration of the \npremonitory stage \xe2\x80\x94 which in some cases lasts for years, \nalthough it generally extends over only a few months, \nand may even be limited to the first two or three attacks \n\xe2\x80\x94 the glaucoma breaks out suddenly, with symptoms of \nhigh inflammation ; the patient is seized with an intense head- \nache and excruciating ciliary neuralgia, the pain shooting \nfrom the orbital and sub-orbital regions to the forehead, temple, \nface and occiput. The pain is always more or less remittent \nin its character, becoming greatly intensified on the approach \nof night, and is frequently accompanied with photopsy, or \nflashes of light. It is also frequently associated with cold or \nicy sensations, attended with a feeling of numbness, or anaes- \nthesia, in and around the affected eye, and in the corresponding \nside of the head. At the same time there is generally more or \nless febrile excitement, accompanied in some cases with nausea \nand vomiting. The eyelids are often red and swollen, the \nsuperficial tissues infiltrated and injected, and the veins greatly \nengorged. The vascularity bears a general resemblance to \nthat of simple irido-choroiditis, but differs from it in the fol- \nlowing particulars. The corneal zone, while it has a similar \ndisposition about the cornea, is composed of vessels exhibit- \ning more numerous anastomoses, a deeper and more livid hue, \nand a sort of varicose enlargement ; but that which chiefly \ndistinguishes the episcleral injection is a whitish or bluish-white \nring, frequently more or less incomplete, and about the fourth \nof a line in breadth, which separates the vascular zone from \nthe edge of the cornea, and called the venous circle. Some- \ntimes the chemosis is so great as to completely hide the \nepiscleral vascularity quite up to the circumference of the \ncornea. The conjunctival injection consists of large vessels, \n\n\n\n212 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\n\nACUTE GLAUCOMA. \n\n\n\ntortuous and more or less vari \ncose, their trunks turned to- \nwards the great fold of the \npalpebral conjunctiva, and their \nK& branches ramifying by bifurca- \ntion ; those on the border of the \ncornea anastomosing here and \nthere with branches from the \nother vascular trunks. (See \nFig. p). There is generally con- \nsiderable photophobia and lachrymation, but not much mucus \ndischarge. The latter presents some peculiar features. In \nconsequence of the frequent motion of the lids, the mucus \ncollects on their edges, or in the angles and folds of the con- \njunctiva, in the form of white froth or foam ; this is the \n"arthritic foam" of the old authors. \n\nTo complete the picture, the cornea becomes nebulous on \nits posterior surface ; the anterior chamber shallow, so that \nthe iris is nearly or quite in contact with the membrane of \nDescemet ; the aqueous humor cloudy ; the iris more or less \ndiscolored ; the pupil dilated, irregular and sluggish ; the \nvitreous humor hazy and opaque ; and the globe abnormally \nhard. Vision is either entirely lost or greatly impaired ; in \nthe latter case the field is generally contracted. As the \ninflammatory symptoms subside the blindness may continue, \nbut this is not the general rule ; the sight may be fully restored. \nThis, however, is only temporary. The acute inflammatory \nattacks continue to recur, the visual field becomes more and \nmore contracted, and finally the sight is entirely lost. At the \nsame time the globe becomes more and more tense, until \nfinally it reaches a state of stony hardness. In other cases \nthe inflammatory symptoms subside permanently, but still the \neye does not recover its normal condition. The inflammation \ncontinues in a low form and becomes chronic ; the glaucomatous \n\n\n\nACUTE INFLAMMATORY GLAUCOMA. 21 3 \n\ndegeneration increases more and more ; and finally all percep- \ntion of light, even quantitative, is lost. This state, called by \nway of distinction glaucoma absolutum or consummatum, is \nsometimes, but very rarely, reached within a few hours, and \nsometimes even within a few minutes, of the setting in of the \nattack. This last variety, known as fulminating glaucoma, is \ndistinguished from the ordinary acute form by the rapid devel- \nopment of glaucomatous symptoms, especially by the sudden \nand complete destruction of vision, followed by atrophy and \ndegeneration of the deep-seated tissues of the globe. \n\nThe ophthalmoscopic symptoms, as well as the etiology, \nprognosis and treatment, will be given after the other forms \nof glaucoma have been described. \n\n2.-CHE0NI0 INFLAMMATORY GLAUCOMA. \n\nIn our description of acute glaucoma we alluded to the \nfact, that after the subsidence of the acute attack, the disease \nfrequently passed over into the chronic form. It may, how- \never, be developed insidiously from the prodromal or premon- \nitory stage. \n\nSYMPTOMS. \xe2\x80\x94 Chronic inflammatory glaucoma, when develo- \nped from the acute, generally assumes at first a sub-acute form, \nat which degree it continues, with more or less decided exacer- \nbations and remissions, for a few weeks, after which the \ninflammatory symptoms become less and less conspicuous, \nwhile the glaucomatous process itself continues slowly to \nadvance. Thus, the globe gradually becomes harder and \nharder, until at last it reaches the highest point of tension. \n(Tn. 3). The cornea becomes hazy, less convex, and more and \nmore anaesthetic, until finally, in some cases, it loses all sensibil- \nity. The sclera becomes atrophied and more or less translucent, \nassuming at last a peculiar waxy or porcelain tint. The \nepiscleral veins are engorged and tortuous, the anterior cham- \nber is narrowed by the pushing forward of the iris until the \n\n\n\n214 PRACTICE OF MEDICINE. \n\nlatter almost rests upon the cornea, the aqueous humor is \nrendered cloudy or turbid, the pupil is dilated and either \nsluggish or immovable, and the iris loses its brilliancy, becom- \ning more or less maculated and discolored. The diminution \nof sight generally keeps pace with these changes, and at the \nsame time the field of vision becomes more and more contrac- \nted. At last the sight is entirely destroyed, not even a trace \nof sensitiveness to light remaining. This state is generally \ncharacterized by a pale-greenish opacity of the lens, constitu- \nting the so-called glaucomatous cataract. This symptom is \nnot due, as is generally supposed, to degeneration of the lens, \nbut to the combined effect of the mixing of the yellow color \nof the lens, peculiar to elderly people, with the bluish-grey \ncolor of the aqueous humor, which the latter assumes after it \nhas become cloudy and turbid. The effect of this green reflex \nis somewhat heightened by the greyish opacity of the vitreous \nand the dilated state of the pupil. While glaucomatous \ncataract is generally due to changes developed in the course \nof the disease, it is not, as was formerly considered, an essen- \ntial, and consequently not a pathognomonic, symptom of \nglaucoma. \n\nAlthough absolute glaucoma may exist for a long period \nwithout any very striking changes in the symptoms, the above \nresult is not generally reached without the recurrence, at longer \nor shorter intervals, of inflammatory attacks and exacerbations ; \nbut these are usually of a low and insidious character, and \nare seldom attended, as in the acute form, with any very great \namount of pain or suffering. Occasionally, however, acute \ninflammatory exacerbations occur, attended with headache, \nciliary neuralgia, photopsy, etc.; and these may recur from \ntime to time, either spontaneously, or as the result of external \ncauses. At a later period the stage of atropic degeneration \nsets in ; the iris becomes greatly narrowed, and is reduced to a \nmere streak, the cornea is softened and rendered opaque, \n\n\n\nCHRONIC NON-INFLAMMATORY GLAUCOMA. 21 5 \n\nhemorrhagic effusions take place in various portions of the \nglobe, the choroid and retina degenerate, sclerotic staphy- \nloma are produced, followed, it may be, by suppurative \ninflammation and general atrophy. \n\n3.-CHR0NIC NON-INFLAMMATORY GLAUCOMA. \n\nGLAUCOMA SIMPLEX, OF DONDERS. \n\nSymptoms. \xe2\x80\x94 This form of glaucoma is chiefly character- \nized by the absence during the earlier stages, and sometimes \nduring nearly its entire course, of any appearance of inflam- \nmatory symptoms. The only symptom that at first is apt to \nattract attention, is a gradually increasing weakness of vision ; \nand this, in the absence of other symptoms, is generally \nattributed to the approach of old age. The defect is most \napparent for near vision, as in reading, writing, etc., though in \nmany cases it is also well marked for distance. Owing to the \nabsence of premonitory symptoms, the approach of the disease \nis generally very insidious ; and so quietly does it advance, \nthat the patient is often unaware of his danger until after it \nhas made considerable progress. Careful examination, how- \never, will generally detect an increase of tension in the weaker \neye, accompanied with rapidly increasing presbyopia and more \nor less hypermetropia. As the disease advances the tension of \nthe globe increases, the cornea loses its sensibility, the ciliary \nveins become congested, the pupil is sluggish and more or less \ndilated, the anterior chamber becomes shallower, the field of \nvision is progressively narrowed, and the sight more and more \ndiminished, until finally all perception of light is extinguished. \nThe disease seldom runs its course, however, without the acces- \nsion of inflammatory symptoms, which may be more or less \nviolent according to the type of the inflammation. When \nacute, the symptoms of acute glaucoma will be superadded to \nthose above-mentioned ; and in all cases there will be more or \nless ciliary neuralgia, cloudiness of the aqueous and vitreous \n\n\n\n2l6 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\nhumors, increase of intra-ocular tension, etc. These symptoms, \nhowever, may be so slight and transitory as scarcely to attract \nattention, and in some cases will be likely to escape detection \nunless particular attention be paid to the objective symptoms, \nsuch, for example, as a slight discoloration of the iris, or some \ncloudiness of the aqueous humor. \n\nOphthalmoscopic Symptoms. \xe2\x80\x94 These are : (i) a char- \nacteristic "cupping" of the optic nerve disc ; and (2) pulsation \nof the retinal arteries. The glaucomatous, or "pressure" \nexcavation, as the cupping of the optic papilla is sometimes \ncalled, is easily distinguished from the other two forms ; \nnamely, from what is known as the congenital or physiological \nexcavation, and also from that which characterizes simple \natrophy of the optic nerve, by not being partial or limited to \nthe central portion of the optic disc, as in the former, nor by a \ngradual sloping from its edges, towards the centre, as in the \nlatter ; but the cup extends quite up to the edge of the disc, \nfrom which the lamina cribrosa suddenly retreats, as if pushed \ndirectly backward by the increased intra-ocular pressure- \nIndeed, so abrupt and precipitous are its edges, that the latter \nmay even over-hang the cup, as though the margin were un- \ndermined. The cupping of the papilla is made apparent by \nthe course of the retinal vessels as they pass over the edge of \nFIG - IO - the excavation. Instead of \n\npassing straight over the mar- \ngin of the disc, as in the nor- \nmal eye, (Fig. 10), we find \nthat as they descend into the \nexcavation they make a more \nor less abrupt curve ; and if \nthe edges of the excavation \nare undermined, the veins, as \nthey curl over them, appear to \nbe so much displaced, that \nwhen they reappear on the \noptic papilla, N orma L .* optic disc they no longer \n\n\n\n\n*After Zander. \n\n\n\nCHRONIC NON-INFLAMMATORY GLAUCOMA. 21/ \n\nseem to be the same vessels. This is especially the case if the \nexcavation is deep, the displacement sometimes equalling, or \neven exceeding, the diameter of the vessel. \n\nSpontaneous pulsation of the retinal veins is a common \noccurrence in healthy eyes ; but spontaneous arterial pulsation \nis known to occur only in cases where there is insufficiency of \nthe aortic valves, or where the intra-ocular tension is consid- \nerably increased. The pulsation is generally limited to the \noptic disc, and is of a rapid and somewhat jerky character. \n\nETIOLOGY. \xe2\x80\x94 Many theories have been advanced to \naccount for the glaucomatous process ; of these not more than \nthree appear to be of sufficient importance to claim our atten- \ntion. The first attributes the increased eye tension, and excav- \nation of the optic disc, to hypersecretion of the fluids of the \neye, the result of some abnormal irritation of the secretory \nnerves, which irritation is regarded as a reflex from the sym- \npathetic. The second attributes the glaucomatous symptoms, \nprimarily, to inflammation of the uveal tract ; the other struc- \ntures of the eye becoming secondarily involved. According to \nthis theory, the irido-choroiditis first gives rise to hypersecre- \ntion of the vitreous humor, and this causes an increase of the \nintra-ocular tension, which latter, by its interference with the \ncirculation, occasions the glaucomatous symptoms. The \nthird and last theory which we shall notice, attributes the \ndisease to a want of elasticity in the sclerotica. The fact that \nglaucoma is pre-eminently a disease of advanced life, and \ngenerally attacks only those whose age exceeds forty or fifty \nyears, in whom the sclerotica appears comparatively rigid and \nunyielding, is regarded by the advocates of this theory as \nfurnishing conclusive evidence that the disease is due to con- \ngestion in the internal circulation caused by a rigid and un- \nyielding capsule. We have not room to examine these theories \nin detail, but are inclined to regard the inflammatory theory \nas the most tenable, notwithstanding the fact that some cases \n\n28 \n\n\n\n218 PRACTICE OF MEDICINE. \n\nof glaucoma simplex seem to run their course without any, or \nat least with but very little, appearance of inflammatory \nsymptoms. It should be remembered, however, (i), that the \nabsence of any external, or of any subjective signs of external \ninflammation, is no proof of its non-existence, the contrary \nhaving been frequently established by ophthalmoscopic evi- \ndence ; and (2) that, in the vast majority of cases, inflamma- \ntory symptoms of greater or less severity do show themselves \nat some period of the disease. On the other hand, there can be \nbut little doubt that rigidity of the sclerotica has more or less \nto do with the origin and progress of glaucoma. For, as Wells \nvery appropriately observes, we find that in youthful indivi- \nduals, in whom the sclerotica is more elastic and yielding, an \nincrease of the intra-ocular tension, dependent upon some \ninflammation of the uveal tract, may exist for some time \nwithout exerting any deleterious effect upon the optic nerve or \nretina. \n\nPROGNOSIS. \xe2\x80\x94 Previous to the year 1856, when Von Graefe \ndiscovered the value of iridectomy in this disease, glaucoma \nwas justly regarded as incurable ; for the disease is of such a \nprogressive and destructive character, that if left to itself, or \nif treated exclusively by other remedies, it leads, sooner or \nlater, to atrophy and permanent blindness. On the other hand, \nso effective has the operation of iridectomy proven in relieving \nintra-ocular tension, and in arresting the progress of the \ndisease, that in those cases in which irreparable damage to the \nstructures of the eye has not yet taken place, the glaucoma- \ntous symptoms have been greatly benefited, and in most cases \nhave entirely disappeared. Much, however, depends upon the \nkind as well as the stage of the disease. Glaucoma fulminans, \nfrom the rapidity with which it runs its course, is extremely \ndangerous. Secondary glaucoma, especially that which super- \nvenes upon hemorrhagic effusions, is equally dangerous, the \noperation either proving inefficient, or else complicating the \n\n\n\nCHRONIC NON-INFLAMMATORY GLAUCOMA. 219 \n\ndisease by increasing the hemorrhagic effusion. The prognosis \nin the latter stages of acute glaucoma, as well as in the chronic \ninflammatory form, must be guarded ; since in the first case \nthere may already be such a deterioration of the retina and \ncupping of the optic nerve, as to render any improvement from \nthe operation temporary and imperfect ; and in the latter, the \nprogress of the disease is so insidious, that serious structural \nchanges of the retina and optic nerve, and especially atrophy \nof the latter, may occur before treatment is instituted. \n\nTreatment. \xe2\x80\x94 As already indicated, operative measures \nstand at the head of remedial agencies in this affection ; and \nof these iridectomy is incomparably the most efficient. When \nwe take into consideration the fact that in the early stages of \nglaucoma, iridectomy is almost a certain cure for it, it is evi- \ndent that to postpone the operation a single day after the \ndisease fully declares itself, is to incur a great and unnecessary \nrisk. It is true the operation sometimes cures even in the \nlater stages, and in nearly all cases it proves palliative, but in \norder to insure the greatest benefit from it, the sooner it is \nperformed the better. The operation is similar to that already \ndescribed, {see Iritis), except that the incision is made in the \nsclerotica, near its junction with the cornea, instead of being \nmade in the cornea itself, in order that by extending the incis- \nion quite up to the ciliary border, a larger section of the iris \nmay be secured ; for the same reason, also, the opening is \nmade as large as the keratome will allow.. In no other way \ncan the intra-ocular tension be so effectually and permanently \nrelieved. Neither myotomy, or division of the ciliary muscle, \nnor paracentesis, nor the more recent operation of sclerotomy, \ncan compare in effectiveness with a large iridectomy. Even a \nsmaller iridectomy, such as is made through the cornea for \nartificial pupil, is not likely to be followed by permanent and \nsatisfactory results. \n\nBut while there can be no question as to the propriety of \n\n\n\n220 PRACTICE OF MEDICINE. \n\noperating as soon as possible after the disease has fully \ndeclared itself, or after the congestive and inflammatory \nsymptoms have ceased to intermit and have become remittent, \nthe case is different during the purely premonitory stage- \nDuring this period we may reasonably expect to benefit the \npatient by the careful administration of well-selected constitu- \ntional remedies. This will be obvious when we take into \nconsideration the fact that, in the great majority of instances, \nthere co-exist various constitutional disturbances, such as \nrheumatism, gout, derangements of the menstrual function, \nhemorrhoids, etc., all of which are amenable to treatment, and \nwhich exercise more or less influence upon the disease. But \nin order to prove curative they must be administered during \nthe period of intermission : if used later than this they must \npossess the quality of reducing intra-ocular tension, otherwise \nthey will prove to be of little or no benefit. We have has yet \ndiscovered no remedy which will surely and permanently \nproduce this effect, although there are several medicines that \nare capable of causing the subjective symptom of tension \nwithin the eye. As before observed, we should be careful not \nto confound this symptom with the objective sense of hard- \nness ; but as the latter is probably due, at least secondarily, to \nhypersecretion of the ocular fluids, it is not at all unlikely \nthat we may yet find remedies which are capable of reducing \nor limiting it, by causing, perhaps, a retrograde metamorphosis \nto take place within the affected tissues. However this may be, \nwe should endeavor, with the light we now have, to equalize \nthe circulation and remedy constitutional derangements, \nespecially during the premonitory period. \n\nTHERAPEUTIC INDICATIONS. \n\nArsenicum. \xe2\x80\x94 Deep-seated throbbing pain in the eyeball, \nespecially at night ; photopsy ; obscuration of sight, amount- \ning at times to almost complete blindness ; periodic burning \n\n\n\nCHRONIC NON-INFLAMMATORY GLAUCOMA. 221 \n\npains in and around the eye, worse at night or after midnight. \nEspecially indicated in cases where there is an increase of the \naqueous humor. \n\nBelladonna. \xe2\x80\x94 Obscuration of sight, with dilatation of \nthe pupils ; rapidly increasing presbyopia ; hypermetropia ; \nrainbow colors around flames, especially when the red pre- \ndominates ; aching pressure within the eye ; also burning pains \nin and around the eye, especially when accompanied with con- \ngestion to the head and face. The best results are obtained \nby using the remedy tolerably high, say the 200th, never less \nthan the 30th. \n\nBryonia. \xe2\x80\x94 This remedy is indicated when there is sore- \nness to the touch in the ciliary region, accompanied with sharp \nshooting pains in the eyes, extending to the head and face; \nalso when there is a sense of fullness and pressure, as though \nthe eyes were being forced out of the sockets ; aggravation of \nthe pains by moving the eyes, or by any exertion of them in \nreading or writing, especially at night. \n\nCedron. \xe2\x80\x94 Severe ciliary neuralgia, especially when the \npains are distinctly periodical ; dilatation of the pupils, with \ndimness of vision ; eyes injected and sore to the touch. This \nremedy is most useful in relieving ciliary irritation and neural- \ngia, especially when the pains appear to follow the course of \nthe supra-orbital nerve. \n\nCimicifuga. \xe2\x80\x94 This is one of our most reliable remedies \nfor ciliary neurosis, especially when there is a sense of enlarge- \nment of the globes, the eyes feeling as though they would \nbe pressed out of the sockets ; also when there are amblyopic \nsymptoms, with dilated pupils ; or congestive headache, with \naching in the eyes and lachrymation. \n\nConium. \xe2\x80\x94 Dilatation of the pupils, with dimness of \nsight, especially when accompanied with protrusion ; feeling of \npressure in the eyes, especially when reading, writing, or doing \nany fine work ; also for photophobia and photopsy, particularly \nin scrofulous subjects. \n\n\n\n222 PRACTICE OF MEDICINE. \n\nGelseminum. \xe2\x80\x94 Amaurotic symptoms, with dilatation of \nthe pupils ; disturbances of the power of accomodation; pain \nin the eyes, either with or without lachrymation. Especially \nindicated in choroidal and venous congestions, either with or \nwithout serous effusion. \n\nHamamelis. \xe2\x80\x94 This remedy is indicated in all venous \ncongestions of the eye associated with hemorrhoids, especially \nif there is much conjunctival vascularity, ciliary neuralgia, \nphotophobia and lachrymation. \n\nKali tod. \xe2\x80\x94 Amaurotic symptoms, with dilatation of the \npupils; burning in the eyes; lachrymation, and a dull, discolored \nstate of the iris. This remedy, which is of undoubted value \nin every form of choroidal congestion and inflammation, has \nappeared to give relief in many cases of incipient glaucoma, \nespecially when occurring in syphilitic constitutions. \n\nPhosphorus. \xe2\x80\x94 This remedy has been found useful in glau- \ncoma, especially when accompanied with determination of \nblood to the eyes, photopsy, photophobia, cromopsia, or play \nof colors around flames, and lachrymation ; also when atten- \nded with a sensation of pressure in the eyes, dimness of vision, \nand dull orbital and circum-orbital pains. \n\nPhytolacca. \xe2\x80\x94 Dimness of vision, with hypermetropia or \nrapidly increasing presbyopia ; dull, aching pain in the eye- \nballs, worse from motion, light, or exercise. Especially suited \nto rheumatic and syphilitic cases. \n\nRhododendron. \xe2\x80\x94 Incipient glaucoma, accompanied with \nviolent attacks of pain in the orbit and head, always worse on \nthe approach of rough weather, or of a thunder storm, and \nameliorated when the storm sets in. The pains are of a \nburning, shooting character, and distinctly periodical. The \nremedy is best adapted to rheumatic subjects. \n\nSpigelia. \xe2\x80\x94 Sharp stabbing pains through the eye and cor- \nresponding side of the head, worse at night and on motion. \nThe remedy is particularly indicated if, along with dimness of \nvision, there is presbyopia, strabismus, or photopsy. \n\n\n\nPRACTICE OF MEDICINE. 223 \n\nSulphur. \xe2\x80\x94 This medicine is generally most useful as an \nintercurrent remedy, especially in scrofulous cases. The \nspecial indications are ; gradual diminution of the power of \nvision ; illusions of sight, photopsy and photophobia ; sharp, \nsticking or stabbing pains in the eyes, worse on motion and at \nnight. \n\nIn addition to the above remedies, the following have also \nbeen recommended : Arm, Cham., Cocc, Colch., Collin., Col- \nocynth, Crot. tig., Hepar, Merc, Nuxv., Prunus spin., Val. Zc. \n\nDiet and Regimen. \xe2\x80\x94 The diet should be liberal, nutri- \ntious, and easily digestible, especially for scrofulous constitu- \ntions and elderly patients. Stimulants should be avoided by all \nexcept those addicted to their use, and then used only in a feeble \nstate of the system, the object being in all cases to keep the \nhealth in the best possible condition. Bright light should \nalways be avoided, or the eyes protected by amber or smoke- \ncolored glasses. The eyes should enjoy perfect rest during the \nattacks, or when the latter follow each other in quick succes- \nsion ; and in no case should they be used for near objects, or \nwhen exercise causes pain or provokes an attack. \n\nART. XI. \xe2\x80\x94 CHOROIDITIS. \n\nWe have already considered anterior, or partial choroiditis, \nunder the head of irido-choroiditis ; and one of the most \nimportant and complicated forms of general choroiditis has \nbeen described under the head of glaucoma. It remains to \nconsider (i) simple serous choroiditis; (2) disseminated or \nexudative choroiditis ; (3) suppurative choroiditis ; and (4) \nsclerotico choroiditis posterior, or posterior staphyloma. \n\n\n\n224 PRACTICE OF MEDICINE. \n\nl.-SIMPLE SEROUS CHOROIDITIS. \n\nSymptoms. \xe2\x80\x94 This form of choroiditis is chiefly character- \nized by diffuse cloudiness of the vitreous humor and consequent \ndiminution of vision. The disease is frequently complicated, \nsooner or later, with serous iritis, the iris becoming more or less \ndiscolored, the pupil dilated or adherent to the anterior cap- \nsule, the aqueous humor hazy and more or less turbid from \nparticles of floating lymph, and the posterior surface of the \ncornea clouded with similar deposits, {Keratitis punctata). The \ndiffuse turbidness of the vitreous is rendered more opaque by \nfixed or floating opacities, of a filiform and membranous \ncharacter, which, according to Graefe, affect the structure of \nthe vitreous humor, leading to the destruction of its septa, and \neven to the dissolution of the zonule of Zinn. The relaxation \nand softening thereby produced frequently give rise to dis- \nplacement of the lens. In other cases the intra-ocular tension \nincreases, the aqueous humor is secreted in greater quantity, \nthe vision becomes more and more impaired, and finallysymp- \ntoms of glaucoma appear. These complications, however, \nrarely take place in simple serous choroiditis, the opacities of \nthe aqueous and vitreous humors generally disappearing \naltogether, or leaving only a slight amount of cloudiness in the \nciliary region. \n\nTreatment. \xe2\x80\x94 Little more is generally required in the \nway of treatment, than to keep the eyes in a state of perfect rest, \nto protect them against bright lights, cold, dampness, etc., to \nkeep the pupil dilated with Atropine, and to hasten the absorp- \ntion of the vitreous opacities by the internal administration of \nKali iod. In those cases in which the intra-ocular tension is \nincreased, the operation of paracentesis may be tried ; but if \nthis fails to relieve, and secondary glaucoma sets in, it will \nprobably be necessary to perform the operation of iridectomy, \n(which see). Aurum, Bryonia, Colocynth, Gelseminum, \nIpecacuanha, Phosphorus, Psorinum, and Sulphur, have been \nemployed in these cases with favorable results. (See Glaucoma). \n\n\n\nPRACTICE OF MEDICINE. 225 \n\n2.-DISSEMINATED CH0H0IDITIS. \n\nSYPHILITIC OR EXUDATIVE CHOROIDITIS. \n\nSYMPTOMS. \xe2\x80\x94 The subjective symptoms of this affection \nare often so light during the early stages, that its existence is \nfrequently not suspected until after the disease has made con- \nsiderable progress. There is generally little or no pain, \nphotophobia, lachrymation, or vascular injection ; the iris is \nbut slightly implicated ; and the only symptom of which the \npatient is apt to complain, is a peculiar impairment of sight, \nin which the vision is more or less obstructed and distorted by \ndark, fixed, cloud-like opacities appearing before it. These \nscotomata, as they are called, are supposed to be due to the \ndissemination or exudation of matter from the choroid upon \nthe under surface of the retina, the pressure of which upon \nthe latter impairs its function by injuring or destroying some \nof its elements. The injury to vision is, of course, greatest \nwhen the exudations are situated in the region of the yellow \nspot, and least when confined to the anterior portion of the \nfundus. The vitreous humor sooner or later becomes diffusely \nclouded, and frequently exhibits fixed or floating opacities, of \na filimentous or membranous appearance. These vitreous \nopacities sometimes make their appearance previous to that \nof the choroidal exudations before mentioned. The latter, \nwhich are far the most important, vary in size from a millet \nseed to large circular patches. They occur both in the stroma \nand upon the retinal surface of the choroid. At first they are \nof a dull, yellowish color ; but at a later period the exudative \nmasses are absorbed, leaving the corresponding parts of the \nchoroid so much thinned as to be more or less transparent, so \nthat the subjacent sclera shines through the patches, giving \nthem a somewhat pearly, glistening appearance. The patches \nare more or less irregular in shape, and are rendered very con- \nspicuous by proliferation of epithelium pigment cells upon \n29 \n\n\n\n2 26 PRACTICE OF MEDICINE. \n\ntheir borders, the blackness of which contrasts strongly with \nthe whiteness of the more central portions. \n\nThe exudation may commence either at the periphery or \nat the posterior pole of the eye, from which parts it becomes \ngradually disseminated over the fundus. In the latter case, \nthe patches sometimes exhibit pale-red areolae round them, \nwhich are thought by some to indicate a syphilitic origin. \nNotwithstanding, however, this is probably the most common \nform of specific disseminated choroiditis, it is far from being \nthe only one, as we find that almost every variety of the \ndisease is sometimes due to syphilis. \n\nDIAGNOSIS. \xe2\x80\x94 The only certain diagnostic signs of the \ndisease are the ophthalmoscopic symptoms ; but these are so \npeculiar as to render it almost impossible to mistake dissemin- \nated choroiditis for any other form of the affection, so long as \nthe vitreous remains sufficiently transparent to allow the details \nof the fundus to be made out. As to the precise seat of the \nexudations, we may readily satisfy ourselves that it is in the \nchoroid, by observing that the retinal vessels can be traced \ndirectly over the patches, and are not obstructed in their course, \nor rendered the least indistinct by them ; moreover, the retinal \nveins retain their normal calibre and straightness, and the \nretina its usual appearance and transparency. At a later \nperiod, the retina generally becomes thinned and atrophied by \nthe pressure of the exudations ; and not unfrequently the optic \nnerve, also, shows signs of atrophy, the blood-vessels becoming \nmore or less indistinct, and in some cases obliterated. \n\nEtiology. \xe2\x80\x94 Disseminated choroiditis is found to be most \nfrequently associated with syphilis; but the insidious form \ncomplicated with serous iritis sometimes occurs in lymphatic, \nscrofulous, and consumptive patients. \n\nPrognosis. \xe2\x80\x94 The prognosis should always be guarded, \nespecially if the exudations are extensive, or are seated in the \nregion of the yellow spot. The most favorable cases, com- \n\n\n\nDISSEMINATED CHOROIDITIS. 22/ \n\nparativcly, are those of a distinctly syphilitic origin, in which \nthe spots are surrounded by reddish areolae. In these and \nother favorable cases, the exudations are sometimes absorbed, \nleaving but slight traces of their former existence behind them. \nIn most instances, however, the choroid, retina and optic nerve \nall suffer to some extent, becoming more or less atrophied and \ndisorganized. \n\nTreatment. \xe2\x80\x94 Disseminated choroiditis has been treated \nmost satisfactorily, in its early stages, with Merc. cor. and Kali \niod. These two remedies are not only indicated in all cases \ndependent upon a syphilitic basis, but they are also serviceable \nin every other form of choroidal inflammation, especially when \ncomplicated with iritis. Nux. v. and Phos. ac. are found to \nbe the most useful remedies after the vision becomes impaired \nin consequence of atropic changes in the retina and optic \nnerve. Of the other remedies which have proven curative, or \nwhich have been found useful in this affection, the following \nare especially worthy of attention : Ars., Bell., Cact, Con., \nPhos., Rut., SiL, Sol. n., Spig. and Sulph. The selection \nshould be governed, to a great extent, by the condition of the \ndigestive, assimilative, and uterine organs. \n\nDiet and Regimen. \xe2\x80\x94 The diet should be plain, unstim- \nulating, nutritious, and easily digestible. The patient should \nbe careful to abstain from all use of the eyes in reading, \nwriting, etc., and to protect them against bright lights by \nwearing colored glasses. Moderate exercise in the open air, \nand whatever tends to invigorate the constitution, will be likely \nto prove beneficial. \n\n3.-SUPPURATIVE CHOROIDITIS. \n\nPANOPHTHALMITIS. \n\nSYMPTOMS. \xe2\x80\x94 As the name denotes, this form of choroiditis \nis characterized by the formation of pus in the choroidal \ntissues. It generally assumes from the first the character of a \n\n\n\n228 PRACTICE OF MEDICINE. \n\nvery acute and severe inflammation, in which sooner or later \nthe choroid, iris, conjunctiva, and all other vascular tissues of \nthe eye participate ; hence it is frequently termed /^-ophthal- \nmitis. The eyelids also become red, hot, and tender, or swollen \nand cedematous, especially the upper lid, which often overlaps \nthe lower in large puffy rolls. Both the palpebral and ocular \nconjunctivae are injected and swollen, the chemosis being so \ngreat as to cover the cornea, or to surround it in the form of a \ntense, livid, circular fold or ring. In these cases the conjunc- \ntiva appears dry, and more or less encrusted with exudative \nmatter ; but when the inflammation is milder, the secretion is \nnot arrested, but oozes out from between the lids in the form of \nmuco-pus. If the chemosis is not too great, and the cornea is \nclear, we generally find the iris bulged forward, discolored, and \nits stroma infiltrated with pus ; and if the pupil is dilated, it \nalso is frequently of a yellowish tint, owing to a purulent \ninfiltration of the vitreous. Sometimes, however, the pupil is \ncontracted, its area occluded with lymph, and its margin adher- \nent, perhaps, to the anterior capsule. The anterior chamber is \nrendered shallow by the bulging of the iris, the aqueous humor \nis clouded, and not unfrequently we discover below the pupil a \nconsiderable hypopyon. In other cases the cornea is opaque \nfrom becoming infiltrated with pus, and either breaks down \ninto a mass of purulent matter, or shrinks into a thin, yellow- \nish, rudimentary membrane. The eye is extremely sensitive \nand painful, and owing to inflammatory swelling of the orbital \ntissues, protrudes more or less from its socket; it is also greatly \nlimited in its motions, and even rendered immovable by the \nsurrounding swelling. The intra-ocular tension is increased, \nand the globe more or less enlarged. These symptoms are \ngenerally accompanied by intense pain, mostly of a paroxysmal \ncharacter, which radiates from the eye to the orbit, head, and \ncorresponding side of the face. The disease is also attended \nwith fever proportionate to the local disorder, which is some- \n\n\n\nSUPPURATIVE CHOROIDITIS. 229 \n\ntimes accompanied with considerable gastric disturbance. \nVision is soon lost, but the patient remains troubled by the \nsubjective symptoms of photopsia, or flashes of light, and \nchromopsia, or the appearance of colored spectra before the eyes. \nSooner or later perforation occurs, either through the cornea \nor between the recti-muscles, and then the suffering is greatly \nmitigated. In some cases the pain and other inflammatory \nsymptoms are much less severe, while at the same time the \nsuppurative process is equally as extensive and disastrous. \nEven the retina undergoes suppurative changes, and also \nbecomes more or less detached from the choroid, in consequence \nof serous or hemorrhagic effusions from that membrane. \n\nETIOLOGY. \xe2\x80\x94 The most frequent causes of suppurative \nchoroiditis are traumatic injuries, both accidental and surgical, \nespecially those involving the ciliary region. Chemical injuries, \nblows, concussions, and other like causes, may also give rise to \nit ; but it is much more apt to follow penetrating wounds and \nsurgical operations, such as are connected with the removal of \nthe lens in cataract operations, or the lodgment of bits of metal \nor other irritating substances within the eye ; in short, whatever \nis capable of giving rise to sympathetic ophthalmia, or of \nexciting suppurative inflammation in the cornea or iris, \nis liable to be followed by panophthalmitis, especially \nin cases complicated with typhus, cerebro-spinal menin- \ngitis, puerperal fever, and other low states of the system. \n\nPROGNOSIS. \xe2\x80\x94 This is so unfavorable, that unless the \ndisease is seen in its very incipiency, there will be very little \nchance of arresting it before it has destroyed the vision, or \neven before it has led to disorganization and collapse of the \nglobe. In most cases it runs a very rapid course, and termin- \nates in perforation and atrophy of the eyeball. The worst \nresults are generally met with in metastatic cases, such as occur \nin cerebro-spinal meningitis or pyemia, since, both eyes being \ninvolved, if the patient does not die of the primary disease, \n\n\n\n230 PRACTICE OF MEDICINE. \n\nwhich is usually the case, he will most probably be left totally \nblind. The suppurative process is, however, sometimes, though \nvery rarely, limited to a very small portion of the globe, and \nif under these circumstances the pus escapes, either by perfor- \nation or otherwise, a certain and sometimes very useful degree \nof vision may be preserved ; but in the vast majority of cases \nperforation does not take place until the eye is irreparably \ninjured and the sight destroyed: The globe now generally \nbecomes more or less atrophied, shrivelling up into a small \nnodular stump, not larger perhaps than a pea, or it may retain \nfor a longer or shorter period a certain degree of fullness and \nsensibility, subject to repeated attacks of inflammatory action, \nespecially if the opening becomes temporarily closed. In these \ncases, if there is much ciliary irritation, and especially if it is \nkept up by the presence of a foreign body within the eye, the \nother eye may become sympathetically involved, as stated \nunder the head of sympathetic ophthalmia. At last, however, \nall inflammatory action subsides, and then the suppurative \nprocess ceases, the perforation becomes permanently closed, \nand the globe dwindles away until it becomes completely \natrophied. \n\nTreatment. \xe2\x80\x94 Whenever suppurative choroiditis is threat- \nened, its occurrence should if possible be prevented, by \ndirecting the treatment against any exciting cause that may \nbe discovered. Thus, if a bit of metal or other foreign body \nhas entered the eye, it should be carefully and speedily remov- \ned, especially if it has penetrated the ciliary body. If it \nhas injured the lens, or if the latter is swollen and cataractous, \nthe lens should be extracted by the flap operation, removing at \nthe same time a portion of the iris. If there is a large hypop- \nyon, and especially if it is complicated with corneal abscess, \nparacentesis or iridectomy should be performed. If the eye is \nbadly bruised or lacerated, and the vision hopelessly destroyed, \nand especially if a foreign body also remains in the eye, the \n\n\n\nSUPPURATIVE CHOROIDITIS. 23 1 \n\nlatter should be removed at once, in order to prevent the occur- \nrence of both suppurative choroiditis and sympathetic ophthal- \nmia, for it is not always safe to enucleate the eye after the \nsuppurative process begins, After suppuration once sets in, \nthere will of course be little if any chance of saving the eye, \nbut the suffering may be greatly relieved, and for this purpose \nthe remedies best calculated to allay ciliary irritation and sub- \ndue inflammation will be the most efficacious. If the inflam- \nmation is very severe, and especially if the case is seen early, \nice-water compresses will be indicated ; but if the latter are \nnot well borne, or if suppuration has begun, and there is intense \nciliary irritation and neuralgia, warm applications will be the \nmost soothing as well as the most beneficial. If the intra- \nocular tension is increased and the pain is very severe, par- \nacentesis, repeated several times if necessary, or an iridectomy, \nwill give great relief; but if the sclerotica is distended with \npurulent matter, or we have reason to believe that there is any \nconsiderable accumulation of pus in the interior of the eye, it \nwill be advisable to open the abscess at once by making a deep \nand free incision into it. Finally, if the suppurative process is \nso protracted as to undermine the health, and especially if its \ncontinuance threatens the life of the patient, the eye should \nbe enucleated without hesitation, notwithstanding the danger \nthereby incurred of the disease extending itself to the meninges \nof the brain. \n\nTHERAPEUTIC INDICATIONS. \n\nAconite is a useful remedy whenever there is high fever, \nespecially in the first stages of the disease, or when the lids \nare red, hot, dry and swollen. \n\nApis is recommended when the lids are cedematous and \nthe conjunctiva chemosed, with stinging pains through the \nglobe. \n\nArnica is indicated during the first stage when the disease \n\n\n\n232 PRACTICE OF MEDICINE. \n\nis of traumatic origin, if the lids are swollen and echymosed, \nand the globe protruded, tense and painful. \n\nArsenicum is sometimes useful in cases attended with rest- \nlessness, thirst, cedematous swelling of the lids and conjunctiva, \nand deep-seated throbbing and burning pains, especially if \nthere is much prostration of the system. \n\nBelladonna is indicated when there is intense ciliary neu- \nralgia, with burning dryness in the eyes, pain in the orbits, and \na severe aching pressure within the globe. \n\nHepar sulph. is indicated after suppuration has commen- \nced. The eye is protruded and externally tender to the touch ; \nthe lids are highly inflamed and swollen, especially the upper ; \nand the pains are deep, throbbing, and ameliorated by warmth. \n\nMercurius is useful in the first stage, when there is much \nburning in the eyes, with ciliary injection and more or less red- \nness and swelling of the lids. \n\nRhus tox. is said to be useful in every stage of the disease, \nespecially the first. The indications are : cedematous swelling \nof the lids ; chemosis of the ocular conjunctiva ; severe orbital \nand circum-orbital pains, aggravated at night and during rainy \nand rough weather. \n\nBryonia, Phytolacca, Silicea, Sulphur, and a few other \nremedies have been recommended, and may occasionally be \nfound useful, not so much by virtue of any direct influence \nthey may have upon the diseased organ, as by contributing to \nthe general physical and mental well-being of the patient. \n\nDiet and Regimen. \xe2\x80\x94 As in other suppurative diseases, \nthe strength will need to be sustained by a free allowance of \nthe most nourishing diet ; and in some cases it may be advis- \nable to administer stimulants, especially if the patient is very \nmuch prostrated, or is old and feeble. \n\n\n\nPRACTICE OF MEDICINE. 233 \n\ni-SCLERO-CHOROIDITIS POSTERIOR. \n\nSCLERECTASIA POSTERIOR \xe2\x80\x94 STAPHYLOMA POSTICUM. \n\nSYMPTOMS. \xe2\x80\x94 Sclero-choroiditis posterior is chiefly char- \nacterized by an intra-ocular inflammation involving the fundus \nof the globe, and accompanied with a greater or less degree of \nmyopia. The inflammation and accompanying myopia may \nexist either with or without a posterior staphyloma of the \nsclera ; and in like manner the bulging of the sclera may occur \nwithout giving rise to any appearance of inflammation in the \nfundus ; hence, although these conditions are often associated \ntogether, there is no necessary connection between them, and \ntherefore the old notion that staphyloma posticum results \nfrom inflammation is, as a rule, erroneous. Nevertheless, when \nthe staphylomatous process advances rapidly, and in nearly \nevery case in which there is a considerable degree of myopia, \nan inflammatory condition of the fundus sooner or later super- \nvenes, and gives rise to sclero-choroiditis. \n\nThe characteristic ophthalmoscopic symptom of staphy- \nloma posticum is a bright, yellowish or bluish-white line or \ncrescent at the edge of the optic disc. It may be limited to \none side, generally the outer, or it may extend quite around the \ndisc, the broadest part being in the direction of the yellow spot. \nAlthough its general form is that of a single or double cres- \ncent, its shape may be quite irregular, assuming in some cases a \nmore or less pointed, in others a zigzag, and in others, still, \na wavy outline, which may be sharply defined, or may \ngradually fade away into the neighboring tissues. The crescent \nis often spotted or marbled over with small patches of dark \npigment, especially on its edges, where the pigment cells of \nthe choroid are not yet entirely destroyed by the advancing \natrophy. It is owing to this thinning of the stroma of the \nchoroid, that the sclera, shining through the former, gives to the \ncrescent its usual glistening-white appearance. \n\n\n\n234 PRACTICE OF MEDICINE. \n\nAmblyopic symptoms, due chiefly to disturbances in the \nintra-ocular tension, frequently manifest themselves. As a \ngeneral rule, the more rapid the development of the staphy- \nloma, the greater will be the disturbance of vision. This \narises partly from the hyperaemic condition of the venous sys- \ntem of the eye, and partly from irritability of the retina. The \nlatter is generally most pronounced when, along with the \namblyopia and disturbance of vision, the patient is troubled \nwith photopsies, such as flashes of light, dazzling points, colored \ncorruscations, etc., or when exposure to the light causes a sense \nof pain and tension in the eye. \n\nAs in other forms of choroiditis, the inflammation fre- \nquently gives rise to cloudiness or opacity of the vitreous \nhumor, especially in its posterior part, which is sometimes \ndetached from the retina by a thin, serous-like transudation. \nThese opacities, which are both movable and fixed, are espec- \nially annoying to the patient, whose short-sightedness renders \nthem unusually distinct. The most serious form of vitreous \nopacity is that which generally precedes detachment of the \nretina, and is supposed to be due to a separation of the vitreous. \nThe following is Iwanoff \'s explanation : \xe2\x80\x94 The vitreous humor \ndoes not expand in proportion as the proterior chamber of the \neye is increased in volume by the staphyloma, but the vitreous \nrecedes from the retina, and the space thus formed between \nthem is filled with a serous exudation, which detaches the \nvitreous more and more from the limiting membrane, and not \nunfrequently separates the latter from the subjacent retina. \n\nSecondary glaucoma, in the form of serous irido- \nchoroiditis, frequently supervenes in the course of sclero- \nchoroiditis posterior, accompanied with periodic cloudiness of \nthe aqueous humor, effusions into the vitreous, and glaucom- \natous excavation of the optic nerve.. The latter varies greatly \nin different cases, being in some instances extremely steep and \nabrupt ; in others it is quite shallow, or confined, apparently, \n\n\n\nSCLERO-CHOROIDITIS POSTERIOR. 235 \n\nonly to the margin of the disc ; and in other cases the disc or its \nmargin is not only cupped, but the latter is surrounded by a \nsecond excavation, which is situated in the sclerotic near the \nedge of the disc. In these cases vision is relatively far less \naffected than in similar conditions in primary glaucoma, in \nconsequence, no doubt, of the relief afforded to the intra-ocular \ntension by the staphylomatous enlargement. Nevertheless, \niridectomy should be performed as early as possible in all cases \nwhere the contraction of the field does not already encroach \nclosely on the centre, in which latter class of cases, according \nto Graefe, the operation sometimes proves injurious. \n\nETIOLOGY. \xe2\x80\x94 Staphyloma posticum is generally hereditary. \nAlthough denied by some, it has been satisfactorily shown by \nJaeger and others, that it is by far the most common in the \nchildren of myopic parents. Its subsequent development is no \ndoubt chiefly due to a hyperaemic condition of the fundus, \ncaused by the severe and long continued straining of the accom- \nmodation of the eyes for near objects. The main reason that \nthe elongation of the eye takes place at the posterior pole, is \nbecause the latter receives no support from either the capsule \nor the muscles of the globe ; but the enlargement is also fav- \nored by the conjoint effects of the relaxation caused by the \nintra-ocular congestion, and the extension resulting from the \nincreased pressure of the fluids. This extension gives rise to \natrophy of the choroid, which is still farther increased by the \nconsecutive inflammation that sooner or later supervenes. \n\nPROGNOSIS. \xe2\x80\x94 The prognosis should always be guarded, \nsince, although no further development of the ectasia may take \nplace for many years, yet it is liable to occur at any time, and \nto progress with great rapidity. This is especially to be feared \nif there is already a co-existing choroiditis, particularly if the \nvisual field is much clouded by it, or if there exist diffuse \nopacities of the vitreous threatening the retina. \n\nTreatment. \xe2\x80\x94 The first and most important point to be \n\n\n\n236 PRACTICE OF MEDICINE. \n\nobserved in treatment is, to see that the patient gives his eyes \nsufficient rest, and that when in use he does nothing that will \nbe likely to over tax their accommodative power. He should \ntherefore be specially warned against using his eyes for any \nconsiderable length of time on near and fine objects, even with \nsuitable glasses, as these require extreme convergence of the \nvisual axes, and thus overtax the power of accommodation ; it \nalso tends to increase the hyperaemic condition of the fundus, \nand to enlarge the posterior staphyloma, by causing undue \npressure of the external muscles. Care should also be taken \nnot to expose the eyes to the direct glare of the light, nor to \ncontinue using them after a sense of fatigue sets in, especially \nfor near objects ; neither should they be used in a stooping \nposture, as this favors congestion. If the light is too dazzling, \nand especially if it causes headache and ciliary neuralgia, it \nshould be tempered by wearing blue or smoke-colored glasses, \nwhich always give marked relief. If the eye is very irritable, \nand especially if there is a hyperaemic state of the optic disc, \nall use of the organ for such purposes as reading, writing, \nsewing, etc., should be abandoned, and the eye should be \nallowed perfect rest until all the symptoms of irritation and con- \njestion have subsided, and even for a considerable period after- \nwards. In those cases in which the conjunctiva is more or less \ninjected, benefit will generally be derived from the employment \nof a weak collyrium, consisting of a grain of the sulphate of \nzinc or copper, two or three grains of the acetate of zinc, or \neight or ten grains of borax, each, to the ounce of distilled \nwater. \n\nTHERAPEUTIC INDICATIONS. \n\nAconite is generally useful in all cases in which there is \nmuch heat and congestion of the external tunics. \n\nBelladonna is indicated whenever there is much ciliary \nirritation and neuralgia, especially if there is a hyperaemic \ncondition of the optic disc and retina. \n\n\n\nSCLERO-CHOROIDITIS POSTERIOR. 237 \n\nCongestive headache with flushed face, sensitiveness to \nlight, and photopsia, is an additional indication. \n\nCactus is also a good remedy in these cases, especially if \nthere is a congested state of the optic nerve and fundus. \n\nCimicifuga is an excellent remedy in most cases of sclero- \nchoroiditis with marked internal and external hpyeraemia, \nespecially if the eye is sore to the touch, or if there is much \nciliary neuralgia and irritation. \n\nCrocus is said to be useful in cases where the pain extends \nfrom the eye to the top of the head, or from the left eye to the \nright. \n\nMerc. cor. \xe2\x80\x94 This is one of our most reliable remedies in all \ncases where the choroid exhibits marked inflammatory changes, \nand its use in such cases should not be hastily abandoned. \n\nPhosphorus. \xe2\x80\x94 Hyperaemia of the retina with congestion to \nthe head, indicated by severe headache, flashes of light, colored \nrings betore the eyes, etc. \n\nSpigelia. \xe2\x80\x94 Severe pain in and around the eyes, especially \non moving them ; great ciliary nervous irritation and conges- \ntion. \n\nZinc. Phos. \xe2\x80\x94 Congestion of the fundus, with fiery balls \nand other luminous spectra before the eyes. \n\nThe following additional remedies have also been recom- \nmended : \xe2\x80\x94 Atropine, (locally), Gels., Glon., Lyco., Kali iod., \nNux v. Physostig., Sulph. and Zinc. \n\nART. XII. \xe2\x80\x94 HYALITIS. \n\nInflammation of the vitreous humor is usually associated \nwith some other disease of the fundus, such as choroiditis, \nretinitis, etc., but it may also occur idiopathically ; at least \nsuch is the opinion of most ophthalmologists, although Pagen- \nstecher, who made numerous experiments on the eyes of rabbits, \ncame to the conclusion that the disease never occurs as a prim- \nary affection, but always depends on changes in the neigh- \n\n\n\n238 PRACTICE OF MEDICINE. \n\nboring structures. Indeed, Galezowski goes so far as to assert \nthat the vitreous humor never can become inflamed, since it \nhas no organized structure, but that the inflammation is always \nconfined to the hyaloid membrane. This, however, is now \nknown not to be the case, it having been clearly proven by \nVirchow, Weber and others, that inflammatory changes fre- \nquently occur in the vitreous, and may assume either the \nsimple or the suppurative form. \n\nl.-SIMPLE HYALITIS. \n\nSimple hyalitis is sometimes, though very rarely, idiopa- \nthic. It is generally secondary to inflammation of the ciliary \nbody, choroid or retina, and consequently the symptoms are \nalmost always combined with those of an accompanying \ncyclitis, choroiditis or retinitis. \n\nSYMPTOMS. \xe2\x80\x94 The disease is chiefly characterized by diffuse \nopacities within the vitreous. If the inflammatory process is \nmuch advanced, connective-tissue opacities, of various forms \nand sizes, may sometimes be discerned even by the naked eye, \nglistening indistinctly in the midst of the diffuse cloudiness ; \nbut at the commencement the opacities are generally too thin \nand indistinct to be recognized, except by the aid of the oph- \nthalmoscope. Viewed through this instrument, the vitreous \nappears at first more or less clouded, and the optic nerve and \nretinal vessels have an indistinct or blurred appearance, as \nthough seen through a mist; the observer may also discover, \nhere and there, thicker opacities in the form of dark specks, \ndelicate filaments, etc. As the inflammation increases, the \nvitreous humor becomes less and less transparent and the \ncloudiness more evenly diffused, so that the details of the \nfundus are rendered either very indistinct, or become entirely \ninvisible. In addition to the fixed and floating opacites above- \nmentioned, neoplastic formations of connective tissue appear \n\n\n\nSIMPLE HYALITIS. 239 \n\nin various portions of the vitreous, having a filamentous or \nmembraneous character, which, variously inter-twined and cross- \ning each other in every direction, divide it into irregular \nsections which sometimes have the form of separate compart- \nments. These appearances are generally most marked in the \nvicinity of the ciliary body, and at the posterior pole of the \nlens, where the opacity is sometimes so great as to be termed \nposterior polar cataract. In some cases vessels are seen in the \nvitreous, which divide and sub-divide in the most varied \nmanner. Sometimes synchesis of the vitreous occurs, that is, \nit becomes partly or completely fluid. This generally occurs \nin proportion to the development of the connective-tissue \nformation. In this state the movable opacities sometimes \ndisappear from the visual field by sinking to the bottom of the \nfundus, but re-appear whenever the eye is subjected to any \nrapid movement. Even when the vitreous is not fluid, the \ndenser opacities are very movable, floating about more or \nless freely on every quick motion of the eye and head. \nIn some cases where fluidity of the vitreous occurs, owing \nto the presence of crystals of cholesterine in the fluid, \nthe floating opacities and crystals present the appearance of \nbright, glittering, star-like bodies, the movement of which \nseems to the patient like a shower of stars. In other cases, \nwhere the proportion of connective tissue in the vitreous \nbecomes very large, the latter detaches itself from the \nlimiting membrane and shrivels up, until in some instances \n\nit occupies less than one-fifth of its natural space. In \nthese cases, also, the retina is often extensively detached, \neither alone or along with the vitreous, the separation \nfinally extending from the ora serrata to the entrance of \nthe optic nerve. These changes, according to IwanofT, most \nfrequently occur when a foreign body, such as a depressed \ncataractous lens, becomes encapsuled ; they also occur in irido- \nchoroiditis, from a gradual shrinkage of the connective-tissue \nproducts developed in the vitreous as a consequence of inflam- \nmatory proliferation. \n\n\n\n24O PRACTICE OF MEDICINE. \n\n2.-SUPPURATIVE HYALITIS. \n\nSuppurative hyalitis generally occurs in connection with \nsuppurative iritis, cyclitis, or irido-choroiditis. It generally \nsupervenes upon injuries of the eye, cataract operations, etc., \nand frequently leads to panophthalmitis and destruction or \natrophy of the globe. \n\nSymptoms. \xe2\x80\x94 Suppuration may commence in any por- \ntion of the vitreous, and may either remain confined to the \npart in which it originates, or it may spread throughout the \nwhole # of the vitreous humor. In some cases the purulent \nmatter appears just behind the lens, {posterior hypopyon), and \nis due to pus which has burst through the retina from the \nciliary body. In this case the other portions of the vitreous \nare frequently normal. Generally, however, the entire vitreous \nbecomes involved in the suppurative process, except in the \ncase of foreign bodies, which frequently give rise to circum- \nscribed abscesses. \n\nEtiology. \xe2\x80\x94 It is generally conceded that hyalitis usually \ndepends oh inflammation of the neighboring structures. In \nour study of cyclitis, irido chorioditis, glaucoma, etc., we have \nseen how uniformly-cloudiness of the vitreous appears amongst \nthe symptoms; but it is especially in the more acute and \nsuppurative forms of those diseases that it is an invariable \nattendant. It may also be excited by the presence of foreign \nbodies, by wounds of the vitreous humor, by loss of vitreous \nafter operations for cataract, by extravasations of blood, etc. \n\nPrognosis. \xe2\x80\x94 Diffuse opacities of the vitreous, when \ndependent on inflammation of the investing vascular structures, \ngenerally soon disappear in cases where the latter take a fav- \norable turn and undergo resolution ; but the contrary occurs if \nthe inflammation is frequently repeated, or if the neighboring \ntissues are much altered. In short, the prognosis depends \nchiefly upon the cause of the inflammation, and the extent to \nwhich the surrounding tissues are implicated. \n\n\n\nSEROUS RETINITIS. 24I \n\nTreatment. \xe2\x80\x94 As the removal of the cause constitutes \nthe first and most important point in treatment, it is evident \nthat whenever the existence of hyalitis depends upon irido- \ncyclitis, irido-chorioditis, or any other disease of the fundus, \nthe treatment will require to be directed to the removal of the \nprimary affection. (See cyclitis, choroiditis, glaucoma, retinitis, \netc.) If the inflammation is due to the presence of a foreign \nbody in the vitreous, and its location can be determined, either \nwith the ophthalmoscope or otherwise, it should be immed- \niately cut down upon, and removed with a Daviel\'s spoon, \n(PL I. Fig. 31), the canular forceps, (Fig. 3), or any other con- \nvenient instrument. If this is found to be impracticable, then \nthe best course is to enucleate the eye at once, and thus save \nthe other eye from being destroyed by sympathetic ophthalmia, \n(which see). Fixed opacities remaining after severe inflamma- \ntion of the vitreous, have sometimes been torn or cut through \nwith a sickle-shaped needle, (Fig. 8), introduced through the \nsclera, and the vision thereby considerably improved. What \neffect, if any, the long-continued administration of such, \nremedies as Baryta, Causticum, Magnesium, Phosphorus, Sepia, \nSilicea, etc., may have upon them has not yet been satisfactor- \nily determined. \n\nART. XIII. \xe2\x80\x94 RETINITIS. \n\nWe are now to consider a class of diseases of the highest \nimportance, which previous to the invention of the ophthalmo- \nscope were very imperfectly understood \xe2\x80\x94 so much so, in fact, \nas to be confounded with an affection of a totally different \nnature, namely, hyperesthesia of the retina. The latter is \ncharacterized by intense photophobia, lachrymation, ciliary \ninjection and neuralgia, while retinitis, as we shall see, is \ndistinguished by no such symptoms. \n31 \n\n\n\n242 PRACTICE OF MEDICINE. \n\n1 -SEROUS RETINITIS. \n\n(EDEMA OF THE RETINA. \n\nSYMPTOMS. \xe2\x80\x94 Serous retinitis, or oedema of the retina, is \nchiefly characterized by a delicate greyish opacity of the fun- \ndus of the eye, which shows itself in the form of a bluish-grey \nveil or mist spread over the surface of the retina, and which \nhides to a greater or less extent the choroidal vessels. The \nopacity, which is due to a serous infiltration of the connective \ntissue of the retina, may be either general or partial, that is, it \nmay affect the whole or only parts of the fundus. In the latter \ncase, the \xc2\xa9edematous cloudiness is most marked in the region \nof the optic nerve entrance, but becomes fainter and fainter as \nit approaches the macula lutea, or yellow spot, in consequence \nof the diminished thickness and greater transparency of that \nportion of the retina. As the oedema increases, the details of \nthe choroid and optic disc are rendered less and less distinct, \nuntil, in severe cases, the fundus presents nearly a uniform \nreddish-grey or bluish-grey appearance. In these cases the \noptic disc appears somewhat swollen and indistinct, but the \nopacity is so diffuse and veil-like as to produce but little alter- \nation in the appearance of the arteries ; the retinal veins, on \nthe contrary, are dilated and more or less twisted in their \ncourse, those in the vicinity of the optic nerve describing com- \nparatively large curves, while the smaller branches are decidedly \ntortuous. The oedematous character of the affection can \ngenerally be made out by carefully observing the varying \ndepths of the vessels in different parts of their course ; as in \nthose places where they are the most superficial, they have a \ndistinctness and clearness of outline which is lost or obscured \nin parts where they dip more deeply into the effusion. Small \nhemorrhagic extravasations are occasionally to be seen in the \nvicinity of the retinal veins, but they are not often met with in \nthis form of retinitis. \n\n\n\nSEROUS RETINITIS. 243 \n\nExternally, the eye appears nearly or quite normal. The \npupil is sometimes slightly dilated and sluggish, but this is \nseldom very noticeable ; and as there are no symptoms of \nirritability present, such as photophobia, lachrymation and \nciliary neuralgia, the disease in its first stage is apt to attract \nbut little attention. Soon, however, the visual field becomes \nmore or less darkened and contracted, and it is this which \ngenerally leads the patient to apply for treatment. His com- \nplaint is that all objects appear as if enveloped in a mist or \nfog, or as if he was looking through a veil. If the disease is \npartial, or if the opacity is limited to only a small portion of \nthe fundus, the corresponding part of the visual field will \nalone be impaired. As the affection progresses, however, both \nperipheral and central vision deteriorate, the sight grows dim- \nmer and dimmer, and if the disease is not arrested the retina \nfinally becomes atrophied, and vision is permanently destroyed. \n\nETIOLOGY. \xe2\x80\x94 Serous retinitis is chiefly due to a hyperaemie \nstate of the optic nerve and retina, superinduced by long ex- \nposure of the eye to bright lights, by mechanical violence, and, \nin many cases, by certain constitutional affections, such as \nsyphilis, albuminuria, etc. As the causes are similar to those \nof the exudative variety, the etiology will be given more at \nlength in the next section. \n\nPROGNOSIS. \xe2\x80\x94 This should be particularly guarded, for the \nreason that the affection is liable to become more or less \nchronic, in which case vision may be lost through atrophy or \ndetachment of the retina, or it may take on the exudative \nform, and lead perhaps to disease of the choroid and vitreous. \n\nTreatment. \xe2\x80\x94 The patient should be strictly enjoined \nnot to exercise his eyes in reading, writing, etc. He should \nalso be careful to protect them from the irritating effects of \nbright light by wearing blue or smoke-colored glasses. \n\nThe internal remedies which have proven most beneficial \nin this form of retinitis are : \xe2\x80\x94 Apis, Ars., Bell., Bry., Cact, \n\n\n\n244 \n\n\n\nPRACTICE OF MLDICINE. \n\n\n\nDigit., Gels., Merc, Phos., and Puis., the latter, more especially \nwhen dependent on menstrual irregularities. The following have \nalso been recommended in complicated cases, or as intercurrent \nremedies : Aeon., Cimicif., Collin., Con., Croc, Hepar., Nux v., \nKali iod., Lach., Sulph., and Zinc. For special indictions see \nprevious sections. \n\nAs illustrative of the character and treatment of a some- \nwhat complicated traumatic form of this affection, we subjoin \nan interesting and instructive case from the N. Y. Ophthalmic \nHospital Rec, 1876, kindly furnished us by F. H. Boynton, \nM. D., Asst. Surg, to the Institution. \n\nChas. Birch, aet. 54, Leominster, Mass. Three weeks before ap- \nplication for treatment, (March 4th, 1876), while bending suddenly \nforward, the eye came in contact with the post of a rocking chair ; \nthe blow was received in the inner angle of the right eye ; lids soon \nbecame ecchymosed, slight discoloration still remaining. V=Per- \nception of light. Field of vision of right eye according to diagram : \n\nFig. 11. \n\xe2\x96\xa0P \n\n\n\nNO VISION. \n\n\n\n\nPERCEPTION OF \nOBJECTS. \n\n\n\nOphthalmoscope shows in right eye diffuse haziness of vitreous, \nserous inflammation of choroid and retina, with effusion under and \ndetachment of latter, as represented by diagram. Optic nerve of left \neye very hyperaemic, V. only -gfo, owing to macula, remnant of \nsmall pox. \n\nMay 5th. Has consented to come into the hospital for treatment. \n\n\n\nSEROUS RETINITIS. \n\n\n\n24S \n\n\n\nHe has been carefully examined by Drs. Allen, Wanstall and myself, \nbut no indicative symptoms could be found. On account of the success \nof Gelsemium in several cases of serous choroiditis (non-traumatic) \nin the hands of Dr. Norton, Gels. 30th was prescribed, dose every \nthree hours. Patient was put to bed, both eyes being carefully padded \nwith lint, and compress bandage applied ; bandage to be reapplied \nthree times in twenty-four-hours. Sol- Atropine instilled to insure com- \nplete rest to the accommodation. Low diet. \n\n14th. Since last date has been constantly in bed. Optic nerve \nvery slightly hyperaemic ; few opacities in vitreous ; detachment as \nper diagram and sharply defined. \n\nFig. 12. \n\n\n\nNO VISION. \n\n\n\n^ I X \n\n\n\nTHIS PART OF FIELD \nCLEAR. \n\n\n\n- 20 \n"200* \n\n\n\nVessels of normal size. Rv.= -\xc2\xa3\xc2\xa3$ ; Lv: \n\nHeretofore both eyes have been constantly bandaged; now, \nyielding to supplication of patient, allow left eye to be free. \n\n25th. Field the same ; vitreous becomes quite hazy after moving \nthe eye; vision not quite as good ; condition has slightly retrograded \nsince allowing one eye free. Now bandage both eyes and confine in \nbed, except one-half hour each day for exercise. Gelsem. 30th. \n\nApril 5th. Ophthalmoscope shows slight opacities in vitreous. \nField of vision perfect. \n\nRv. (floating). V.= jft; with + 36, ^ nearly. \n\nOn the former site of detachment is an exudative choroiditis, \nquite circumscribed (see Fig. 13). Macula lutea, cloudy; nerve, slightly \nhyperaemic. \n\n\n\n246 PRACTICE OF MEDICINE. \n\nFig. 13. \n\n\n\n\nTHE ABOVE CUT REPRESENTS THE PATCH OF EXUDATION REMAINING \n\n8th. Continued and remarkable improvement, very slight hazi- \nness of fundus ; no flocculi ; nerve still slightly hypersemic. \nV=|-\xc2\xa7- without glasses. During the last few days of treatment, I \nexperienced much difficulty in retaining the patient in the hospital. \nOn the evening of the 8th he surreptitiously took his departure. \n\nMay 19th. I am in receipt of a letter from the gentleman, dated \nMay 17th, saying that since he left the hospital, there has been grad- \nual improvement. For the first three weeks he kept the bed most of \nof the time ; since which time he has been working at his trade \n(joiner) ; experiences some difficulty in doing fine work. \n\nIn recording this most satisfactory result, I experience much em- \nbarrassment in deciding how much, if any, credit to give Gelsemium \nas an agent in attaining the desired end ; undoubtedly the recent in- \nvasion, bandaging and complete rest, were active factors. I would \nsuggest its use in serous inflammations of the iris, choroid, and retina, \nin those cases not requiring other interference, and its effects noted, \nthat there may be no doubt as to its efficacy. \n\nNote by the Author. \xe2\x80\x94 This is a very interesting case, and the \ncomments upon it by Dr. Boynton are judicious. That Gelseminum \nexerted a favorable influence cannot, we think, admit of question ; \nat the same time there is no doubt that the immediate instillation of \nAtropine, by diminishing intra-ocular tension, though attended by \n\n\n\nEXUDATIVE RETINITIS. 247 \n\nsome risk, contributed powerfully to promote absorption ; and also, \nthat the bandaging, rest, and recent invasion, had, as Dr. B. surmises, \nmuch to do with the speedy recovery of the patient. On the whole, \nwe regard this as being in some respects a model case, the treat- \nment reflecting great credit upon the surgeons of the N. Y. Ophthal- \nmic Hospital. \n\n\n\n2.-EXUDATIVE OR PARENCHYMATOUS RETINITIS. \n\nSYMPTOMS. \xe2\x80\x94 This form of retinitis is characterized by \ninflammatory changes in the parenchyma of the retina, whereby \nthe membrane undergoes cell proliferation, hypertrophy, fatty \nor colloid degeneration, and sclerosis. The optic disc is gen- \nerally of a greyish-red or pink color, and its boundaries are so \nindistinct that in many cases its position can only be recog- \nnized by the course of the central vessels, as they emerge from \nthe hollow in which they are imbedded in the centre of the \ndisc. In these cases the retina loses to a great extent its \ntransparency, and becomes dull and dirty looking, with perhaps \nsome appearance of striae, or of dark and light spots, which \ngive it more or less of a marbled appearance. As a general \nrule, however, it presents a somewhat uniform, but very fine \ngranular appearance, in which the natural tint of the subjacent \nchoroid is entirely hidden, and the vessels more or less deeply \nveiled. Extravasations of blood, in the form of points or \nsmall spots, frequently occur, either lying superficially on the \nveins, or situated more deeply, in which case they have a some- \nwhat indistinct or blurred appearance. When the hemorrhagic \nextravasations are large or very numerous, they constitute a \ndistinct form of the disease known as Retinitis apoplectica, \n(which see). \n\nThe pathological changes above sketched vary considera- \nbly in different cases, according to their nature, seat and \nextent. Thus, if the exudation is seated in the more external \nor choroidal layers of the retina, the vessels will not present \n\n\n\n248 PRACTICE OF MEDICINE. \n\nthe indistinct and interrupted appearance that they will when \nit occupies the inner layers, since in the latter case they are \nnecessarily more or less hidden by the exudation. We also \nfind that, when thus situated, the exudations generally present \nthe appearance of light cream-colored or greyish-white non- \nstriated spots or patches, over which the retinal vessels are \nseen to pass without interruption. In these cases the in- \nflammatory process frequently originates in the choroid \ninstead of in the retina, to which it subsequently extends \nby cell proliferation, giving rise to fatty or colloid degen- \neration of the external layer, with sclerosis of the external \nlimiting membrane. When, on the other hand, the exuda- \ntions are seated in the inner portion of the retina, they \nare generally somewhat striated, and the vessels instead of \npassing straight over them are more or less interrupted, or \nconcealed from view. At first the inflammatory changes con- \nsist, chiefly, of hypertrophy of the stroma and connective \ntissue fibres, the latter of which may increase so rapidly as to \ncompress, and thereby cause more or less atrophy of the nerve \nfibres. At the same time, the optic nerve fibres and ganglion \ncells increase by proliferation, giving rise to sclerosis, and after- \nwards, perhaps, undergoing fatty degeneration. The internal \nlimiting membrane also becomes hypertrophied and uneven, \noccasionally exhibiting upon its inner surface minute eleva- \ntions, caused by under-lying points of exudation. This variety \nof retinitis frequently originates in inflammation of the ciliary \nbody and choroid, and is then associated with irido-cyclitis or \nirido-choroiditis. \n\nUncomplicated cases are attended with little or no irrita- \ntion, the chief subjective symptoms being a greater or less \nobscuration of the visual field, corresponding to the points of \nexudation. If these occupy the centre of the field, the injury \nto vision will, of course, be much greater than when the centre \nis clear, especially for small or near objects; the obscurity \n\n\n\nEXUDATIVE RETINITIS. 249 \n\ndiminishing in proportion as the spots are removed from the \ncentre*. Where the exudative form is combined with the \ndiffuse, or where the entire retina becomes affected, the \nobscurity is often general, and vision is sometimes reduced to \na mere perception of light. As a general rule, however, the \nperiphery of the retina escapes, and then, if the vitreous also \nremains clear, the patient may be able to so adjust the optic \naxis as to obtain a fair degree of eccentric vision. Moreover, \nthe exudations and hemorrhagic effusions may be absorbed, \nthe intra-ocular congestion be relieved, the oedema subside, \nand then, if the choroid, retina and optic nerve are not too \nmuch injured, the vision may decidedly and permanently \nimprove. (See Dr. Boynton\'s case, page 267). But such \nfavorable results do not always occur, especially in com- \nplicated cases. Months and even years may elapse before \nthe disease makes any considerable progress, and then \nnew points of exudation may suddenly appear, accompanied \nperhaps by marked symptoms of inflammation ; or the \naccompanying irido-cyclitis, choroiditis, etc., may subside only \nto burst out again with increased violence; and this may occur \nagain and again, each fresh attack or exacerbation developing \nnew points of exudation, until finally the inflammation has \nrun its course. In these cases the integrity of the retina is \nnever entirely restored. The portions of membrane corres- \nponding to the points of exudation are frequently transformed \ninto connective tissue, and although the process of degenera- \ntion by which the transformation is effected is generally very \nslow, it continues until the affected portion of the retina loses \nall sensibility to light, in consequence, probably, of atrophy of \nthe nerve elements. In other cases the entire retina as well as \nthe choroid and optic nerve undergo atropic changes, and \nvision is hopelessly lost. \n\n*Micropsia, in which all objects appear smaller to the patient than they really are, \nis sometimes observed in these cases. If, for example, the patient is told to draw a \ncertain figure, such as a circle, he will invariably draw it too small. \n\n32 \n\n\n\n2$0 PRACTICE OP MEDICINE. \n\nETIOLOGY. \xe2\x80\x94 The causes of exudative retinitis are prob- \nably the same as those which give rise to the diffuse form ; \nindeed, the latter is generally developed along with the former. \nIn most cases it is due to some constitutional affection, such as \nsyphilis, diabetes, albuminuria, etc. It may also be caused by \nsome other disease of the eye, such as irido-cyclitis or chor- \noiditis ; or it may depend upon disturbances in the circulation, \nsuch as occur in uterine or heart affections. Among other \nprobable causes, we may also mention, long exposure of the \neyes to intense light, tuberculosis, retinal hemorrhages, cere- \nbral diseases, and even sympathetic influences. \n\nPROGNOSIS. \xe2\x80\x94 This we have already sufficiently indicated. \nDuring the progress of the disease, so long as the region of \nthe macula lutea remains clear, the sight may be sufficiently \ngood for the patient to recognize very small objects, and even \nto read the finest print. At the same time it will be difficult \nfor him to distinguish large or distant objects, in consequence \nof the field of vision being more or less interrupted and dimin- \nished. But sight is not generally entirely lost until the optic \nnerve elements have become atrophied. Nor is the injury to \nvision always proportionate to the changes observed in the \nfundus. Tolerable, and even excellent, vision may frequently \nbe obtained after serous and hemorrhagic effusions have taken \nplace, and even after fatty degeneration has occured, as these \nproducts are all capable of being absorbed. The affected \nportions of the retina, however, rarely if ever become perfectly \nnormal. Permanent changes in both the choroid and retina \noccur under the most favorable circumstances, and some impair- \nment of vision is always to be expected. \n\nTreatment. \xe2\x80\x94 The treatment of exudative retinitis is \nalmost identical with that of cedema retinae, (which see). So \nlong as improvement can result from increased absorption, \nbenefit may be expected from the administration of Mercurius, \nespecially the Corrosivus. This remedy has frequently been \n\n\n\nSYPHILITIC RETINITIS. 25 1 \n\nfound very effectual in promoting the absorption of patches of \nexudation, and in clearing up the visual field, the results being \nespecially favorable when the disease is of syphilitic origin. \n(See Retinitis syphilitica). Hemorrhagic effusions are often \nquickly absorbed under the use of Belladonna, Crotalus and \nLachesis, especially the latter. (See Retinitis apoplectica). \nOther remedies will be found under the nephritic variety, \n(which see). When the disease has existed a long time, and \nthe choroid and retina are already much atrophied, of course \nbut little improvement can be expected. In this case, it is gen- \nerally advisable to confine our treatment chiefly to the employ- \nment of such measures as are best calculated to preserve the \nexisting vision ; and for this purpose especial attention should \nbe paid to the patient\'s health, and to the observance of suita- \nble hygienic rules. Great care should also be taken to guard \nagainst a renewal of the inflammation, by avoiding any of the \nknown causes, such as exposure of the eyes to bright light, \netc. Should relapses occur, they will require to be treated \naccording to specific indications, having reference more espec- \nially to the particular forms they may be found to assume \xe2\x80\x94 \nas, for example, the inflammatory or hemorrhagic \xe2\x80\x94 and to the \ncauses which may be supposed to give rise to them. \n\n3.-SYPHILITIC RETINITIS. \n\nThis is a peculiar form of diffuse retinitis, occuring in \npersons whose constitutions have become tainted with secon- \ndary syphilis. Authorities differ as to the diagnostic value of \nits symptoms, Wells asserting that it is occasionally possible \nto diagnose the nature of the malady from the ophthalmo- \nscopic appearances alone, while Stellwag claims that the disease \nhas no peculiar symptoms, but that its syphilitic nature is \nindicated solely by the presence or previous existence of the \nsymptoms of constitutional syphilis. We shall find that while \n\n\n\n252 PRACTICE OF MEDICINE, \n\nthe former statement is substantially true, it will frequently be \nimpossible to clear up the diagnosis until we have obtained a \nknowledge of the history and constitutional condition of the \npatient. \n\nSYMPTOMS. \xe2\x80\x94 At first there are no characteristic symptoms. \nThere is generally more or less venous hyperaemia, but this is \nsometimes only partial. As in simple serous retinitis, the \noptic disc is slightly swollen and its margin rendered some- \nwhat indistinct by the serous infiltration, which gives to the \ndisc and surrounding retina the appearance of being covered \nwith a delicate bluish-grey veil or mist. The opacity, which \nis often extremely faint, is most pronounced along the course \nof the vessels and in the vicinity of the optic disc, where it is \ndistinctly striated. Small, glistening white points generally \noccur in the region of the macula lutea, which frequently \ndisappear and reappear every few days, accompanied with \ncorresponding changes in the vision. In this region, also, we \nsometimes find the peculiar reddish-brown tint, or copper colon \nso characteristic of syphilis. Occasionally we meet with white \nspots or patches, either isolated or in the form of irregular \nstripes, which, being seated in the innermost retinal layers, \nmay so compress some of the vessels as to give them the \nappearance of white tendonous lines, or bands. Neither the \nwhite spots, nor the punctated appearance in the region of the \nmacula lutea, are pathognomonic symptoms, as they both \noccur in nephritic retinitis ; but in the latter affection, in addi- \ntion to other peculiarities, they are readily distinguished by \nbeing of a brighter and more glistening aspect. (See Retinitis \nalbuminurica). \n\nSyphilitic retinitis is frequently complicated with choroid- \nitis, and sometimes with irido-choroiditis and keratitis punctata, \nor with syphilitic iritis. Not unfrequently it follows one or \nmore attacks of iritis. According to Stellwag, it is peculiarly \napt to occur if, during convalescence from specific iritis, or \n\n\n\nSYPHILITIC RETINITIS. 253 \n\nbefore entire removal of the disease, the eye is exposed to \nfunctional sources of injury. \n\nHemorrhagic effusions sometimes occur, but they are \nusually small and insignificant ; occasionally, however, they \nare both numerous and extensive. They may be seated in \nany of the layers of the retina, or upon its external surface, \nbetween it and the choroid. The latter membrane frequently \nundergoes extensive changes, consisting chiefly in atrophy of \nthe epitheliel layer and aggregation of the pigment cells, in \nthe form of small black spots interspersed with little grey \npoints ; or the atrophic changes may extend still deeper, and \ninvolve the stroma of the choroid, giving rise to large grey \npatches, bordered with pigment, through which the choroidal \nvessels may be seen. \n\nVision is often greatly impaired ; and so rapidly does the \nsight diminish, that the course of only two or three weeks we \nhave known the patient to be unable to read No. "L," Snellen. \nAs a matter of course, the disturbance of vision is greatest \nwhen the region of the macula lutea is affected ; and, as already \nstated, the fluctuation frequently corresponds with changes \nwhich occur in the punctiform opacities of that region. The \nvisual field is only slightly diminished, but photopsies, and \nthat peculiar symptom, micropsia, are of frequent occurrence. \n(See Exudative Retinitis. \xe2\x80\x94 Note). \n\nPROGNOSIS. \xe2\x80\x94 Although, as a rule, the disease progresses \nvery slowly, and is subject to frequent relapses, the nerve \nelements of the retina are not apt to be affected, and hence the \nprognosis is generally favorable. In case, however, there \nshould be much hypertrophy of the connective-tissue element, \nthe latter may so press upon the nervous structure of the retina \nas to give rise to more or less atrophy and permanent impair- \nment of vision. Moreover, the functional condition of the \nretina is liable to be greatly injured by the frequent relapses to \nwhich the disease is subject. \n\n\n\n254 PRACTICE OF MEDICINE. \n\nTreatment. \xe2\x80\x94 The remedies which have proven eminently \ncurative in this affection, are Merciirins corrosivus and Kali \nhydriodicum. They may be used either singly or in alterna- \ntion, as may best suit the particular indications ; and if the \npatient is brought under their influence at an early period of \nthe attack, the disease will generally be found to yield in the \nmost satisfactory manner. But if the inflammation has already \ngiven rise to extensive tissue changes, but little good can be \nexpected of any internal treatment, especially if the nerve \nelements are implicated. We notice, however, that Asafcetida, \nArum, Cinnabaris, Petroleum, Thuya, and a few other remedies, \nhave been recommended for this form of retinitis, and they \nmay prove serviceable in some cases, provided the specific \nindications correspond with the constitutional as well as the \nlocal symptoms ; for we confess that we have but little faith \nin any but specific constitutional remedies in this affection. \n\n4.-NEPHRITIC RETINITIS. \nRETINITIS albumin urica, in bright\'s disease. \n\nThis form of diffuse retinitis derives its name from the \nfact that it occurs in connection with Bright\'s disease of the \nkidney, and that its ophthalmoscopic symptoms are, in many \ncases, so peculiar and constant, as to enable us, from the retinal \nappearances alone, to determine with certainty the coexistence \nof the kidney affection. Having in the preceding sections \ndescribed the common characters of diffuse retinitis with \nsufficient fullness, we shall give but a brief sketch of the re- \nmaining varieties of retinitis, confining our remarks chiefly to \nthe more important and characteristic. \n\nSymptoms. \xe2\x80\x94 The symptoms of nephritic retinitis are, for \nthe most part, similar to those of the syphilitic variety; the \nchief difference being that they are generally much more \nstrongly defined. Thus, the optic disc is more swollen, and \n\n\n\nNEPHRITIC RETINITIS. 255 \n\nits margin rendered more indistinct, by the serous infiltration, \nwhich, extending for some distance beyond the disc, presents \nthe appearance of a bluish-grey or reddish-grey veil spread \nover the fundus, and conceals to a greater or less extent the \ndetails of the underlying choroid. The disc and surrounding \nretina generally exhibit a distinctly striated appearance, which \nis chiefly due to hypertrophy and sclerosis of the connective \ntissue element. The retinal veins are enlarged, dark, and \nsomewhat tortuous ; but the arteries are normal, or slightly \ncontracted. Dark and light spots frequently appear in the \ncourse of the vessels, in consequence of the varying depths of \nthe infiltration. The latter is sometimes so great, especially \nin the vicinity of the optic nerve, as to render the optic disc \nquite swollen and prominent, and conceal more or less com- \npletely the retinal vessels. Hemorrhagic effusions also take \nplace in different portions of the retina, and these are frequen- \ntly numerous and extensive. This is, no doubt, partly due to \ndisease of the vascular coats, but chiefly to disturbances in \nthe general circulation arising from hypertrophy of the left \nventricle, which is generally present in Bright\'s disease, and to \ncongestion of the retinal circulation caused by the swelling of \nthe optic nerve. \n\nBut the most characteristic symptoms of nephritic retinitis \nare met with at a more advanced state of the affection. We \nthen notice in the region of the macula lutea small, white, \nglistening spots, presenting more or less of a stellate figure, \nthe characteristic appearance of which may afterwards be lost \nin consequence of their becoming merged in the general exuda- \ntion. We also observe a broad, glistening white band around \nthe optic entrance, but separated from it by a zone of greyish- \nbrown infiltration, the outer border of which is very irregular, \nand broken up into circumscribed patches of exudation, or \nextended along the retinal vessels towards the periphery, \nespecially on the inner side of the retina. At an earlier \n\n\n\n2 $6 PRACTICE OF MEDICINE. \n\nperiod, or in less characteristic cases, these symptoms are less \nprominent, the retina in the vicinity of the optic disc appearing \nalmost normal, and the peculiar white exudation, instead of \nforming a broad, white ring about the optic disc, lying in scat- \ntered patches, or extending along the course of the vessels. \nEven in these cases, however, the exudation in the region of \nthe yellow spot has more or less of a stellate or streaky \nappearance, characteristic of the renal affection. \n\nThe pathological changes just noticed are found to be due to \nfatty degeneration of the cellular and connective tissue elements \nof the retina, especially the latter, which, in the region of the \nmacula lutea, are so arranged as to converge towards the \ncentre of the yellow spot, and hence the peculiar stellate \nappearance at that point. The striated appearances are due, \non the other hand, to sclerosis of the optic nerve fibres, and, \nthough much less conspicuous, are of far greater importance \nthan those arising from fatty degeneration, which, unlike the \nformer, are capable of being absorbed. Similar changes take \nplace in the coats of the retinal vessels, and also in the chorio- \ncapillaris, in consequence of which the diameter of both the \nchoroidal and retinal vessels is more or less diminished. \n\nThe sight is usually very much impaired, central vision \nbeing the most, and peripheral the least, deteriorated. The \nfield of vision is but slightly if at all contracted, but it gener- \nally contains extensive gaps corresponding to the pathological \nchanges above noted. Sudden attacks of amaurosis sometimes \noccur from uraemic poisoning, but these are easily distinguished \nfrom the loss of vision arising from inflammatory changes in \nthe retina, which is gradually progressive, besides being accom- \npanied by other symptoms of uraemia, such as headache, \nvertigo, sickness, convulsions, loss of consciousness, paralysis, \netc. Although frequently attended with symptoms of derange- \nment of the digestive functions, such as anorexia, nausea, \nsickness, etc., the impairment of vision is often the first symp- \n\n\n\nNEPHRITIC RETINITIS. 257 \n\ntorn that attracts the attention of the patient ; and it is not \nperhaps until an opthalmoscopic examination reveals the true \nnature of the complaint that the disease of the kidney is sus- \npected. As a general rule, however, nephritic retinitis does not \nappear, or is not recognized, until the kidney disease is fully \ndeveloped, and is most frequently met with in the later stages \nof the chronic affection, after amyloid degeneration has set in. \n\nETIOLOGY. \xe2\x80\x94 The nature of the connection between neph- \nritic retinitis and Bright\'s disease of the kidney, is not known. \nBy some, the disease of the retina is supposed to be due to \nthe congestion arising from hypertrophy and dilatation of the \nleft ventricle, which is a common accompaniment of nephritic \nretinitis. This view would seem to be supported by the fact \nthat hemorrhagic extravasations are not only of constant \noccurrence in this form of the affection, but appear at the very \ncommencement of the disease. Others, again, refer the \ndisease to mal-nutrition of the retina caused by the presence \nof urea in the blood. The retinitis and albuminuria are both \nobserved in the later months of pregnancy, the kidney affection \nbeing dependent, no doubt, as suggested by Virchow, on \nmechanical obstruction of the renal circulation. They also \noccur after scarlatina, cholera, pyaemia, typhoid fever, etc., and \nthen the retinitis is referable to the coexisting albuminuria. \n\nPROGNOSIS. \xe2\x80\x94 Nephritic retinitis very rarely results in \ncomplete blindness, and, on the other hand, normal vision is \nseldom regained after extensive pathological changes have \ntaken place in the substance of the retina. When these \nchanges are due simply to fatty degeneration of the connective \ntissue elements, the patches may be absorbed and vision re- \nstored ; but when atrophy of the optic nerve, or sclerosis of the \noptic nerve fibres, ensue, vision is permanently impaired. \nThose cases, on the contrary, that are secondary to the exan- \nthemata, or that occur in advanced pregnancy, or after the \nexcessive use of spirituous liquors, etc., admit of the sight \nbeing fully restored. \n\n\n\n258 PRACTICE OF MEDICINE. \n\nTREATMENT. \xe2\x80\x94 This should, of course, be chiefly addressed \nto the kidneys. For this reason we have more confidence in \nPhos. ac, and Plumb., in these cases, than in any other reme- \ndies, but the following have also been recommended : \n\nIn acute nephritis : Canth., Chelid., Kali acet., Terebinth. \n\nIn chronic nephritis : Ars., Hepar, Phos. ac, Sulph. \n\nIn fatty degeneration: Ars., Canth., Phos. \n\nIn granular dege7ieration : Ars., Colch., Plumb. \n\n/;/ amyloid degeneration: Ars., Phos. ac, Sulph. \n\nFor urcemic symptoms: Ferr., Opi. \n\nFrom alcoholic drinks: Ars., Nux v. \n\nIn pregnancy: Apis, Colch., Gels., Kal., Merc. cor. \n\nIn scarlatina: Apis, Ars., Apoc, Hell., Merc \n\n5.-LEUCJEMIC RETINITIS. \n\nComparatively little is known concerning this somewhat \nrare form of retinitis. It was first described and figured by \nLiebreich, in 1861, but its chief characteristics were first point- \ned out by Becker and Leber, in 1869. \n\nSymptoms. \xe2\x80\x94 The chief characteristic symptoms of leucae- \nmic retinitis are : a pale orange-yellow hue of the fundus, due \nto an excess of the white blood corpuscles, and a pale pinkish \ncolor of the retinal vessels, especially the veins, which are often \ndilated and tortuous. The optic nerve entrance is also pale \nfrom the same cause, and its margin is obscured by a serous \ninfiltration which extends a considerable distance from the \ndisc, in the vicinity of which the retina presents the usual \nstriated appearance. Small extravasations of blood likewise \noccur in different parte of the fundus, but they, also, are of a \npale reddish color; whilst along the course of some of the \nblood-vessels, and in the region of the macula lutea, are seen \nwhite stripes and spots, due to an extravasation of the color- \nless blood corpuscles, as first shown by Leber. The latter, in \n\n\n\nLEUCjEMIC RETINITIS. 259 \n\nhis dissections, was unable to verify the observation of Reck- \nlinghausen relative to a varicose and hypertrophied condition \nof the optic nerve fibres, but he satisfied himself thattherewasnot \na trace of fatty degeneration of the retina, as in retinitis albumin- \nurica. In some cases, more or less atrophy of the retina has \nbeen observed, the result of pressure arising from previous \nintra-ocular hemorrhages. \n\nTreatment. \xe2\x80\x94 This, to be of benefit, should be addressed \nto the coexisting leucocythaemia. In the absence of any \nexperience, we would suggest a trial of the following remedies: \nArs., Calc, Chin., Ferr., Nat. m., 01. jec, Phos. ac. \n\n6 -RETINITIS APOPLECTICA. \n\nHemorrhagic effusions are not, as we have seen, peculiar \nto this form of retinitis, comparatively small extravasations \ntaking place occasionally in nearly every variety of the affec- \ntion ; but hemorrhagic retinitis, so-called by way of eminence, \nis distinguished chiefly by an extreme tendency to hemorrha- \ngic effusions into the different layers of the retina. \n\nSymptoms. \xe2\x80\x94 In retinitis apoplectica there is more or less \nserous infiltration of the optic nerve and retina, but no exuda- \ntive or degenerative changes, such as are common to other \nforms of retinitis. Nor is the oedema generally very marked, \nbut only sufficient, in most cases, to render the disc slightly \nindistinct, and its margin somewhat irregular and obscure. \nThe veins, on the other hand, are dark, tortuous, and very \nmuch enlarged ; while here and there are seen numerous \nextravasations of blood, which, by overlying the retinal \nvessels, frequently interrupt their continuity. The arteries are \nmore normal in their appearance, but more or less contracted, \nand in some cases, particularly in the vicinity of the optic \ndisc, are changed into narrow, tendon-like bands. \n\nThe hemorrhagic effusions may occur in any portion or \nlayer of the retina, and even in the optic disc itself ; but, for \n\n\n\n260 PRACTICE OF MEDICINE. \n\nobvious reasons, they occur most frequently along the course of \nthe blood-vessels, between the inner and outer layers of the \nretina, often pushing aside the elements of the latter, and mak- \ning their way to the more superficial layers, especially the cho- \nroidal, towards which they are prone to extend. In these cases, \nthe patches of effusion will often be found to be situated be- \nneath the retinal vessels, and to have a more distinctly circum- \nscribed appearance than when seated in the internal portions of \nthe retina, where they are generally larger and darker, and \noften hide a portion of the vessels from view. In some cases, \nthey break through the internal limiting membrane into the \nvitreous, and give rise to dense opacities. The patches under- \ngo very little change in their appearance for a long time, but \nfinally the process of absorption sets in, and they gradually \nbecome lighter and lighter, assuming at last a peculiar greyish \ntint. In some cases, however, instead of undergoing absorp- \ntion, they degenerate into dark, friable masses, giving rise to \nblack patches of pigment, often of considerable size. \n\nVision is, of course, more or less impaired ; but, unless the \nhemorrhage takes place in the vicinity of the macula lutea, the \nsight is not usually so much injured as the ophthalmoscopic \nappearances would indicate. Sometimes, however, the attack \nis very sudden, and the patient, after experiencing a sensation \nof sickness and vertigo, may become nearly or quite blind \nwithin a very few moments. The field of vision is generally \nsomewhat narrowed, and exhibits, here and there, spots or \nspaces corresponding to the patches of effusion ; or in some \ncases, it may be, to their shadows, as first suggested by Heymann. \n\nETIOLOGY. \xe2\x80\x94 The disease is frequently caused by disturb- \nances of the general circulation, such as are met with in cardi- \nac, hepatic and uterine affections, especially those arising from \nhypertrophy of the left ventricle, disease of the aortic valves, \nand menstrual suppression. It may also arise from tumors, or \nany other impediment to the return of venous blood from the \n\n\n\nRETINITIS APOPLECTICA. 261 \n\neye, situated within the orbit or cranium. A more frequent \ncause, however, especially in elderly people, is atheromatous or \nfatty degeneration of the coats of the retinal vessels, in which \ncase, as Wells observes, the cerebral vessels would be likely to \nbe similarly affected. \n\nPROGNOSIS. \xe2\x80\x94 This should be particularly guarded, owing \nto the great tendency of the disease to relapses, which, if fre- \nquently repeated, greatly impair the function of the retina, and \nlead, sooner or later, to atrophic changes in the retina and optic \nnerve. \n\nTreatment. \xe2\x80\x94 The above enumeration of causes shows \nthat the treatment should be addressed to them, and to the \ngeneral condition of the patient, rather than to the pathologi- \ncal state of the retina, over which remedies can exert but little \ndirect influence. Thus, if the heart is at fault, Cactus, Gel- \nseminum, and other cardiac remedies, will be indicated ; portal \nobstruction will call for Mercurius, Nux v., Podophyllum, etc. ; \nand menstrual suppression will require such remedies as Aco- \nnite, Belladonna, Senecio, Sepia, etc. Phosphorus has been \nrecommended for the hemorrhagic diathesis, and Arnica, Cro- \ntalus and Lachesis to promote absorption of the extravasa- \ntions. \n\n7.-KETINITIS PIGMENTOSA. \n\nPIGMENT DEGENERATION OF THE RETINA. \n\nAlthough much diversity of opinion exists regarding the \npathology of this affection, some regarding it as a peculiar form \nof choroiditis, some referring it to chronic perivasculitis of the \nretinal vessels, and some to chronic inflammation of the retina \nitself, we shall find it most convenient to describe it as retinitis \npigmentosa, the name by which it is generally known. \n\nSymptoms. \xe2\x80\x94 The disease is chiefly characterized by the \nappearance of numerous spots of black pigment in the inner \n\n\n\n262 PRACTICE OF MEDICINE. \n\nlayers of the retina. These spots are of various forms and \nsizes, most of them having a branched or stellate appearance, \nwhich has led to their being compared, not inaptly, to bone \ncorpuscles. The deposits first make their appearance at the \nperiphery of the fundus, generally on the inner or nasal side of \nthe retina, and thence gradually extend in opposite directions, \nforming a more or less broad band in the middle zone, leaving \nthe central, and perhaps the temporal, portion of the retina \nunaffected ; ultimately, however, the remaining portions of the \nmembrane, including the region of the macula lutea, may be- \ncome involved in the degenerative changes. The retinal ves- \nsels are often greatly contracted, and their walls thickened, the \nsmaller branches being obliterated, or changed into narrow \ntendon-like bands. In many cases, however, the vessels, in \nsome parts of their course, instead of being bright and trans- \nparent, look like fine, black lines, owing to the presence of pig- \nment in their walls. This circumstance, in connection with the \nfact that the pigment is generally deposited along the course \nof the vessels, has led many ophthalmologists to refer the dis- \nease to degenerative changes in their coats \xe2\x80\x94 an opinion which \nseems to be confirmed by a case of Schweigger\'s, in which, as \nstated by Wells, he found, on microscopical examination, that \nthe pigmentation was confined to the retinal vessels, the coats \nof which were thickened and the smaller branches obliterated, \nthese changes extending beyond the pigmentation. But the \nchoroid, retina, and optic papilla also become degenerated, the \nformer being more or less deprived of its pigment epithelium, \nso that its vessels are rendered visible, and the retina under- \ngoing atrophy of its nerve elements and hyperplasia of its con- \nnective tissue elements. To complete the picture, the external \nlimiting membrane of the retina becomes destroyed, and the \ngranular layer, being no longer confined, becomes more or less \nmixed with the pigment cells of the epitheliel layer of the \nchoroid; and as these find their way more freely into the retina in \n\n\n\nRETINITIS PIGMENTOSA. 263 \n\nsome places than in others, they become heaped up, here and \nthere, into little black masses of pigment, which give to the \nretina its peculiar tessellated or mottled appearance. \n\nThe subjective symptoms in this affection are no less strik- \ning than the objective, the disease being characterized from its \ncommencement by hemeralopia, or night-blindness, and by a \nmarked circular contraction of the field of vision. The former \nis due to a torpid condition of the retina, resulting from an in- \nsufficient supply of blood, in consequence of the diminished \nnumber and calibre of its vessels ; and the latter arises, in all \nprobability, from pigmentation of the retina. As a conse- \nquence of these changes, the patient may be able to see well \nenough in a direct line during the day, or in a bright light ; \nbut as soon as night approaches, or the field of vision is less \nstrongly illuminated, the sight becomes very much impaired. \nWhen the visual field becomes greatly contracted, the manner \nof the patient is rendered somewhat awkward and uneasy, in \nconsequence of his being obliged to roll his eyes about in \nevery direction in order. to direct the visual axis upon each \nindividual object. As long as the region of the macula lutea \nis unaffected, the sight may remain good for central vision ; \nbut as soon as this region is invaded, which generally occurs \nbetween the ages of 35 and 50, the sight deteriorates, the retina \nand optic nerve gradually become atrophied, and, sooner or \nlater, the disease leads to complete blindness. The affection \ngenerally occurs in both eyes, and is frequently both hereditary \nand congenital. Although the pigment degeneration may not \nappear until after puberty, the disturbances of vision generally \noccur at a much earlier period, and in all cases the disease \ndates from infancy or early childhood. \n\nETIOLOGY. \xe2\x80\x94 It is evident, from the above, that the etiology \nof this affection is not well understood. As already stated, \nthe disease is generally hereditary. It is found to be frequent- \nly associated with deaf-mutism, and other congenital malform- \n\n\n\n264 PRACTICE OF MEDICINE. \n\nations, and is especially liable to occur from the intermarriage \nof relatives. \n\nPROGNOSIS. \xe2\x80\x94 This is very unfavorable, the disease, as al- \nready stated, ending, sooner or later, in complete blindness. \n\nTREATMENT. \xe2\x80\x94 This can, of course, only be palliative ; \nbut, if proper attention is paid to the general health, and the \neyes guarded against all injurious influences, undue exertion, \netc., the course of the disease, which is always very slow, may \nbe such as not to produce blindness for many years. Kali \nhydriodicum, Mercurius corrosivus, and a few other remedies, \nhave been recommended, and may, in some cases, prove tem- \nporarily beneficial ; but care should be taken not to push them \nbeyond the point of healthful reaction, as their continued use \nhas sometimes led to rapid deterioration of the central vision. \n\nART. XIV. \xe2\x80\x94 NEURITIS OPTICA. \n\nInflammation of the optic nerve, according to Stellwag, \nmay be either partial or general ; may be limited to a few bun- \ndles, or embrace its entire thickness ; may be confined to the \norbital or cranial portion of the nerve ; may embrace the en- \ntire nerve of one or both eyes ; may extend from the retina \nalong one or both nervous tracts to the corpora geniculata \n{neuritis ascendens) ; or it may originate within the cranium \nand descend to the optic papilla {neuritis descende?is) ; in short, \nit may assume a great variety of forms and degrees, depending \nchiefly upon its anatomical relations. A certain degree of \noptic-neuritis is generally associated with different forms of \nretinitis, and has already been described. We shall here treat \nonly of the idiopathic affection, of which there are two princi- \npal forms, namely, (1) ascending, and (2) descending optic-neu- \nritis. \n\n\n\nPRACTICE OF MEDICINE. 265 \n\n1.-ASCENDIN& OPTIC-NEURITIS. \n\nENGORGED PAPILLA, ISCILEMIA OF THE DISC. \n\nSYMPTOMS. \xe2\x80\x94 This form of optic-neuritis begins at the \noptic disc and extends upwards along the course of the nerve, \nbut generally stops short at the lamina cribrosa. It is chiefly \ncharacterized by great oedema and swelling of the papilla \xe2\x80\x94 \nwhich, however, may be only partial \xe2\x80\x94 by numerous and exten- \nsive extravasations of blood within and around the disc, and \nby great enlargement and tortuosity of the retinal veins, which \nare dark and engorged with blood, while the arteries, on the \nother hand, are very much contracted, and sometimes almost \nentirely empty. \n\nEtiology. \xe2\x80\x94 The engorgement of the papilla is generally \ndue to an obstruction in the central vessels of the retina, caused \nby tumors, or other diseases, within the orbit or cranium. This \nobstruction soon gives rise to oedema and swelling of the optic \nnerve, hypertrophy of the connective tissue elements, and, \nfinally, to more or less inflammation of the optic nerve fibres \n\nThe researches of Schwalbe, Schmidt, and other recent ob- \nservers, have thrown new light upon the etiology of this affec- \ntion, and have so far disproved the old notion that the engorg- \ned papilla is generally due to certain cerebral conditions, which \nimpede the venous circulation of the optic nerve by an increase \nof intra-cranial tension, or by direct pressure upon the cavern- \nous sinus, as to render it highly probable that the engorgement \nis due rather to a veritable dropsy of the optic nerve sheath, \ncaused by the passage of the arachnoidal fluid between the ex- \nternal and internal sheaths of the optic nerve to the lamina \ncribrosa and papilla, where it is arrested, and gives rise to more \nor less strangulation and swelling. The congestion and conse- \nquent oedema are, of course, still further increased by the un- \nyielding scleral ring surrounding the swollen papilla. Manz \nthinks that dropsy of the sheath, and consequent engorgement \n\n\n\n266 PRACTICE OF MEDICINE. \n\nof the papilla, may occur, not only in cerebral affections, ac* \ncompanied by serous effusions, but by any cause, such as an \nintra-cranial tumor, capable of displacing the normally exist- \ning arachnoidal fluid, and forcing a portion of it into the sheath \nof the optic nerve. \n\nMixed forms of optic-neuritis frequently occur, in which \nthe symptoms of engorged papilla are not so pronounced and \ncharacteristic as above represented, but which shade off, as it \nwere, into those of \n\n2 -DESCENDING OPTIC-NEUEITIS. \n\nNEURO-RETINITIS, NEURITIS DESCENDENS. \n\nSymptoms. \xe2\x80\x94 This form of optic-neuritis, as its name \nindicates, commences extra-ocularly, the inflammation extend- \ning downwards to the optic papilla. The swelling and \nhyperaemia of the disc are much less than in the engorged \npapilla, and the veins are less dilated and tortuous ; the \narteries, on the other hand, especially those of the retina, are \ngenerally very much contracted. The optic disc is reddish \nand swollen, its outline indistinct and more or less obscured by \nhemorrhagic effusions having a striated appearance, some of \nwhich are only apparent, consisting of newly-developed and \nclosely arranged microscopic blood vessels. The optic disc \nand retina are diffusely clouded, the latter somewhat exten- \nsively, constituting what is called nearo-retinitis. White spots \nsometimes appear in the region of the macula lutea, which \nrenders the disease liable to be mistaken for nephritic retinitis; \nbut, as pointed out by Von Graefe, the arrangement of the \nspots in neuro-retinitis is different, being situated much nearer \nto the optic disc ; moreover, the oedema of the retina in the \nvicinity of the disc is greater, the swelling of the optic nerve \nis also greater, and the veins are larger and more tortuous. \n(See Nephritic Retinitis). \n\nThe sight is often much impaired, but the diminution of \n\n\n\nDESCENDING OPTIC-NEURITIS. 267 \n\nvision does not always correspond to the extent of the morbid \nchanges, being in some well-marked cases of optic neuritis \nperfectly normal. Occasionally, however, the sight diminishes \nvery rapidly, so that in the course of a few hours or days the \npatient may be unable to distinguish light from darkness. In \nmost cases, the field of vision is more or less contracted ; and \nthis condition is generally associated with a sluggish and \ndilated state of the pupil. \n\nA great variety of subjective symptoms are met with in \ndifferent cases, such as headache, vertigo, loss of memory, \nvomiting, impairment of the special senses, epileptic attacks, \nparalysis, etc. These symptoms generally point to a cerebral \norigin of the neuritis, and are often the occasion of much \nsuffering; the headache, especially, is often very severe and \nprotracted, and generally extends over the whole head. The \npatient is also frequently annoyed with photopsies and chrom- \nopsies, due chiefly, no doubt, to disturbances in the circulation. \n\nETIOLOGY. \xe2\x80\x94 Optic-neuritis frequently originates in cere- \nbral meningitis, the inflammation extending to the optic nerve, \nand giving rise to descending neuritis. It has also ocurred in \nconnection with cerebro-spinal meningitis, with intra-cranial \ntumors, abscesses, syphilitic deposits, hydatid cysts, blood-clots, \netc. According to Jackson, optic-neuritis should be looked \nfor in every form of cerebral disease, especially those that give \nrise to cerebral fever. In some cases the disease appears to \nbe hereditary. The disease also occurs in young and delicate \nfemales, and is then generally traceable to some menstrual \ndisturbance, or disorder of the central nervous system, such as \nspinal irritation, chorea, etc. \n\nPROGNOSIS. \xe2\x80\x94 This is generally unfavorable, most cases of \noptic-neuritis resulting sooner or later in atrophy of the nerve \nand loss of vision. ** The prognosis is said to be more favorable \nin the case of children than in adults ; also, that acute and \nrapidly progressing cases afford, as a rule, a more favorable \n\n\n\n268 PRACTICE OF MEDICINE. \n\nprognosis than the chronic and gradual. So far as the general \nprognosis is concerned, those are especially favorable in which \nthe affection is due to some temporary and removable cause, \nsuch as menstrual irregularities, spinal irritation, etc. But \nwhen the brain is affected, the question of vision is merged in \nthe more important one of saving the patient\'s life, and then \nthe case belongs to the domain of general practice. \n\nTreatment. \xe2\x80\x94 More good will generally be accomplished \nby suitable hygienic measures, and by attention to the general \nhealth, than by any specific treatment of the eye symptoms. \nWhenever practicable, the removal of the cause, whether it be \nan inflammation or tumor in the orbit, or functional disturban- \nces of the circulation, such as arise from menstrual irregularities, \nwill generally give the most prompt and lasting relief. In the \ngreat majority of cases, however, the treatment will of necessity \nbe merely palliative, and will require to be mainly directed to \nthe relief of the patient\'s sufferings. \n\nIn the absence of any precise indications, the following \nlist of remedies is suggested, the selection to depend upon the \ngeneral action of the remedy and the exigencies of each \nparticular case: \xe2\x80\x94 Apis, Ars., Aur., Bell., Bry., Cact., Cim., \nCollin., Con., Croc, Gels., Kali iod., Lach., Lept., Merc, Nux v. \nPhos., Puis., Spig., Sulph., Zinc. \n\nART. XV. \xe2\x80\x94 INFLAMMATION OF THE ORBITAL TISSUES. \n\nUnder this head we shall describe, very briefly, (i) inflam- \nmation of the capsule of Tennon (Bonnet\'s capsule); (2) \ninflammation of the cellular tissue of the orbit ; and (3) \nperiostitis of the orbit. \n\n\n\nPRACTICE OF MEDICINE. 269 \n\n1 -CAPSULITIS TENONII. \n\nINFLAMMATION OF THE CAPSULE OF TENNON. \n\nThe ocular capsule, known as the capsule of Tennon or \nBonnet, is sometimes subject to inflammation. \n\nSYMPTOMS. \xe2\x80\x94 There is, generally, considerable pain in and \naround the eye, and in some cases it is severe, extending to the \nface and corresponding side of the head. The globe is some- \nwhat protruded and its motions impaired, but the most marked \nsymptom is a greater or less degree of chemosis, the ocular \nconjunctiva being red and swollen, and accompanied with con- \nsiderable episcleral injection. The eyelids, also, are somewhat \nswollen and inflamed, but the conjunctival secretion \nis but little if any increased. At the same time, the cornea, \niris and other tissues of the eye remain unaffected. Choroid- \nitis and hyalitis are said in some cases to attend or precede \nthe affection, but as a general rule vision continues unimpaired \nthroughout the progress of the case. The disease usually \nruns a slow but safe course, the effusion between the capsule \nand sclera being absorbed. \n\nETIOLOGY. \xe2\x80\x94 Cold and erysipelas are said to be the chief \ncauses, especially the former. It may also be of traumatic \norigen, as in irido-choroiditis following cataract operations, or \nthe inflammation sometimes excited by the operation for \nstrabismus. \n\nTreatment. \xe2\x80\x94 When the disease is of catarrhal or rheu- \nmatic origin, warm fomentations will be appropriate, and \nwill generally give great relief. If on the other hand the \ndisease is due to trauma, cold applications will be required. If \nthe inflammation is very severe, Aconite and Belladonna, \neither singly or in alternation, may be employed, aided, if \nnecessary, by a Belladonna lotion or ointment. \n\n\n\n270 PRACTICE OF MEDICINE. \n\n2.-CELLULITIS ORBITJE. \n\nINFLAMMATION OF THE CELLULAR TISSUE OF THE ORBIT. \n\nSYMPTOMS. \xe2\x80\x94 Inflammation of the orbital cellular tissue \nis generally of a very acute character, and, as in other forms \nof cellulitis, soon terminates in suppuration and abscess. \nOwing to the unyielding nature of the cavity in which the \nparts are lodged, the inflammatory swelling, which is always \nvery great, and especially so after suppuration has set in, gives \nrise to the most intense and agonizing suffering within the \norbit, the pain extending to the surrounding parts and often \nto the whole head. The eyelids are red, hot, and very much \nswollen, the conjunctivae much injected, and accompanied in \nmost cases with great chemosis, in the centre of which the \ncornea is deeply imbedded. The swelling of the orbital \ntissues causes more or less protrusion of the globe, and \nalthough this is not at first very perceptible, it gradually \nincreases, until at last the palpebral are unable to cover the \norgan, and the latter stands out, more or less, from between \nthem. Pressure upon the globe, or any attempt to move it, \nexcites intense pain, and therefore the patient keeps the eye per- \nfectly still. As suppuration occurs the pain slightly abates, \nbecomes intermittent and throbbing, and is attended with \nmanifest rigors. These symptoms are generally accompanied \nwith considerable fever, especially at night ; and if the inflam- \nmation extends to the brain, delirium, vomiting, and other \ncerebral symptoms, ensue. If the suppuration is extensive \nthe pus ultimately makes its way to the surface, either present- \ning at the orbital margin, or under the conjunctiva where it \npasses from the lid to the globe. In some cases the inflamma- \ntion spreads to the globe, and then the symptoms of panoph- \nthalmitis are added to those already described. (See Suppurative \nChoroiditis. Even when the suppuration is confined to the \norbital tissues, the vision is often greatly impaired, either by \n\n\n\nCELLULITIS ORBITS * IJt \n\nthe stretching of the optic nerve or by the pressure upon it, \nand the field of vision is also more or less contracted. The \nretinal veins are frequently dilated and tortuous, the retina and \noptic disc more or less infiltrated with serum, and when the \ndisease is protracted it sometimes gives rise to optic-neuritis. \n\nBut inflammation of the orbital cellular tissue is some- \ntimes far less acute, and may even be of a chronic character. \nIn these cases the symptoms are proportionably less severe. \nMatter forms and makes its way to the surface more slowly, \nthe eye gradually protrudes from between the lids, which \nbecome somewhat red and swollen, and finally perforation \noccurs and the pus is evacuated. \n\nETIOLOGY. \xe2\x80\x94 Orbital cellulitis may be induced by sudden \natmospheric changes, by exposure to cold and wet, or by other \nphysical causes. It may also arise from the extension of \ninflammation from neighboring parts, as in purulent conjunc- \ntivitis, panophthalmitis, erysipelas of the head and face, etc. \nOccasionally the inflammation supervenes upon severe consti- \ntutional diseases, such as typhus fever, purperal fever, pyaemia, \netc. But the most frequent causes are of a traumatic charac- \nter, such as penetrating, contused, or incised wounds of the \norbital tissues, injuries received from the lodgement of foreign \nbodies in the orbit, operations upon the lachrymal sac, eyelids, \neye, etc. \n\nPROGNOSIS. \xe2\x80\x94 This varies according to the nature and \nextent of the complications. If, as is not unfrequently the \ncase, the cellulitis becomes complicated with periostitis of the \norbit, it may result in caries or necrosis of the latter, in which \ncase the pus may find its way into the antrum Highmorianum, \nor into the cranium ; or the inflammation may extend back- \nward along the periosteum directly to the membranes of the \nbrain, and give rise to cerebral inflammation or abscess. Life, \nas well as vision, may also be jeopardized by inflammation and \nsuppuration of the globe, or by such an impairment of the \ngeneral health as to preclude recovery. \n\n\n\n272 PRACTICE OF MEDICINE. \n\nTreatment. \xe2\x80\x94 During the first stage, or before suppura- \ntion sets in, cold compresses should be employed, the latter \nbeing conjoined with the internal use of Aconite, unless the \nsymptoms call for some other remedy, such as Apis, Bell., Bry., \nRhus, etc. But if suppuration has already set in, warm appli- \ncations, such as fomentations and poultices, will be required. \nThe latter will generally be found to be the most convenient, \nnot only for the purpose of promoting suppuration, but to \nfacilitate the discharge of pus:, which should always be evac- \nuated at the earliest possible period, either through the \nconjunctiva, or if this is impracticable, then through the lid \nitself. The internal remedies best adapted to this stage are : \nArs., Hep., Lach., Merc, Sil., Sulph. \n\nIf there should be any doubt as to the presence of pus in \nthe orbital cavity, the upper lid may be retracted, and a small \nexploratory incision made, by passing a narrow-bladed knife \n(PL I. Fig. 13) through the conjunctiva, above the upper surface \nof the globe, into the orbit, and if pus oozes out, the opening \nshould be enlarged so as to permit of its free evacuation. In \norder to avoid injuring the globe, care should be taken to \ndirect the edge of the instrument slightly upward in making \nthe incision. A warm emollient poultice should then be \napplied, and if this fails to keep the opening patulous, the lips \nof the wound should be carefully separated with a probe, or, ii \nnecessary, a small tent may be inserted, being careful to remove \nit at least once a day. If the sinus is a long one, and \nespecially if it seems indisposed to heal, a mild astringent \nlotion should be injected every time it is dressed. A careful \nexamination should also be made from time to time, in order \nto discover the condition of the bone, and if necrosis is found \nto exist, the sequestrae should be removed as fast as they may \nbecome detached. \n\nDiet and Regimen. \xe2\x80\x94 The general health of the patient \nshould receive careful attention, and the diet should be of the \n\n\n\nPERIOSTITIS OF THE ORBIT. 273 \n\nmost nutritious and liberal character. Long-continued suppu- \nration may demand the use of malt liquors, especially if the \npatient\'s health has been already undermined by serious ill- \nness. \n\n3. -PERIOSTITIS OF THE OBBIT. \n\nOrbital periostitis may be either acute or chronic. The \nformer is generally attended by high inflammatory \n\nSymptoms. \xe2\x80\x94 The symptoms of acute orbital periostitis \nare similar to those of orbital cellulitis, except that they are \ngenerally somewhat less severe, and the protrusion of the globe \nis more or less oblique, as respects the antero-posterior diame- \nter of the ball, instead of being direct. Moreover, the move- \nments of the globe are less restricted in some directions than \nin others, owing to the periostitis being confined to a particu- \nlar part of the orbit. Where the sensations of the patient and \nthe obliquity of the globe are not sufficient to determine the \nseat of the disease, it may frequently be detected by gently \npressing the globe back into the orbital cavity in different di- \nrections, the pain and swelling corresponding to the seat of \nthe inflammation. The cellular tissue, as well as the bone \nitself, also become more or less inflamed, the former sometimes \nto a great extent, in which case pus is formed in considerable \nquantity, causing marked protrusion of the eye, and a corre- \nsponding limitation of its movements. \n\nIn chronic periostitis, the symptoms are the same as in the \nacute form, but much less severe. Thus, the orbital and circum- \norbital pain, the redness and swelling of the lids, the chemosis, \nthe conjunctival and episcleral injection, and the ocular protru- \nsion, are generally less pronounced, while the course of the \ndisease is more insidious and protracted. The pain, which is \nusually most severe at night, is always increased when pressure \nis made on the globe in the direction of the swelling, which\' \n\n\n\n274 PRACTICE OF MEDICINE, \n\nmay often be detected in this manner. More or less suppura- \ntion generally occurs, the matter sometimes accumulating be- \nneath the periosteum and separating it from the bone, in which \ncase the latter is apt to become necrosed. If this should occur, \nthe inflammation or the pus may extend into the frontal sinus, \nor into the cavity of the cranium, giving rise to either menin- \ngitis or abscess of the brain. In other cases, the periosteum \nswells and forms nodes, or tumors, which, after the inflamma- \ntion has run its course, generally disappear, leaving, perhaps, \nonly a little thickening of the periosteum ; sometimes, however, \nthe tumors ossify and become permanent. \n\nETIOLOGY.\xe2\x80\x94 Acute periostitis is frequently due to the \nsame causes that give rise to orbital cellulitis, and is often as- \nsociated with it. Operations on the lachrymal sac are especially \napt to give rise to it. So, also, are concussions and injuries of \nthe orbit, whether made by blows, by cutting instruments, or \nby the lodgement of foreign bodies within the orbital cavity. \nSometimes the disease is secondary, the inflammation extend- \ning from the frontal sinus, or other neighboring cavities. The \nchronic form, on the contrary, is frequently due to syphilis. \nMany cases occur, also, among scrofulous and badly-nourished \nchildren. \n\nPROGNOSIS. \xe2\x80\x94 Orbital periostitis generally ends in recov- \nery, though in some cases, especially when the roof of the orbit \nbecomes carious, the inflammation may travel tc the brain and \ncause death. In most cases, however, the caries and necrosis \nare limited to the margin of the orbit, resulting, when healed, \nin contraction of the integuments, and, in many cases, causing \nmore or less ectropium. But the worst results, so far as the in- \ntegrity of the eye is concerned, are experienced when the pos- \nterior portion of the orbit becomes carious, for this always \ngives rise to extensive suppuration of the orbital tissues, and \nnot unfrequently affects the optic nerve, destroying its function \nby inflammation, or so compressing it as to lead to atrophy. \n\n\n\nDACRYO-ADENITIS. 275 \n\nTREATMENT. \xe2\x80\x94 Simple periostitis requires similar treat- \nment to that recommended for inflammation of the cellular \ntissue of the orbit (which see). It is especially important that \nall collections of matter should be evacuated as soon as possi- \nble after they are detected, and that care should afterwards be \ntaken to favor the escape of pus and other morbid products. \nWhen the disease can be traced to some dyscrasia of the sys- \ntem, anti-scrofulous or anti-syphilitic remedies will generally \nbe indicated, such as Cist, c, Kali iod., Kali brom., Merc, pro- \ntoiod., Nit ac, 01. jec\xe2\x80\x9e Sulph., etc. \n\nART. XVI.\xe2\x80\x94 INFLAMMATION OF THE LACHRYMAL APPARATUS. \n\nDiseases of the lachrymal organs are frequently met with, \nbut inflammation of these parts is comparatively rare. Ery- \nsipelatous inflammation frequently occurs at the internal angle \nof the eye, and the attendant swelling, being situated over the \nlachrymal sac, may give rise to symptoms resembling, in some \nrespects, those of inflammation of the sac itself ; but it gener- \nally subsides without involving these parts to a degree sufficient \nto cause suppuration, or any other unpleasant consequences. \nWe shall embrace what we have to say concerning inflamma- \ntory affections of the lachrymal organs under the two heads of \n(1) Dacryo-adenitis, and (2) Dacryo-cystitis. \n\nl.-DACRYO-ADENim \n\nINFLAMMATION OF THE LACHRYMAL GLAND. \n\nSYMPTOMS. \xe2\x80\x94 Acute inflammation of the lachrymal gland \nis seldom an idiopathic affection. It is characterized by great \nheat, redness and swelling, such as accompanies the formation \nof acute abscess in other parts. Sometimes the inflammatory \nproducts are absorbed, and the swelling subsides ; but, in most \ncases, suppuration occurs, and generally continues long after \n\n\n\n2J6 PRACTICE OF MEDICINE. \n\nthe opening of the abscess. The suppurating cavity is com- \nparatively deep, and usually opens and closes several times be- \nfore it becomes permanently healed. In some cases, however, \nthe opening remains patulous, and a small fistulous sinus is \nformed, through which the lachrymal secretion continues to \nooze. But dacryo-adenitis is most frequently of a chronic \ncharacter, and runs a very slow and tedious course. It usually \nmanifests itself by the appearance and gradual development of \nan irregular, more or less hard, and immovable swelling at the \nouter and upper portion of the orbit. When the tumor is large, \nit pushes the globe downwards and inwards, and sometimes \nimpedes its movements, especially in the opposite direction. \nThe tumor is not generally painful, nor sensitive to the touch ; \nbut, if the swelling is of considerable size, or if the inflamma- \ntion is at ail acute, it maybe both painful and tender, especially \non pressure. In some cases the upper lid is red and cedema- \ntous, the palpebral conjunctiva injected and somewhat swollen, \nand the ocular conjunctiva, perhaps, chemotic. Occasionally, \nboth glands become inflamed at the same time, and then the \ndeformity is symmetrical. \n\nEtiology. \xe2\x80\x94 In most cases, dacryo-adenitis is the result of \na blow, or fall ; but it may also be due to cold, or it may spring \nfrom chronic inflammation of neighboring parts. \n\nTreatment. \xe2\x80\x94 In the acute form, Aconite, Belladonna and \nBaryta internally, in connection with cold or ice-water com- \npresses externally, will favor resolution of the inflammation ; \nbut if suppuration threatens it should be encouraged by the \nuse of hot fomentations and poultices, and as soon as pus forms \nit should be let out by making a free incision into the abscess. \nHepar, Merc, and Silex are the internal remedies most fre- \nquently indicated after suppuration sets in. In the chronic \nform, Bar. iod., Kal. iod., and Phytolacca should be tried ; but, \nif the swelling remains, and especially if it impairs the mobili- \nty of the eye-ball, or causes its displacement, the tumor should \nbe extirpated. \n\n\n\nPRACTICE OF MEDICINE. 277 \n\n2.-DACRY0-CYSTITIS. \n\nINFLAMMATION OF THE LACHRYMAL SAC. \n\nSYMPTOMS. \xe2\x80\x94 Acute inflammation of the lachrymal sac is, \nwhen fully developed, a very painful affection \xe2\x80\x94 much more so \nthan the limited extent of membrane involved would lead us \nto expect ; moreover, there is generally much constitutional \ndisturbance, or feverishness, attending the disorder \xe2\x80\x94 peculiari- \nties which are chiefly due, no doubt, to the vascularity of the \naffected membrane, and the unyielding character of the bony \ncanal in which the latter is inclosed. A dull, shooting pain is \nfirst felt in the region of the lachrymal sac, at the inner angle \nof the eye, at which point there appears a small, hard, circum- \nscribed swelling, which afterwards becomes hot, red and tense, \nand so sensitive that the patient cannot bear to have it touched. \nThe neighboring parts also frequently become red and swollen, \nthe oedema extending to the eyelids and face, and even to the \ntemple. The conjunctiva is more or less injected and swollen, \nespecially the large fold of that membrane, and there may also \nbe some chemosis. The nose generally appears dry and stop- \nped up, in consequence of the closure of the nasal duct, which \nprevents the passage of fluids into the nostrils. At this time, \nthe appearances are such that the disease is liable to be mis- \ntaken for erysipelas of the face. This is especially true of \nthe lids, which are extensively infiltrated with serum, and are \nred and glistening. But a close examination of the parts will- \nreveal a marked prominence and redness in the region of the \nsac, the circumscribed enlargement of which is also apparent \nto the touch. \n\nAfter a time, varying from a few days to as many weeks, \naccording to the violence of the inflammation, suppuration of \nthe sac occurs ; the swelling becomes still more prominent, and \nif left to itself often bursts and gives exit to pus, or pus \n\n\n\n278 PRACTICE OF MEDICINE. \n\nmingled with tears and mucus, though the latter do not gen- \nerally begin to be discharged until after the inflammation has \nsomewhat receded. After perforation occurs, the pain, \nswelling, and other inflammatory symptoms, rapidly subside ; \nand in the course of a few weeks more, if circumstances favor, \nthe opening may heal up, and complete recovery take place. \nUsually, however, the persistent flow of muco-purulent matter \nand tears wholly prevent the closure of the opening, or if not, \nthe closure is but temporary, as the inflammation soon relapses, \nand leads again to perforation, and so the process is continued, \nuntil what is called a fistula lachrymalis, or more properly a fis- \ntula of the lachrymal sac, is established. Sometimes, especially \nin chronic cases, more than one external opening is formed, in \nconsequence of the cellular tissue in the vicinity of the sac \nbreaking down into small abscesses, which finally open in the \nusual manner by perforation. \n\nMore frequently, however, the inflammation does not \nadvance to suppuration and the formation of fistulae. The \nnatural secretion, so to speak, of the mucous membrane, \nbecomes so altered by the inflammatory process as to resemble \npus, and in this state either escapes spontaneously through \nthe puncta lachrymalia, or is forced out whenever pressure is \nmade on the distended sac. The relief thus obtained causes \nthe inflammation to recede ; the secretion gradually becomes \nthinner and more natural, and at last changes into clear mucus. \nAs the congestion and tumefaction abate, the sac and duct \nagain become pervious, the lachrymal secretion takes its \nnatural course into the nose, and the disease is at an end. \n\nETIOLOGY. \xe2\x80\x94 Dacryocystitis is generally a secondary \naffection, being due to an extension of the inflammatory pro- \ncess from the conjunctival or nasal mucous membrane, as in \ngranular conjunctivitis, nasal catarrh, periostitis and caries of \nthe nasal bones, etc. It is especially apt to occur under these \ncircumstances in scrofulous and syphilitic patients. It is \n\n\n\nDACRYOCYSTITIS. 279 \n\nfrequently associated with erysipelas, but whether as cause or \neffect is uncertain. It also frequently follows blennorrhea of \nthe sac. When idiopathic, it is generally of catarrhal origin. \n\nTREATMENT. \xe2\x80\x94 If seen at the commencement, we should \nendeavor to prevent the formation of an abscess, by the local \nuse of cold or ice-water compresses, and the internal adminis- \ntration of such remedies as Aconite, Belladonna, Baryta, etc.; \nbut as soon as pus appears in the lachrymal sac, we should try \nto avert perforation, and secure a ready exit for the discharge, \nby slitting the upper canaliculus with Weber\'s knife, (PI. II, \nFig. 38), and then, if the opening into the sac is contracted, \npassing the knife into the latter, and dividing its neck. Gentle \npressure upon the walls of the sac will then cause the free \nescape of its contents, the pus continuing to ooze out of the \nopening, and welling up freely whenever the slightest pressure \nis made upon the swelling. A probe should now be used to \ndilate the nasal duct, so as to restore the passage into the nose. \nBut if suppuration has already progressed so far as to render \nperforation inevitable unless otherwise relieved, it is better to \nlay the sac open, by making a free incision into it, in a down- \nward and outward direction, and thus give exit to the pus. \nA warm-water dressing, or a poultice, should now be applied, \nand the wound kept open until the discharge ceases, which \nwill generally occur as soon as the inflammation subsides, and \nthe nasal duct is rendered pervious. If the lachrymal pas- \nsages remain closed after the inflammation abates, the canali- \nculus should be divided, and the nasal duct dilated by a probe, \nas already described. The same operative procedures should \nbe had recourse to, in case perforation has already taken place. \nIf the ulcerated opening fails to heal readily, and becomes \nfistulous, its edges should be stimulated from time to time \nwith sulphate of copper, when it will soon close. If, after the \nperforation has healed, the lining membrane of the sac con- \ntinues to secrete muco-purulent matter, the passage should be \n\n\n\n280 PRACTICE OF MEDICINE. \n\nsyringed out daily with a solution of alum or sulphate of zinc, \nof the strength of one or two grains to the ounce of distilled \nwater, or a weak preparation of Hamamelis or Muriate of \nHydrastia, may be used in the same manner. These injections \nwill not only clear the sac of irritating secretions, but will \ndiminish the discharge by lessening the inflammatory process. \nThe injections should be made every day, or every other day, \nas may be found most beneficial ; and, if necessary, they should \nbe gradually strengthened as improvement occurs. Any con- \nvenient syringe will answer to inject the fluid, but it will \ngenerally be necessary to first pass a silver canula, by one of \nthe canaliculi, through the sac into the duct, and to this the \nnozzle of the syringe should be attached. Or, if preferred, \nwe may introduce Spier\'s lachrymal catheter (PL II, Fig. 39) \nthrough the inferior punctum and canaliculus, and inject the \nsac through the upper canaliculus, by means of an Anel\'s \nsyringe the injection passing out again through the catheter \nlying in the inferior canaliculus.* If the parts are tense \nand hypertrophied, it may be necessary to facilitate the \nintroduction of the tube, by previously dividing the neck of \nthe sac and the internal palpebral ligament. This is most \nreadily effected by first slitting up the canaliculus with \n\nWeber\'s beak-pointed knife, (PI. II, Fig, 38), and after passing \nthe point of the instrument quite down into the sac, turning \nits cutting edge forwards and outwards, and incising the \nligament from within. \n\nThe internal treatment for blennorrhcea of the lachrymal \npassages may be gathered from the following indications : \n\nDischarge thin and acrid : Alum., Ars., Arum t., Cinnab., \nMerc. \n\nDischarge thin and bland : Euph., Sil. \n\nDischarge thick and bland : Calc, Puis. \n\nDischarge very profuse : Arg. nit., Euc. g., Hepar, Nat. m., \nMerc. \n\nObstinate : Calc, Fluor, ac, Petrol., Sil. \n\nOccasionally useful. \xe2\x80\x94 Brom., Calend., {topically), Hydras, \nKali iod., Lach. Sulph. \n\n\n\nSee Am. Horn.. Obs. t vol. viii, p. 360. \n\n\n\nDISEASES OF THE EYE. 28 1 \n\n\n\nART. XVII. \xe2\x80\x94 ADDITIONAL THERAPEUTIC INDICATIONS. \n\nThe remedies mentioned in the preceding pages are those \nupon which the author has hitherto chiefly relied in the treat- \nment of ophthalmic inflammation ; but as the list is in some \ninstances somewhat meagre, we have gleaned from our hom- \noeopathic literature the following additional therapeutic hints, \nwhich will no doubt be found serviceable in particular cases * \n\nAgaricus. \xe2\x80\x94 Spasmodic action of the muscles of the eye- \nlids and globe ; twitching of the lids, accompanied with great \nheaviness ; twiching and jerking of the eyeballs, with soreness, \naching, and outward pressure. Spasmodic movements gen- \nerally disappear during sleep, but return on waking. Great \nweakness of the eyes ; vision soon becomes obscured, espec- \nially for near objects ; everything appears blurred and \nindistinct. \n\nThis remedy has cured muscular asthenopia, with weak- \nness of the internal recti ; also anaemia of the choroid, retina \nand optic nerve. \n\nAilantus gland. \xe2\x80\x94 Conjunctivitis, with aching, burning, \nsmarting and roughness ; purulent discharge, with agglutination \nof the lids in the morning. \n\nThis new remedy is said to have cured chronic gono- \nrrhoea! ophthalmia. \n\nAlumina. \xe2\x80\x94 Burning sensation in the eyes, with or without \nlachrymation, especially at night ; itching and smarting of the \nlids and canthi ; nightly agglutination ; weakness of the upper \nlids, which hang down as if paralyzed ; conjunctiva red and \ninflamed ; edges of the lids itch and burn ; cilia drop out ; \nphotophobia ; squinting, and dimness of vision. \n\nIn blepharitis ciliaris ; trachoma ; muscular asthenopia, \nwith weakness of the internal recti ; amaurosis. \n36 \n\n\n\n282 ADDITIONAL \n\nAmy I nit. \xe2\x80\x94 Eyes staring; conjunctiva bloodshot; pupils \ndilated ; vision obscured ; chromopsia ; veins of the optic \ndisc enlarged, varicose and tortuous. \n\nIn exophthalmic goitre, by olfaction. \n\nAsafcetida. \xe2\x80\x94 Crampy, drawing and boring pains around the \nbrows ; stitching and burning pains in the eyes, with dryness, \nand sensation as if sand was in the eye ; pressure in the eyes ; \nheavy feeling in the eyelids, as if sleepy. \n\nCiliary neuralgia, keratitis, iritis, irido-choroiditis, and \nretinitis, are said to have been benefited by this remedy, \nespecially syphilitic cases. \n\nAsarum. \xe2\x80\x94 Severe burning in the lids, with or without \nwatering of the eye; conjunctiva deeply injected ; violent con- \ngestive headache. \n\nChronic blepharitis and asthenopia, attended with severe \nheadache, are reported as having been cured by this remedy. \n\nAurum mnr. \xe2\x80\x94 Vascularity and opacity of the cornea ; \nciliary injection ; photophobia; tearing pains in the globe, \nespecially the left ; complete loss of vision. \n\nSeveral cases of diffuse keratitis, accompanied with the \nabove symptoms, have been reported cured by low attenuations \nof this remedy ; also a case of amaurosis, with great prostra- \ntion, occurring suddenly after a severe attack of scarlatina. \n\nBaryta tod. \xe2\x80\x94 Drs. Liebold and Woodyatt report cases of \ndiffuse and obstinate phlyctenular keratitis, in scrofulous \nsubjects, successfully treated with this remedy ; the lymphatic \nglands "feel like a string of beans between the muscles." \n\nCalcarea iod. \xe2\x80\x94 Severe ciliary irritation, pain, photophobia, \nlachrymation, spasm of the lids. \n\nReported serviceable in nearly every form of scrofulous \ninflammation of the eye, particularly chronic blepharitis, \nphlyctenular and suppurative keratitis, especially when com- \n\n\n\nTHERAPEUTIC INDICATIONS. 283 \n\nplicated with enlargement of the glands of the neck and \nthroat. \n\nCedron. \xe2\x80\x94 Eyes protruding ; pupils fixed and dilated ; \ndimness of vision, especially at night ; objects appear red at \nnight and yellow in the day time ; pressive and shooting pains \nin the forehead and temples, worse over the left eye. \n\nSupra-orbital neuralgia, especially when dependent upon \niritis, choroiditis, and other intra-ocular troubles, appears to \nhave been frequently relieved by this remedy. \n\nChelidonium. \xe2\x80\x94 Violent pressive and shooting pains in the \neyes ; neuralgic pains in the brows and lids ; feeling of sand \nin the eyes, especially on movement ; redness, burning and \nswelling of the eyelids, with morning agglutination ; yellow- \nness of the sclerotica ; dimness of vision, with faintness ; \nflickering and brilliant specs before the eyes. \n\nIntermittent ciliary neuralgia, catarrhal conjunctivitis, \nand rheumatic amaurosis, are reported as having been cured by \nthis remedy. \n\nCicuta. \xe2\x80\x94 Diplopia ; things look black ; eyes protrude, \nwith a staring look ; pupils first contracted, then considerably \ndilated ; when standing or walking, the sight vanishes, and \nobjects appear to advance, recede, and waver, from vertigo. \n\nCicuta has cured double vision, vertigo, blepharitis with \nagglutination of the lids, and photophobia ; but its chief value \nappears to be in spasmodic affections of the eyes and lids. \n\nClematis. \xe2\x80\x94 Smarting pain in the eyes and in the margins \nof the lids ; burning pain in the lids and canthi ; stitches and \nburning in the inner canthus, with weak sight and lachrymation. \n\nChronic blepharitis and conjunctivitis, keratitis, iritis, and \nkerato-iritis, occuring in scrofulous subjects, have been cured \nor greatly benefited by this remedy. \n\nComocladia. \xe2\x80\x94 Aching soreness in the globes, which feel \nheavy and larger than natural ; painful pressing-out sensation, \n\n\n\n284 ADDITIONAL \n\nas if something was pressing on top of the eyeballs ; severe \npain in the balls, extending to the head ; pains increased by \nwarmth. \n\nIn ciliary neuralgia associated with asthenopia, and \nchronic iritis. \n\nCrocus. \xe2\x80\x94 Burning in the eyelids ; burning and smarting in \nthe eyes, as from smoke ; spasmodic twitching of the lids, \nespecially the upper ; aching in the eyeballs, with epiphora, \nworse on reading ; upper lids feel heavy ; pupils dilated ; \nsight obscured, as by a mist, worse for central vision. \n\nThis remedy seems to have relieved a variety of ophthal- \nmic troubles, chiefly menstrual, or occurring in hysterical \nwomen ; such as nictation, with epiphora ; nightly twitching \nof the lids, with lachrymatfon ; asthenopia, associated with the \nabove symptoms, or when attended with a sensation as if the \npatient had been weeping ; pains in the eye and head, occur- \nring in sclero-choroiditis posterior, etc. \n\nCrotalus.- \xe2\x80\x94 Yellow, sunken appearance of the eyes ; pres- \nsure in and above the orbits ; oozing of blood from the eyes, \nwhich appear ecchymosed ; frequent vanishing of sight, \nespecially in damp weather, or when reading. \n\nIn ciliary neuralgia and amblyopia, occurring in women, \nand aggravated at the menstrual period ; it also appears to be \nindicated in retinal hemorrhages, as first pointed out by \nDr. Liebold. \n\nCroton tig. \xe2\x80\x94 (Edematous swelling and itching of the \neyelids ; weakness of the eyes, with lachrymation ; violent \nstinging and burning pains in the eye, with inflammatory \nredness and irritation of the conjunctiva ; violent inflammation \nof the eye occurred on the second day, attended with ulcera- \ntion of the ocular conjunctiva, irritation of the iris with \ncontraction of the pupil, conjunctival and episcleral injection, \nprofuse lachrymation, photophobia, and violent pains, disturb- \ning the nights rest. \n\n\n\nTHERAPEUTIC INDICATIONS. 285 \n\nPhlyctenular ophthalmia and keratitis, either with or \nwithout ulceration of the cornea, are said to have yielded \nspeedily to this remedy, especially when the characteristic \neruption also appeared on the lids and face. \n\nCyclamen. \xe2\x80\x94 Dilatation of the pupils, with obscuration of \nsight ; stupefaction, with sensation of a fog before the eyes. \n\nAmblyopia, diplopia, hemiopia, and convergent strabis- \nmus, are said to have been relieved by this remedy. \n\nFluoric ac \xe2\x80\x94 Violent itching in the canthi ; increased \nlachrymation ; sensation as of cold wind blowing in the eyes ; \nvision disturbed by dark, floating opacities. \n\nLachrymal fistula, of a years duration, and dark spots \nbefore the eyes, caused by movable opacities of the vitreous, \nare reported to have been relieved by this remedy. \n\nHamamelis. \xe2\x80\x94 Painful inflammation of the eyes and lids, \nwith extreme congestion ; ecchymosis of the lids ; intra-ocular \nhemorrhage. \n\nThis remedy, used locally as well as internally, has been \nsuccessfully employed in traumatic conjunctivitis, keratitis and \niritis, caused by burns, splinters, blows, etc.; also in ulceration \nof the cornea, and in internal hemorrhages, especially when \nof traumatic origin. \n\nKali bicli. \xe2\x80\x94 Conjunctiva deeply injected, with heat and \nuneasiness ; eyelids inflamed and swollen ; papillae of the \npalpebral conjunctiva enlarged ; cornea ulcerated ; photopho- \nbia and dimness of vision. \n\nTrachoma, pannus, corneal opacities, and rheumatic iritis, \nthe latter in a syphilitic patient, have been successfully treated \nby this remedy. \n\nKalmia. \xe2\x80\x94 Sensation of stiffness in the eyelids, and in the \nmuscles around the eyes ; itching in the eyes ; glimmering \nbefore the eyes, exactly in the axis of vision ; dimness and \nloss of vision, especially on looking down, worse in the \nmorning. \n\n\n\n286 ADDITIONAL \n\nSclero-choroiditis anterior, asthenopia with stiffness of the \nrecti muscles, and retinitis albuminurica, have all been cured, \nor greatly benefited, by the internal administration of Kalmia. \n\nLycopus virg. \xe2\x80\x94 The chief symptom is a painful pressure \nin the eyeballs. \n\nLycopus has relieved protrusion of the eyes, with tumul- \ntuous action of the heart, and is even reported to have cured \nexophthalmic bronchocele. \n\nPhytolacca. \xe2\x80\x94 Burning, smarting and itching in the eyes, as \nif sand were in them, with profuse lachrymation ; dull, heavy \npain in the eyeballs, worse from motion, light, and reading ; \nan eruption (probably enlarged papillae) on the conjunctiva; \neyelids cedematous and agglutinated. \n\nThis remedy is reported to have cured catarrhal ophthal- \nmia, with lachrymation and photophobia ; also granular \nconjunctivitis, with circum-orbital pain and soreness ; great \nbenefit is also said to have resulted from its internal adminis- \ntration in a case of traumatic suppurative choroiditis, in which \nthe lids were enormously swollen, the conjunctiva chemosed, \nand the anterior chamber filled with pus. \n\nPrimus sp. \xe2\x80\x94 Lancinating and shooting pains in and around \nthe eye, and in the corresponding side of the head ; pain in \nthe eyeball as if it were crushed or wrenched ; pain in the \nglobe as if it were pressed asunder ; sharp, piercing pains, \nextending to the eye ; aggravation of the pains from motion. \n\nThis remedy not only seems to relieve almost every form \nof ciliary neuralgia, but to be of great value in the treatment \nof various ophthalmic disorders of which this symptom is a \nprominent feature, such as irido-cyclitis, choroiditis, chorio- \nretinitis, etc. \n\nRuta. \xe2\x80\x94 Feeling of heat and sensation as of fire in the \neyes, with soreness when reading by candle-light ; pressure on \nthe upper wall of the orbits, with tearing pain in the eyeballs ; \ndimness of vision from exerting the eyes too much by reading \nor fine work. \n\n\n\nTHERAPEUTIC INDICATIONS. 2%J \n\nIn asthenopic symptoms arising from over-exertion of \nthe eyes. \n\nSantonine. \xe2\x80\x94 Dimness and loss of vision ; giddiness ; \ntroubled sight, with dilatation of the pupils ; convulsive \ntwitchings of the eyes and lids. \n\nThis remedy is reported to have been successful in a con- \nsiderable number of cases of asthenopia, amaurosis, and \ncataract (?). \n\nSenega. \xe2\x80\x94 Swelling, burning and pressure of the eyelids, \nwith burning pain in the margins ; eyelashes in the morning \nfull of hard mucus ; illusions of sight ; extreme sensitiveness \nof the eyes to light. \n\nSenega appears to act very beneficially in blepharitis and \nconjunctivitis, attended with the above symptoms ; and is said, \nalso, to have promoted absorption of hypopya, and of less \nfragments after cataract operations. \n\nStaphysagria. \xe2\x80\x94 Itchings of the margins of the eyelids ; \npimples around the inflamed eye ; sticking shocks in the eye- \nball, as if it would burst ; illusions of sight ; dilation of the \npupils; aching and pressure in the eye; lachrymation and \nphotophobia. \n\nThis is an old and well-known remedy for blepharitis, \nstyes, and small tarsal tumors ; and it is also reported to have \ncured several cases of the so-called "arthritic ophthalmia." \n\nSticta. \xe2\x80\x94 Burning in the eyelids, with soreness of the ball \nin closing the lids, or turning the eyes. \n\nIn catarrhal conjunctivitis, with profuse but mild discharge. \n\nZinc phos. \xe2\x80\x94 Retinal hyperemia ; extreme sensitiveness of \nthe eyes to light ; photopsia, photophobia, and chromopsia. \n\nIn hyperesthesia and hyperemia of the retina. \n\n\n\n288 PRACTICE OF MEDICINE. \n\n\n\nTABLE A. \n\nOPHTHALMIC SYMPTOMS. \n\ni. Agglutination\xe2\x80\x94 Bell., Calc, Care, v., Caus., Euphorb., \nHep., Kali, Lyc, Nat. m., Nux v., Phos., Puls., Rhus., Ruta, Sep., \nSilic, Staph., Bry., Ign., Stann., Alum., Croc, Nit. ac, Plumb., \nSulph., Thuja. \n\n2. Burning \xe2\x80\x94 Ars., Arn., Bell., Bry., Calc, Con., Cham., \nCroc, Dig., Rhod., Ruta, Spig., Spong., Thuja., Alum., Canth., \nFerr., Graph., Ign., Kali, Nit. ac, Plumb., Puis., Rhus. Sep., Staph., \nSulph., Aeon., Agar., Aur., Bar., Chin., Dros., Hell., Lyc, Mur. ac, \nNux v., Phos., Silic, Strain. \n\n3. Dryness \xe2\x80\x94 Bry., Staph., Sulph., Ver at., Bell., Puis., Agar., \nBar., Caust., Croc, Euph., Kali, Lyc, Nat. m., Nux v., Phos., Spig. \n\n4. Lachrymation \xe2\x80\x94 Acon., Arn., Bell., Bry., Calc, Caust., \nChin., Coloc, Digit., Euph., Ferr., Graph., Hep., Ign., Kali a, \nLyc, Merc, Nat. m., Nux v., Phos., Puls , Rhus, Ruta, Spig., \nSpong., Stram., Sulph., Verat. a. Alum., Ars., Bar., Chelid., Con., \nCroc, Rhodod., Seneg., Sep., Sil., Stan., Staph., Zinc, Agar., Camph., \nCanth., Carb. v., Cina, Coff., Hell., Lach., Op., Petr., Ph. ac, Plat. \n\n5. Neuralgia \xe2\x80\x94 Atrop., Bell., Cedr., Cham., Prunus sp., \nSpig., Chin., Cinnab., Sil., Asafcet., Bry., Cimicif., Crotal., Ign., Mez., \nNat. m., Plat., Sulph., Thuj. \n\n6. Pupils, Dilated \xe2\x80\x94 Acon., Bell., Calc, Chin., Cina, Croc, \nHep., Hyosc, Ign., Ipec, Sec c, Spig., Stram., Verat., Zinc. \nAgar., Am., Hell, Nux v., Ph. ac, Puis., Ars., Aur., Caust., Con., \nCupr., Dig., Mur. ac, Nit. ac, Petr., Plumb., Stann. \n\nPupils, Contracted \xe2\x80\x94 Arn., Camph., Cham., Chin., Cic, Hyosc, \nIgn., Puls., Sulph., Verat., Aeon., Agar., Ars., Aur., Bell., Cina, \nCocc, Dros., Plumb., Sec c, St) am., Calc, Canth., Digt., Hell., Mur. \nac, Ph. ac, Stann., Thuj. \n\n7. Redness, Inflammatory. \xe2\x80\x94 Acon., Apis, Arn., Ars., Bell., \nBry., Calc, Cham., Chin., Digt., Euphr., Ign., Merc, Nat. m., Nit. \nac, Nux v., Phos., Ph. ac, Puls., Rhus, Sep., Silic, Spig., Sulph., \nVerat., Coloc, Cupr., Euphorb., Ipec, Kali, Lyc, Staph., Bar., \n\n\n\nOPHTHALMIC SYMPTOMS. 289 \n\nCamph., Canth., Carb. v., Con., Dulc, Ferr., Graph., Hep., Hyosc, \nOp., Plumb. \n\n8. Smarting\xe2\x80\x94 Agar., Con., Merc, Nux v., Rhus,Val., Alum., \nCanth., Chin., Graph., Sep., Staph., Ars., Bell., Bry., Calc, Carb. v., \nCaust., Croc., Dros., Euphor., Hell., Hep., Kali, Lye, Mur. ac, \nNit. ac, Phos., Ph. ac. Sulph., Thuj. \n\n9. Swelling\xe2\x80\x94 Ars., Rhus, Stram., Bry., Carb. v., Hep., Nux, v. \nPhos., Plumb., Ruta, Sulph. \n\n10. Ulceration, Tarsal\xe2\x80\x94 Spong., Sulph., Am., Calc, Cham., \nLyc, Phos., SiL, Staph., Alum., Bar., Caust., Kali, Nit. ac, Sep. \n\n11. Ulceration, Corneal. \xe2\x80\x94 Arg. n., Ars., Aur., Calc, \nGraph., Hepar., Kali bic, Merc, Aeon., Canth., Cinnab., Nat. m., \nSilic., Sulph., Apis, Arn., Cham., Chin., Cimicit., Con., Crot. tig., \nHam., Puis.. Rhus. \n\n12. Vision, A. \xe2\x80\x94 Amblyopia: Bell., Phos., Zinc, Gels., Merc, \nSant., Aeon., Alum., Arn., Ars., Aur., Bar., Bov., Calc, Chel., Chin., \nCrot., Cyclam., Ign., Kali, Lye, Nat. m., Puis., Ruta., Sep., SiL, \nSulph., Thuj. \n\nB. \xe2\x80\x94 Chromopsia. \xe2\x80\x94 Bell., Con., Croc, Digit., Kali, Alum., \nArs., Calc, Cann., Canth., Hep., Hyos., Merc, Ph. ac, Phos., Sep., \nSpig., Stram., Zinc. \n\nC. \xe2\x80\x94 Diplopia. \xe2\x80\x94 Bell., Digit, Euphorb., Hyosc, Puls., Sec. c, \nSulph., Verat., Aur., Cic, Stram., Agar., Graph., Nit. ac, Merc, \nPetr. \n\nD. \xe2\x80\x94 Hemiopia. \xe2\x80\x94 Aur., Lith. c, Lyc, Mur. ac, Nat. m., Sep., \nBov., Cyclam., Digt., Calc, Chin., Lob., Viola od. \n\nE. \xe2\x80\x94 Hemeralopia. \xe2\x80\x94 Hyos., Ranun., Verat., Arg. nit., Digt., \nSulph., Bell., Chin., Lyc, Merc, Puis., Stram. \n\nF. \xe2\x80\x94 Photophobia. \xe2\x80\x94 A con., Arn., Ars., Bell., Bry., Cham., \nChin., Con., Euphr., Graph., Hep., Ign., Merc, Nux v., Puls., \nSep., Sulph., Cic, Cin., Croc, Sant., Alum., Camph., Coff., Hell., \nKali, Lyc, Mur. ac, Nit. ac, Ph. ac, Sil. \n\nG. \xe2\x80\x94 Pholopsia. \xe2\x80\x94 Bell., Bry., Spig., Bar., Caust., Kali, Sil, \nVerat., Ars., Aur., Calc, Coloc, Croc, Digt., Dulc, Nat. m. Nux v., \nOp., Petr., Ph. ac, Staph., Stram. \n\nH. \xe2\x80\x94 Vitreous Opacities. \xe2\x80\x94 Kali iod., Sil., Sulph., Calc, Nat. \nm. Nit. ac, Phos., Sep., Arn., Bell., Carb. v., Caust., Ham., Kal., \nLach., Lyc, Merc, Petr., Prunus, Sol. n. \n\n\n\n29O PRACTICE OF MEDICINE. \n\nTABLE B. \n\nOPHTHALMIC INFLAMMATION. \n\ni. Conjunctivitis \xe2\x80\x94 Apis, Arg. nit., Bell., Euphr., Merc, \nPuls., Rhus, Sep.. Sulph., Am., Ars., Calc, Cham., Cinnab., Graph. , \nHepar., Ign., Nux. v., Sang., Spig., Zinc, Alum , Chelid., Croc, Cupr., \nEuphor., Kali bic, Nat. m., Sen., Thuj. \n\n2. Blepharitis \xe2\x80\x94 Acon., Alum., Apis, Arg. nit., Ars., Calc, \nCaust., Cinnab. . Euphr., Graph., Hepar, Merc, Nat. m., Petr., \nPuls., Sep., Silic, Aur., Cham., Crot. fig, Merc, Nux v., Psor., Rhus, \nStaph., Tellur., Bell., Clem., Colch., Kali, Lye, Phos. ac, Sang., \nSeneg., Viola trie. \n\n3. Keratitis \xe2\x80\x94 Acon., Apls, Arg. nit., Arn., Ars.. Aur., Calc, \nCanth.. Cham., Chin., Cimicif., Con..tCrot. tig., Euphr., Graph., \nHam., Hepar., Kali bic, Merc, Nat. m.. Nux v. Puls., Rhus, \nSec c, Sil., Sulph., Aur. m., Bar., Sep., Thuj., Vaccin., Alum., \nBell., Caust., Chin., Kreos., Nit. ac, Seneg. \n\n4. Episcleritis. \xe2\x80\x94 Acon., Kal., Merc, Silic, Thuj., Puis., \nCocc. , Spig., Sulph. \n\n5. Iritis. \xe2\x80\x94 Acon., Arn., Ars., Aur.. Bell., Bry., Calend., \nCedr., Chin., Clem., Con., Euphr., Gels., Ham., Hepar., Kali iod., \nMerc, Nit. ac, Nux v., Petr., Rhus, Silic, Spig., Sulph., \nTerebinth., Thuj. Arg. nit., Asafcet., Cinnab., Nat. m., Puis., Cocc, \nCrot. tig., Hyos., Led., Plumb., Stilling., Zinc. \n\n6. Cyclitis \xe2\x80\x94 Kali iod., Merc, Bell., Bry., Rhus, Silic. 3 Apis., \nArs., Aur., Prunus sp., Thuj. \n\n7. Choroiditis \xe2\x80\x94 Aur., Bell., Bry., Gels., Kali iod., Merc, \nNux v., Phos., Prunus sp., Puls., Sulph., Apis, Ars., Hepr., Phyt., \nRhus t., Acon., Coloc , Ipec, Psor., Ruta, Sil., Sol. nig. \n\n8. Glaucoma. \xe2\x80\x94 Bell., Bry., Cedr., Coloc, Phos., Pru. sp., \nRhododen., Spig., Kali iod., Merc, Phyto., Arn., Ars., Aur., Cham., \nCocc, Collin., Con., Crot. tig., Gels, Ham.. Nux v., Sulph. \n\n9. Retinitis \xe2\x80\x94 Bell., Bry., Cact., Con., Merc, Nux v., Phos., \nPuls., Apis, Asafcet., Ars., Aur., Gels., Kalm., Kali iod., Aeon., \nCollin., Croc, Lach., Leptan., Spig., Sulph., Zinc. \n\n10. Orbital Cellulitis. \xe2\x80\x94 Acon., Apis, Hepar., Lach., Merc, \nRhus., Calc, Kali iod., Caust., Sil., Sulph. \n\n11. Dacryocystitis \xe2\x80\x94 Acon., Hepar, Merc, Puls., SiL.,Arumt., \nArg. nit., Euphr., Petr., Cinnab., Hydras., Nat. m., Sang., Stilling., \nSulph. \n\n12. Fistula Lachrymalis \xe2\x80\x94 Arg. nit., Brom., Fluor, ac, \nCalc, Lach., Petr., Nat. m., Silic, Sulph. \n\n\n\nSYMBLEPHARON. 2CjI \n\nDIV. II. \n\nRESULTS OF OPHTHALMIC INFLAMMATION. \n\nMany of the consequences of ophthalmic inflammation have \nalready received the attention at our hand which their rela- \ntive importance, and the general object we have had in view, \nhas seemed to demand. Others, however, have been but \nbriefly noticed, or only incidentally referred to, and will there- \nfore require to be separately considered. But as we have \nalready devoted as much space to the subject of inflammation \nas we can well spare for that purpose, we shall aim in what \nfollows to be as brief and practical as possible. \n\n1.-SYMBLEPHAE0N. \n\nThis term denotes a more or less extensive adhesion of \nthe mucous membrane of the lids to that of the globe. The \nadhesions may be direct and close, so as to cause very great \nlimitation of the movements of the ball ; or they may consist \nof narrow bridges of connection, either slender and chord-like, \nor thin and membranous. These loose attachments are \nsupposed to be formed by the movements of the globe, and \nconsequent stretching of the original adhesions. The affection \nmay be produced by any cause which gives rise to ulceration of \nthe two opposed conjunctival surfaces, whether it be the acci- \ndental introduction of caustic substances, such as lime or \nmortar, between the lids, or the destruction of the superficial \nepithelial layers by the knife or caustic, as in careless oper- \nations for the removal of trachoma, pterygium, etc. \n\nTreatment. \xe2\x80\x94 When the adhesions are extensive, it is \nalmost impossible to prevent their ultimate reunion after sep- \naration. Surgeons of the highest eminence have recorded \ntheir repeated attempts and failures in this direction. The \ndifficulty seems to lie in the contraction of the new formations, \n\n\n\n292 PRACTICE OF MEDICINE. \n\nand the consequent difficulty of permanently separating the \ngranulating surfaces. Almost every form of mechanical contri- \nvance has been made use of to prevent the junction of the raw \nsurfaces ; and for this purpose shields of metal, glass, ivory, \nand other substances, have been interposed between the lids \nand globe ; but as contraction takes place during the process of \ncicatrization, the interposed substance is gradually pushed out, \nand although the case may seem to do well at first, the operation \nis almost certain, in the end, to prove a failure. Probably Mr. \nWordsworth\'s glass shell, mentioned by Wells, which has a \ncentral opening for the cornea, and resembles an aitificial eye, \nwould, as the inventor claims, be successful in many cases, \nprovided it were worn continuously for a sufficient length of \ntime ; for it should be remembered that, as in the case of \nburns, the new formation is imperfectly organized and liable to \nabsorption, and consequently, as pointed out by Walton, con- \ntraction continues for some time after the completion of the \ncicatrix. \n\nOf the many operative procedures that have been devised \nfor symblepharon, the following appear to be the most reliable, \nand may be adopted in moderate cases with reasonable pros- \npect of success : \n\n1. That of Amussat, which consists in freely dividing all \nexisting adhesions, and then daily carrying the point of a \nprobe, or of a cutting instrument, to the extremity of the \ndivision ; this is continued until the pyogenic surfaces are cica- \ntrized, and can no longer grow together. \n\n2. Petrequin\'s ligature process, which consists in carrying \na double ligature through the adhesion, one portion of which is \ntied with great firmness close to the sclerotica, and the other \nwith a less degree of compression near the lid. As the former \nsloughs away at an earlier period than the latter, the part near \nthe eyeball heals before the other, and the cicatrization be- \ncomes too far advanced to admit of its reattachment to the \nouter part. \n\n\n\nANCHYLOBLEPHARON. 293 \n\n3. Arlt\'s process, which consists in first passing two liga- \ntures through the symblepharon close to the cornea, and after \ncarefully dividing the adhesions as far back as the retro-tarsal \nfold, doubling down the symblepharon so as to bring its con- \njunctival surface in apposition with the raw surface of the \nglobe, and then passing the ligatures through the lid close to \nthe orbital border, tying them on the outside. After the orbi- \ntal wound has healed, if the shrunken remains of the symble- \npharon prove troublesome to the patient, they may be safely \nsnipped off with a pair of scissors. \n\n4. Teale\'s method by transplantation. This consists in \nfirst separating the adhesions in the usual manner, beginning at \nthe margin of the cornea, and then interposing one or more flaps \nof conjunctiva previously dissected from neighboring portions \nof the globe. The flaps are adjusted in their new positions by \nmeans of fine silk ligatures, "and their vitality is further pro- \nvided for by incising the conjunctiva near their base, in any \ndirection in which there seems to be undue tension." He also \nstitches together the margins of the gap from which the trans- \nplanted conjunctiva has been removed. In adjusting the flaps, \ngreat care should be taken to prevent the doubling in of their \nedges, which would be likely to prevent the full success of the \noperation. \n\n2 -ANCHYLOBLEPHARON. \n\nThis term denotes a firm adhesion of the two lids, which \nmay be either complete or partial, congenital or acquired. In \nthe majority of cases the adhesion is partial, and is usually \nlimited to the outer angle. The union is generally of a mem- \nbranous nature, especially in congenital cases ; but when com- \nplicated with symblepharon, or when caused by severe mechan- \nical or chemical injuries, it is apt to be thick and tendinous. \n\nTreatment. \xe2\x80\x94 If the adhesion is membranous, or if it is \n\n\n\n294 PRACTICE OF MEDICINE. \n\nlimited to one or more points, the lids should be carefully \nseparated upon a director, and readhesion prevented by care- \nfully drying the edges, and then touching the raw surfaces with \ncollodion, as first suggested by Walton ; but if the union is \nlarge and broad, and especially if it is confined to the palpebral \nangle, the most appropriate and effective treatment is the oper- \nation of Canthoplasty, (which see). \n\n3.-BNTR0PIUM. \n\nBy entropium is meant a more or less extensive inversion \nof the lids. It is usually complicated with trichiasis, or turning \nin of the cilia, which is generally regarded as constituting the \nfirst degree of entropium. We recognize two principal forms \nof the affection ; the spasmodic, which usually occurs in \nelderly people, and hence is frequently called senile entropium; \nand the chronic, which is generally due to inflammatory and \nstructural changes in the conjunctiva and tarsal cartilages. \nThe former, which is frequently temporary, is generally met \nwith in the lower lid, but it may also occur in the upper. The \naffection is often accompanied with great irritation from the \nfriction of the cilia against the globe, which frequently gives \nrise to inflammation, and leads sooner or later to ulceration \nand opacity of the cornea. \n\nTreatment. \xe2\x80\x94 The most simple and effective treatment \nfor spasmodic entropium, particularly in senile cases, is the \noperation of canthoplasty, care being taken to make the incision \noblique instead of horizontal, so as to relax the orbicularis \nmuscle to the fullest extent. Generally, the incision should \nbe in a downward direction, because it is usually the lower lid \nthat is affected. If this fails to keep the lid in its natural \nposition, its external surface should be painted with collodion, \nthe contraction of which in drying is sometimes sufficient, \neven without the operation, to prevent the lid from again \nbecoming inverted. \n\n\n\nentropium. 295 \n\nWhen the central part of the lid is greatly relaxed, as it \nusually is in old cases, some surgeons, in order to equalize the \ntension, instead of extending the edge of the lid, as above \nrecommended, remove a triangular piece of integument from \nthe central, or most relaxed portion. An incision is first made \nabout one and a half lines from the free border of the lid, and \nparallel with it, extending on either side to within one or two \nlines of the commissure. Two oblique incisions are then \nmade from points about midway between the centre and the \ntwo extremities of the horizontal incision, converging towards \nthe orbital border, so as to include a triangular portion of the \nintegument, which is dissected up and removed. The sides of \nthe wound are then united by two or three fine sutures, the \nhorizontal incision being left to itself. When healed, the \ncicatrix will be in the form of the letter T. In very bad \ncases, especially where there is a narrowing of the palpebral \nfissure, it is best to combine this operation with that of can- \nthoplasty, above described. \n\nIn case there is much contraction and incurvation of the \ntarsal cartilage, it may also be found necessary to remove a \nportion of the latter, which is best done by turning back the \nupper angles of the V-shaped incision in the operation just \ndescribed, as far as the ends of the horizontal incision, and then \ncutting out a wedge-shaped portion of the cartilage, by mak- \ning two nearly parallel incisions into it along the palpebral \nmargin nearly down to its inner surface, at the same time \nsloping them towards each other so as to meet near its posterior \nsurface. The strip to be removed is then seized with a pair \nof forceps, and detached with a few touches of the scalpel. \nThe extent to which this "grooving process" should be carried, \nwill depend, of course, upon the degree of contraction and \ndislocation of the cartilage. \n\nIf these operative procedures fail to rectify the position \nof the lids, there remains no other resource than to remove the \nhair-follicles, as described under Trichiasis, (which see). \n\n\n\n2g6 PRACTICE OF MEDICINE. \n\n4.-ECTR0PIUM. \n\nEctropium is the reverse of entropium ; that is, it is a \nturning out of the eyelid, so that more or less of its conjunc- \ntival surface is exposed. It is generally confined to the lower \nlid, though it may affect both. There are various degrees of \nthe affection, ranging from a slight eversion of the border of \nthe lid, to one in which the entire surfaces are reversed. Of \ncourse this malposition of the lids interferes with the proper \ndischarge of the tears, so that the eye is always more or less \nsuffused and watery ; and in severe cases, especially of the \nlower lid, they frequently pour over the side of the cheek, \ninflaming and excoriating the latter, and even increasing the \nectropium, by causing contraction of the integuments. In \nfact, it is this contraction of the skin near the edges of the \nlids, during cicatrization from long-continued excoriation, \nburns, wounds, etc., that most frequently gives rise to ectro- \npium. But severe forms of conjunctivitis, especially the \npurulent and granular, also produce it, in consequence of the \nextensive swelling and hypertrophy of the conjunctiva, the \neversion being aided by the action of the orbicularis. Other \ncauses are : paralysis of the portio dura, chronic blepharitis, \nor lippitudo, abscess of the lids, abscess and caries of the \norbit, especially of its margin, intra-orbital tumors, cancerous \ngrowths, and exophthalmos. \n\nTreatment. \xe2\x80\x94 If the cause of the displacement can be \nremoved, acute and recent cases will, as a general rule, require \nno additional treatment, except the simple replacement of the \nlid, and its retention in the normal position by a compress \nbandage. But when the eversion is of long-standing, the tar- \nsus becomes more or less elongated, so that the lid will no \nlonger fit the globe, even after it is restored to its natural \nposition. It then becomes necessary to narrow the palpebral \n\n\n\nECTROPIUM. 297 \n\nfissure by the operation of tarsoraphia. This operation, devised \n\nby Walther, may be performed as follows : \xe2\x80\x94 The operator \n\nascertains the extent of the surplus tissues, by first reducing \n\nthe dislocated lid, and then, having put its border slightly on \n\nthe stretch, pinches up the loose tissues at the outer canthus, \n\nuntil the margins of the two lids fit each other, marking with \n\nink the boundaries thus included. He then inserts a horn or \n\nivory spatula between this portion of the lids, and, beginning \n\nat the outer canthus, makes a crescent-shaped incision along \n\nthe previously-marked boundary, through the skin and cellular \n\ntissue, to the point where the two lids should meet. He then \n\nshaves off this portion of the lids, including its cilia, as far \n\nback as the outer canthus, being careful not to leave any of \n\nthe hair follicles behind, as these would grow again. The two \n\nraw surfaces are then brought together, and secured by three \n\nor four interrupted sutures. In order to lessen the strain upon \n\nthe sutures, adhesive strips may be applied in such a manner \n\nas to draw the integuments towards the junction of the lids, \n\nwhich should be that of a straight horizontal line. When \n\nthere is a marked difference in the length of the tarsal edges, \n\nit is generally necessary before completing the operation, in \n\norder to prevent a bulging of the fascia and cartilage, under \n\nthe sutures, to excise a portion of the latter, in shape like an \n\nItalic V ; the edges of the incision should then be included in \n\nthe suture. \n\nFor ectropium resulting from cicatrices near the margin of \n\nthe lids, and causing their eversion by traction, a great variety \n\nof operations has been devised, most of which are simple \n\nmodifications of the following, which is known as DiefTen- \n\nbach\'s :\xe2\x80\x94 The cicatrix, or so much of it as may be necessary, \n\nis removed by a triangular-shaped incision, the base of which \n\nis turned towards the ciliary margin, and the apex to the \n\ncheek. The incision which forms the base of the triangle, is \n\nthen extended on each side at right angles to the sides of the \n\nformer triangle, and the flaps thus formed are raised a little \n38 \n\n\n\n298 PRACTICE OF MEDICINE. \n\nfrom the subjacent parts, brought together so as to fill the \ntriangular space previously occupied by the cicatrix, and the T- \nshaped wound thus formed united by fine sutures. In case the \nciliary margin remains too much relaxed, tarsoraphia may be \nadvantageously united with this operation. \n\nFor such exceptional cases of ectropium and lagophthal- \nmos as will not admit of being successfully treated by the \nabove operations, the reader is referred to the larger works on \nophthalmology, particularly those of Wells and Stellwag, \nwhere he will find a great variety of blepheroplastic operations \nfully illustrated and described. \n\n5.-TRICHIASIS. \n\nThis is a disease in which the eyelashes are inverted, or \nturned inward toward the globe. The malposition may affect \nthe whole or only a portion of the cilia, which are always more \nor less degenerated and distorted. Supernumery cilia are \nnot uncommmon in these cases, as many as four or five having \nbeen found to spring from the same hair-follicle. These gen- \nerally have the appearence of new hairs, being for the most \npart short, fine and colorless. In some cases the cilia appear \nto be arranged in two distinct rows, and then the disease is \ncalled distichiasis. The misplaced cilia are generally turned \ninwards, and by constantly sweeping against the globe excite \nconsiderable irritation, which is accompanied, in some cases, \nby severe lachrymation and photophobia. If the abnormal \nfriction is allowed to continue, vascular keratitis sets in, and \nthis is followed by pannus. It may also cause severe spasm \nof the lids, which in turn may give rise to some degree of \nectropium. \n\nETIOLOGY. \xe2\x80\x94 The most frequent causes of trichiasis are \nthose which give rise to structural changes in the edges of the \nlids, such as blepharitis ciliaris, purulent and granular ophthal- \nmia, cicatricial contractions, etc. \n\nTreatment. \xe2\x80\x94 This is either palliative or radical. The \n\n\n\nTRICHIASIS. 299 \n\npalliative treatment consists in removing the misdirected cilia, \nas fast as they grow, with forceps. If this treatment is con- \ntinued for a sufficient length of time, it may finally result in \natrophy of the hair-follicles, and thus prove radical ; but as a \ngeneral rule the cilia continue to grow, and require to be ex- \ntracted as often as they are reproduced. The radical treatment \nconsists in either giving to the cilia a more natural and harm- \nless direction, or else in extirpating the bulbs of the inverted \nlashes. The latter is generally the most successful method ; \nbut the loss of the cilia is so disfiguring to the patient, \nespecially in the upper lid, that the operation should, if possi- \nble, be avoided. Sometimes we can succeed in turning the \ncilia away from the globe, by merely pinching up a fold of the \nintegument near the ciliary border, and excising it. When \nthis will answer the purpose, it is the best plan to adopt, as it \nnot only preserves the cilia, but the success of the operation is \nconfirmed by the subsequent contraction, and the subsidence of \nthe irritation and swelling. If this fails to meet the indication, \nwe may frequently succeed by first making perpendicular incis- \nions down to the cartilage at the extremities of the trichiasis, \nand then uniting them at the ciliary margin by carrying an in- \ncision along the edge of the lid, between the meibomian ducts \nand cilia ; after which sufficient of the integuments should be \nexcised to evert the cilia, and with them any coexisting entro- \npium. If this procedure, which is a modification of Von \nGraefe\'s operation, will not suffice, then the best method, not- \nwithstanding the resulting deformity, is to remove the hair \nbulbs. This operation is both tedious and painful, especially \nwhen a considerable number of the cilia are misplaced, and \ntherefore it is better to perform it when the patient is under the \ninfluence of chloroform. A horn or any other suitable spatula is \nfirst placed under the lid, and is held there by an assistant, \nwho at the same time raises the lid from the globe, and causes \nits edge to be somewhat everted. Then the edge of the lid \nis split, or divided into two layers, to the depth of about two \n\n\n\n300 PRACTICE OF MEDICINE. \n\nlines, with a scalpel or other suitable knife, (PI. I, Fig. 22), \nbeing careful not to continue the incision into the lachrymal \npuncta. The incision should be made close to the surface of \nthe cartilage, so that all the hair-follicles may be included in \nthe anterior layer. The integument is then divided behind the \nhair-bulbs, by a horizontal incision extending down to the \nfascia, which, if the trichiasis involves the whole of the lashes, \nshould meet the free border of the lid at an obtuse angle, two \nlines beyond the commissure. The portion thus included may \nthen be liberated with a few touches of the scalpel ; and if any \nof the hair-bulbs still remain, they should be carefully excised, \notherwise some of the cilia will be reproduced. Sutures are \nnot required, but a wet compress should be applied, and in a \nfew days the wound will be healed. Should there have been \nany coexisting entropium, or rolling in of the edge of the \nlid, it will be corrected by contraction of the cicatrix. \n\n6.-XEE0PHTHALMIA. \n\nThis affection, sometimes called xerosis conjunctivae, con- \nsists in a dry or cuticular state of the conjunctiva, which loses its \ncharacter of a mucous membrane, and no longer secretes. \nThe surface of the membrane becomes rough, scaly, and of a \ngreyish-white color, being sometimes finely granulated, at \nothers resembling cicatricial tissue. The opposed surfaces are \nso dry, rough and stiff, as greatly to hinder the movements of \nboth the eye and lids ; and this is still farther increased by \ncontraction of the conjuctiva, and by a greater or less accum- \nulation of hardened epitheliel scales within the narrowed \nconjunctival sac. In the great majority of cases, also, there \nis partial symblepharon, the lids adhering to each other and to \nthe caruncula ; the puncta are frequently obliterated ; and the \nupper lid is sometimes so much shortened, that the eye cannot \nbe shut, producing the state of lagophthalmus. When the \nglobe or lids are moved, the ocular conjunctiva is thrown into \nfolds round the cornea. No moisture is perceived on rubbing \n\n\n\nPTERYGIUM. 301 \n\nthe cornea, the surface of which is generally rough, uneven, \nand greatly deficient in sensibility. The cornea is generally \nobscure, the opacity being so great, in some cases, that the \ncolor of the iris and the state of the pupil cannot be recog- \nnized. Not only the cornea, but also the conjunctiva, becomes \nanaesthetic, dust and dirt accumulating between the lids, and \nexciting little or no irritation. \n\nEtiology. \xe2\x80\x94 This incurable affection is generally caused \nby chronic granular conjunctivitis ; and is most apt to result \nfrom neglected or badly treated cases, especially when deep \nscarification and too severe caustics are employed. It also \nfollows diphtheritic conjunctivitis, especially when the latter is \nattended with sloughing. Symblepharon accompanied with \nsevere inflammation, trichiasis, entropium, logophthalmos, and \ninjuries resulting from burns, strong acids, etc., are among the \nless frequent, but occasional causes. \n\nTreatment. \xe2\x80\x94 This is merely palliative, the best we can do \nbeing to mitigate, or temporarily relieve the dryness of the \nconjunctiva, by the frequent use of some bland fluid, such as a \nweak solution of glycerine, milk, artificial serum, etc. These \ncollyria act beneficially by washing away the hardened epithe- \nlium from the surface of the cornea, and thus render the latter \nmore transparent. \n\n7.-PTERYGIUM. \n\nThis term, which is derived from a Greek word signifying \na wing y is used to denote an hypertrophied condition of the \nconjunctival and episcleral tissues. It is usually situated at \nthe inner canthus, and is of a triangular form, the base at the \nsemilunar fold, and the apex near the margin of the cornea, \ntowards the centre of which it gradually advances. It presents \nmore or less of a tendinous or fibrous structure, and is traversed \nin the direction of its length by numerous nearly parallel \nbloodvessels. It is divided into two principal forms, according \nto the greater or less degree of hypertrophy exhibited at \n\n\n\n302 PRACTICE OF MEDICINE. \n\ndifferent periods of its growth. While thin, transparent and \ndelicate, it is called pterygium tenue or membranaceum, but \nwhen it becomes thick and fleshy, it is termed pterygium \ncrassum or carnosum. It is generally somewhat loosely con- \nnected with the subjacent parts, so that it can be easily raised \nwith the forceps ; but if the conjunctival portion contains any \nconsiderable amount of ligamentous or tendinous tissue in its \nstructure, it is thereby rendered less yielding, and may even \nimpede to some extent the movements of the globe. \n\nPterygium usually occurs about the middle period of life, \nand makes its appearance quite insensibly, the disease \nfrequently making considerable progress before the patient is \naware of its existence. \n\nIts growth is generally very slow, the pterygium advancing \ngradually to the margin of the cornea, where its progress is \nsometimes arrested ; in other cases it extends more or less on \nto the cornea, but it seldom passes beyond the centre. The \ncorneal portion is less vascular and more compact and tendin- \nous than the conjunctival, especially the extreme point of the \npterygium, which not unfrequently appears round and bead-like. \n\nEtiology. \xe2\x80\x94 The chief cause of pterygium appears to be \nsome injury which irritates the ocular conjunctiva, such as may \nresult from prolonged exposure to wind, dust, heat, etc. \nHence its usual seat at the internal canthus, where the con- \njunctiva is most exposed to the operation of such agencies. \nHence, also, its frequent occurrence among the inhabitants of \nhot climates, and among sea captains, stone-cutters, masons, \netc. Pterygium may also result from phlyctenular keratitis, \nsuperficial ulceration of the margin of the cornea, or any other \ncause capable of giving rise to inflammatory hypertrophy of \nthe conjunctival and episcleral tissue. \n\nTreatment. \xe2\x80\x94 If the pterygium is small, or thin and \nvascular, it may yield to Arg. nit., Ars., Calc, Chin., Lach., \nNux mos., Psor., Ratan., Spig., Sulph., or Zinc, all of which \nhave proved beneficial in particular cases. But if the occupa- \n\n\n\nPTERYGIUM. 303 \n\ntion or habits of the patient are such as to favor its growth, it \nwill be necessary to abandon them before any internal treat- \nment will be likely to prove successful. If symptoms of \nsevere irritation exist, they should be allayed by appropriate \ntreatment ; and for this purpose much good sometimes results \nfrom the use of mild astringent collyria, especially if there is \nany catarrhal or other form of ophthalmia connected with it. \n\nBut if the pterygium is large and thick, and especially if \nit is composed of true connective tissue, these means are \ninsufficient, and we can only remove it by resorting to opera- \ntive procedures. But since these are not always perfectly \nsuccessful \xe2\x80\x94 the cicatrix or some portion of hypertrophied \ntissue remaining, which may even necessitate a further opera- \ntion \xe2\x80\x94 so long as the pterygium does not interfere, nor seem \nlikely to interfere, with vision, or with a free and unrestricted \nmovement of the globe, it should not be operated upon. On \nthe other hand, if the morbid growth has so far encroached on \nthe cornea as to impede vision, or if it should threaten to do \nso, and especially if its size and character are such as to limit \nto any considerable degree the movement of the globe, we \nshould remove the pterygium by one of the following methods: \n\n(1). Excision. \xe2\x80\x94 The patient having been brought under \nthe influence of an anaesthetic, the lids separated by the \nstop-speculum (PL II, Fig, 33), and the globe turned slightly \nin the direction of the pterygium, and there held by a^suitable \ninstrument, (PI. I, Fig, 16), the operator seizes the growth with \na pair of reliable forceps, and raises it sufficiently to pass a \npointed narrow-bladed knife (Fig. 13) under it, with which he \nfirst excises the corneal, and then the scleral portion, dissecting \nthe latter toward the palpebral fold to a distance of one and \na half or two lines from the margin of the cornea, thus far \nfollowing exactly the edges of the pterygium, and keeping \nclose to the surface of the cornea and sclerotica. From this \npoint the dissection is continued toward the base of the \npterygium, not by following the edges of the latter, as before, \n\n\n\n304 PRACTICE OF MEDICINE. \n\nwhich would form a triangular wound, but by two converging \nincisions, meeting in front of the reflection, so as to give the \nwound somewhat of a rhomboidal shape. Having removed all \nhypertrophied tissue, the edges of the wound should be closed by \ntwo or three fine sutures. A protective bandage should then be \napplied, and in three or four days the sutures may be removed. \n\n(2). Ligation. \xe2\x80\x94 The lids having been separated and the \nglobe fixed as above described, the operator raises the ptery- \ngium with a pair of forceps, and passes a fine curved needle, \narmed with a double silk ligature, beneath it from border to \nborder, first near the margin of the cornea, and afterwards at \nthe base of the pterygium. The thread now forms a double \nloop on one side of the pterygium, by cutting one thread of \nwhich, the ligature, after the removal of the needle, is divided \ninto three portions, an outer, middle, and inner one. The ends of \nthe inner thread are first tied, then those of the outer, and \nfinally the two ends of the middle one, which are both on the \nsame side of the pterygium. At the expiration of four or five \ndays, the ligated portion of the pterygium may be easily \ndetached with the forceps. \n\n(3). Transplantation. \xe2\x80\x94 This operation, which was first \nintroduced by Desmarres, and afterwards greatly improved by \nKnapp, is now generally performed in the following manner : \xe2\x80\x94 \nThe corneal portion of the pterygium is first dissected off, and \nexcised. Two curved incisions are then made in the direction \nof the retro-tarsal folds, from the upper and lower borders of \nthe base of the pterygium. The latter is next divided into \ntwo equal portions by a horizontal incision extending to its \nbase. After this, two small conjunctival flaps are formed, one \non either side of the wound, for the purpose of covering it. \nThe contraction of the flaps causes the two curved incisions to \ngape sufficiently to receive the corresponding halves of the \npterygium, where they are secured by fine sutures. Finally, \nthe conjunctival flaps are brought together over the former \nseat of the pterygium, and there united. \n\n\n\nDISEASES OF THE EYE. 305 \n\n8.-0PACITIES OF THE COENEA. \n\nUnder the head of Keratitis will be found a general \ndescription of the nature, situation, and extent of the various \nforms of corneal opacity. They may be summarized as \nfollows : \n\n(1). Epithelial or Nebulous Opacities. \xe2\x80\x94 These are thin and \nsuperficial, appearing like a mist or cloud upon the surface of \nthe cornea. They are sometimes so fine as to be extremely \ndifficult of detection, unless the cornea is examined with a \nconvex lens or by lateral illumination. \n\n(2.) Parenchymatous Opacities. \xe2\x80\x94 These thicker and \ndeeper-seated forms of opacity are named, from their color, \nleucoma. When "complete," the entire cornea has a whitish or \nbluish-white appearance, very much resembling the sclera, the \nsurface frequently retaining its normal lustre. When "partial," \nthe opacity is more or less cloud-like, the border being irregular, \nand gradually shaded off into the unaffected portions of the \ncornea. The color varies from a greyish or bluish transparency \nto a yellowish, or even chalky-white tint. \n\n(3). Tendinous or Cicatricial Opacities. \xe2\x80\x94 These are more \nor less superficial, according to the depth of the original ulcer. \nThey generally have a tendinous or glistening-white appear- \nance, especially the central portions. The edges are frequently \nindistinct, owing to their being surrounded by an epithelial \ncloudiness, the result of recent inflammatory changes, which \nin the course of time becomes absorbed. \n\n(4). Calcareous Opacities. \xe2\x80\x94 These opacities, consisting of \nthe carbonate and phosphate of lime, are of a brownish tint. \nThey are situated just under the epithelium, and have an \nirregular and somewhat indistinct outline, shading off more or \nless gradually into the normal transparent cornea. \n\nPROGNOSIS. \xe2\x80\x94 This depends chiefly upon the duration, \nnature, and extent of the opacity. When recent, and especially \n\n\n\n306 PRACTICE OF MEDICINE. \n\nwhen occurring in young and vigorous patients, they almost \nalways disappear sooner or later without treatment. Ten- \ndinous and cicatricial opacities never disappear altogether ; \nbut at first they are generally surrounded by a cloudy border, \nwhich clears up in the course of time, the remaining opacity \nbeing lessened in extent, and its effect on vision greatly \ndiminished. \n\nTreatment. \xe2\x80\x94 The cure of recent cases of corneal \nopacity is frequently hastened by the internal use of the \nfollowing remedies. \xe2\x80\x94 Apis, Cannab., Chel., Crotal., Euph., \nHep., Merc, Puis, n., Rhus and Sulph. Even old cases of \nleucoma are reported to have -been greatly benefited by the \npersistent administration of Ac. nit., Aur., Calc, Cup. al., \nHep., Kali bic, Kali iod., Merc, Nat. sul., Sil., Spong., and \nSulph. Of these, the following have also been employed \nexternally : \xe2\x80\x94 Cup. al., Kali bic, Kali iod., Merc, and Nat. sul. \nThere being no characteristic eye symptoms in these cases by \nwhich to make the selection, the indications will have to be \nsought for in other organs ; but if there is no derangement of \nthe patient\'s health to guide us, we may, if all inflammatory \nsymptoms have disappeared, endeavor to promote absorption \nby the cautious use of irritants, such as Merc, dulc, Nat. sul., \netc, a small quantity of which may be daily dusted into the \neye. Or we may make use of irritating collyria, beginning \nwith weak solutions of the sulphate of zinc or copper, and \neither changing or gradually strengthening them as the eye \nbecomes accustomed to their use. For this purpose we have \ngenerally found nothing better than a collyrium of Kali iod, \n(grs. ij \xe2\x80\x94 v ad \xc2\xa7 j). The action of these agents is often \nincreased by the instillation of Atropine, which promotes \nabsorption by diminishing the intra-ocular tension. Calcareous \nopacities should be carefully scraped off with a scalpel, as \nrecommended by Dixon and Bowman. As this is a very \npainful operation, and denudes the cornea of epithelium, it \n\n\n\nSTAPHYLOMA OF THE CORNEA. 30? \n\nshould be done with the greatest care, and only a small \nquantity removed at a time ; a little olive or other bland oil \nbeing afterwards applied to the eye. \n\nIn old and incurable cases, vision may sometimes be \nimproved by diminishing the intensity of the diffused light by \nmeans of stenopaic spectacles. These are so constructed as \nto permit only the central rays to pass, thus cutting off the \nirregularly refracted rays from the periphery. These specta- \ncles, while they often answer very well for near objects, as in \nreading, writing, sewing, etc., are not adapted to general use, \nthe field of vision being too much contracted to permit of \nfreely moving about, as in walking, driving, etc. \n\nIf these means fail of restoring serviceable vision, then our \nonly resource is an artificial pupil, made behind a transparent \npart of the cornea ; selecting for this purpose the operation of \niridectomy, iriodesis, iridoenkleisis, or corydialysis, according \nas one or the other may best suit the condition of the cornea \nand the optical principles involved in the case. See Operations \nfor A rtificial Pupil. \n\n9.-STAPHYL0MA OF THE COENEA. \n\nThere are three principal forms of corneal staphyloma, \nnamely, (i), kerato-conus, or conical cornea; (2), kerato-globus, \nor buphthalmos ; and, (3), staphyloma of the cornea and iris. \nThe first two forms are chiefly due to a weakening and thin- \nning of the corneal tissue, and the last to ulceration and \nsloughing of the cornea, followed by prolapse and subsequent \nadhesion of the iris. \n\nA.\xe2\x80\x94 Conical Cornea. \n\nKERATO-CONUS. \n\nThis form of staphyloma, if considerable, may be easily dis- \ntinguished by viewing the eye in profile, when the conical shape \n\n\n\n308 PRACTICE OF MEDICINE. \n\nof the cornea will be readily perceived. Slight cases, however, \nmay be either entirely overlooked, or mistaken for amblyopic \nforms of myopia, unless we make an ophthalmoscopic examin- \nation, when the smallest amount of conicity may be detected. \nIn these examinations we use only the mirror, through which, \nif we view the cone exactly in the line of its axis, all the \nlight will be reflected, and we shall see a bright red space, \nsurrounded by a dark zone, and this again surrounded by \nanother circle, which is red. If viewed obliquely, the part of \nthe cone opposite to the light will be darkened. If we \nexamine the interior of the eye, we can only see a small \nportion of the fundus ; while the retinal vessels and the border \nof the optic nerve entrance appear distorted and more or less \nindistinct. The slightest movement of the eye or mirror \ngreatly increases the distortion, the irregular refraction through \nthe cornea frequently giving a curled or twisted appearance to \nthe vessels, and also to the border of the optic disc. \n\nVision is always more or less impaired, and, in many \ncases, is insufficient to serve any useful purpose, the distortion \nand confusion of the retinal images being too great to admit \nof much improvement by any kind of stenopaic apparatus. \nMoreover, the apex of the cone seldom remains transparent, \nbut sooner or later becomes hazy or opaque, and, in some cases, \neven tendinous or cicatricial. \n\nEtiology. \xe2\x80\x94 Inflammation is supposed to be one of the \nchief causes of kerato-conus ; but it cannot be the sole cause, \nas many cases occur in which no signs of inflammatory action \never appear. Neither is the bulging forward of the cornea due \nto intra-ocular pressure, for such eyes are almost always ab- \nnormally soft. It appears to be due, rather, to a weakening \nand thinning of the cornea, the latter becoming more and \nmore attenuated as the staphyloma increases. \n\nPrognosis. \xe2\x80\x94 The development of conical cornea is gen- \nerally very slow. It is often interrupted in its course, stop- \n\n\n\nSTAPHYLOMA OF THE CORNEA. 309 \n\nping short at a certain point, then resting, perhaps, for years, \nand then increasing again without any apparent cause. Or it \nmay cease at any stage of development and become perma- \nnently stationary. It is a singular circumstance in these cases \nthat, however thin the apex of the cone may become, it never \ngives way unless it is accidentally ruptured. The disease is \nseldom monocular, but generally affects both eyes, either sim- \nultaneously or in succession. \n\nTreatment. \xe2\x80\x94 It is highly probable that the progress of \nkerato-conus may, in some cases, be checked by the persistent \nuse of proper homoeopathic remedies, even in cases in which \nthere is no co-existing inflammation ; but, as yet, we are \nobliged to confess that we know of no internal remedy on \nwhich we can place reliance as a curative agent is these cases. \nIt is true that Drs. Allen and Norton, in their work on \'\'Oph- \nthalmic Therapeutics," say that Calc. iod. has seemed to act \nfavorably in their hands, and that "decided benefit has been \nobtained from its use in checking the progress of both conical \ncornea and staphyloma." The same remedy is even reported \nby H. Goullon to have cured a case of kerato-conus ; but this \nmay well be taken cum grano salts, as we cannot conceive of \nthe possibility of materially reducing the conicity of the cor- \nnea, except by incision, and this is generally very far from \nbeing a successful operation. Some diminution, however, may \nresult from lessening the intra-ocular pressure by means of an \niridectomy ; and, as we may in this manner possibly arrest the \nprogress of the disease, and at the same time improve the \nvision, by making a pupil opposite the peripheral portion of \nthe cornea, where it still retains, to a great degree, its normal \ncurvature, it is the operation most frequently performed. The \niridectomy should be of only moderate size, and, as suggested \nby Wells, should be made slightly upwards and inwards, so \nthat a part of the base of the artificial pupil may be covered \nby the upper lid. When the conicity of the cornea is slight \n\n\n\n3IO PRACTICE OF MEDICINE. \n\nand almost stationary, some prefer an iridodesis to an iridec- \ntomy, with a view of displacing the pupil towards a portion of \nthe cornea which is less abnormally curved, so as to lessen the \ndiffusion and irregular refraction of the rays passing through \nit. Others, again, make an iridodesis on opposite sides of the \npupil, so as to change the latter into a long, narrow slit, with a \nview to render the aperture stenopaic ; but the operation is \nsaid to offer no advantages over the ordinary method. \n\nB\xe2\x80\x94 Kerato-Qlobus. \n\nBUPHTHALMOS. \n\nIn this disease the entire cornea, and generally the ante- \nrior portion of the sclerotica also, are bulged forward in such \na manner as to give a uniform spherical curvature to the cor- \nnea, and a greater or less increase in the size of the whole an- \nterior portion of the eyeball. This increase is often so consio^ \nerable as to present an appearance similar to that of exoph- \nthalmos, the front portion of the globe protruding between the \nlids, and giving to the eye a peculiar staring expression, whence \nit has derived the name of buphtlvalmos . The effect of the \nenlargement is to increase the size of the anterior chamber in \nevery direction. Hence the disease was for a long time re- \ngarded as a dropsy of the anterior chamber {Jiydr ophthalmia \nanterior). The iris is stretched so as to be proportionally en- \nlarged, the fibres appearing slightly separated, especially \ntowards the ciliary margin. It is frequently somewhat cupped, \nparticularly in a backward direction, and is occasionally tremu- \nlous, perhaps from losing the support of the lens, which is \nsometimes dislocated. The pupil is usually dilated and slug- \ngish, and more or less of its margin is sometimes adherent to \nthe anterior capsule. The cornea may remain entirely trans- \nparent ; but, in most cases, it is more or less clouded, especially \n\n\n\nSTAPHYLOMA OF THE CORNEA, 311 \n\non the periphery, and, in some instances, it is uniformly and \ndensely opaque. As the disease progresses, glaucomatous \nsymptoms supervene ; the tension increases, the optic disc \nbecomes excavated, the lens is rendered opaque, the vitreous \nseparates and becomes fluid, detachment of the retina occurs, \nand atrophy finally ensues ; or else, in consequence of the \nthinning of the anterior portion of the globe, the ball becomes \nruptured. In either case, the disease is almost certain to ter- \nminate, sooner or later, in complete blindness. \n\nETIOLOGY. \xe2\x80\x94 The etiology of this disease is somewhat \nobscure. It does not appear to be due to the increased intra- \nocular pressure, since glaucomatous symptoms do not generally \ngive rise to bulging of the cornea. Neither does it arise from \nan increased secretion of the aqueous humor. It must, there- \nfore, either originate in such an abnormal condition of the \ncornea as would constitute a predisposition to the disease, or \nelse it must result from a weakening and thinning of the cor- \nneal tissue in consequence of some severe inflammation, such \nas vascular keratitis or pannus. The latter is probably the \nchief factor in its production in most cases. \n\nTreatment. \xe2\x80\x94 This is similar to the treatment recom- \nmended for Glaucoma (which see). \n\n\n\nC. \xe2\x80\x94Staphyloma of the Cornea and Iris. \n\nThis form of staphyloma is one whose walls are compos- \ned, either wholly or in part, of cicatricial tissue, and is gener- \nally the result of ulceration. Partial staphyloma is, in the \nmajority of cases, only an advanced stage of what is called \nstaphyloma tridis, or prolapse of the iris. As the latter usually \noccurs during the inflammatory process, the prolapsed iris soon \nbecomes covered with lymph, which gradually assumes a cica- \ntricial character, and, being weaker or more extensible than \n\n\n\n312 PRACTICE OF MEDICINE. \n\nthe normal cornea, readily yields to the intra-ocular pressure, \nand gives rise to "partial" staphyloma. The growth of the \nstaphylomatous protrusion is generally slow and subject to \nmany interruptions ; but, if not permanently checked, it may \ngradually extend until it involves a considerable portion of the \ncornea ; and, if the original perforation was extensive, it may \neven implicate the whole of the corneal tissue, and thus be \ntransformed into a "total" staphyloma. The walls of the pro- \njection may preserve, to a great degree, their former transpa- \nrency and delicacy, in which case, either through mechanical \nviolence or a sudden contraction of the recti muscles, they fre- \nquently burst. But, in most cases, as the staphyloma enlarges \nthe walls increase in thickness, and, when it protrudes between \nthe lids, the external irritation frequently excites more or less \ninflammatory action, which tends still further to augment the \nsize of the morbid growth. \n\nETIOLOGY. \xe2\x80\x94 As already stated, the most frequent cause of \nstaphyloma of the cornea is ulceration. But it may also be \nproduced by wounds and injuries, or by any operation, such as \nflap extraction, which becomes complicated with prolapse of \nthe iris. Total staphyloma is frequently caused by ulceration \nor sloughing of the entire cornea. \n\nTREATMENT. \xe2\x80\x94 Internal remedies can have no beneficial \neffect upon staphyloma of the cornea, unless it be in retarding \nits development by lessening inflammatory action. In this \nway some good may possibly result, in particular cases, by the \nadministration of such remedies as the inflammatory compli- \ncations may specially indicate. The most approved treatment \nfor partial staphyloma, especially if recent, is iridectomy. \nThis operation at once lessens the intra-ocular pressure, and \nthus not only arrests the bulging of the* cornea, but may also \ncause it to diminish in size. At a later stage of the affection, \nglaucomatous symptoms may set in, and then, of course, iri- \ndectomy should on no account be omitted. Fortunately for \n\n\n\nSTAPHYLOMA OF THE CORNEA. 313 \n\nthe success of the operation, the place of election in these \ncases is generally opposite the most transparent portion of the \ncornea, namely, the periphery. In some cases of partial \nstaphyloma, it is advisable to combine iridectomy with the \nmethodical use of a pressure bandage ; but if, for any reason, \nthe latter is not well borne, or if it seems to excite pain or un- \neasiness within the eye, it had best be dispensed with, and the \neye simply shaded. \n\nTotal staphyloma does not admit of any restoration of \nvision, the only object of treatment being to improve the per- \ngonal appearance of the patient, and relieve him from an an- \nnoying and painful disfigurement by removing the projection. \n\nOf the numerous methods of operating in these cases, we \nshall only mention two, namely, (1) Excision and (2) Borelli\'s \noperation. \n\n1. EXCISION. \xe2\x80\x94 The lids being widely separated by an \nassistant, the point of a cataract knife (PL I., Fig. 29), with the \nedge turned downward, is made to penetrate the base of the \nstaphyloma in such a manner that, when pushed forward and \nmade to cut its way out, it shall divide the lower two-thirds of \nthe staphyloma in the plane of its base. The collapsed \ngrowth is then seized by forceps, and the remainder divided \nwith scissors ; or, if the operator prefers, a flap may be formed \nfrom it with which to cover the opening at the base of the \nstaphyloma. A pressure bandage is then to be applied, and \nthe resulting inflammation moderated by rest and the internal \nadministration of Aconite. \n\n2. Borelli\'s Operation. \xe2\x80\x94 This consists in transfixing \nthe tumor by two needles, in such a manner as to form a cross. \nA ligature is then passed round the staphyloma, behind the \nneedles or pins, and firmly tied. In the course of three or \nfour days the tumor generally sloughs off, and in a week or so \nafterwards the wound is healed. If the staphyloma is small \nor partial, its whole base should be included within the liga- \n\n\n\nV \n\n314 PRACTICE OF MEDICINE. \n\nture ; but if large or total, only a part of it should be em- \nbraced, and care should also be taken not to draw the ligature \ntoo tight, otherwise it may cut through the walls of the tu- \nmor, or suppurative choroiditis may supervene and destroy the \neye. \n\n1Q-ANTERI0E SCLERO-CHOROIDAL STAPHYLOMA. \n\nSclero-choroidal staphyloma may affect the anterior, later- \nal, or posterior portion of the sclerotica, but is mostly confined \nto the anterior and posterior zones. The latter has already \nbeen described under the head of "Sclero-Choroiditis Poste- \nrior." The former is no more a primary affection than the \nlatter, but is a secondary effect of an inflammation of the an- \nterior part or the whole of the uveal tract ; in other words, it \nmay proceed from a partial or total sclero-choroiditis. The in- \ncreased tension of the globe distends the sclerotica from with- \nin, while the resistance of the membrane is probably dimin- \nished by its participation in the inflammation. In this way \nthe sclerotica becomes thinned, and raised into prominences of \nvarious magnitude. These vary in size from that of a small \ngrain to a filbert ; or the whole anterior portion of the scle- \nrotica may be raised into one irregular, mulberry-like tumor \nround the cornea, and then the disease is called "Annular \nStaphyloma." As the staphyloma increases, the sclerotica be- \ncomes more and more atrophied and discolored, the affected \npart assuming a dusky, bluish-grey appearance, due to the \nshining through of the choroid. The growth of the tumor is \nsometimes very rapid, and is then usually attended with severe \npain and other symptoms of acute inflammation ; but, as a \ngeneral rule, the progress of the disease is very slow and grad- \nual, its course corresponding with that of the inflammatory \naffection on which it depends. When the latter becomes \n\n\n\nOPACITIES OF THE VITREOUS HUMOR. 315 \n\nchronic, the staphyloma generally remains stationary, or slowly \nprogresses ; but during periods of exacerbation, the eye be- \ncomes painful and the disease makes perceptible progress. \n\nTREATMENT. \xe2\x80\x94 During the early stages of the affection, \nthe treatment is the same as that for Choroiditis (which see). \nBut when the staphyloma has existed for some time, and is \nlarge, we may have to remove it by an operation. For this \npurpose we may adopt either of the methods described under \nthe head of "Staphyloma of the Cornea and Iris." \n\nII -OPACITIES OF THE VITEEOUS HUMOR. \n\nOpacities of the vitreous are of two distinct forms, or \nclasses \xe2\x80\x94 the diffuse, and the filiform or membranous. The dif- \nfuse variety presents itself in the form of a greyish mist or \nnebulosity, scattered here and there through the vitreous hu- \nmor, or spread out like a veil over the fundus, and giving a \nblurred appearance to the vessels of the retina and optic disc. \nThis form developes rapidly, extends quickly through the en- \ntire vitreous, and clears up just as quickly, appearing and dis- \nappearing from time to time, according to the condition of the \nvascular envelope of the vitreous, which serves as the develop- \ning membrane. When these changes occur very suddenly, \nthere is reason to apprehend the most serious consequences, as \nthey are frequently succeeded by detachment of the retina. \nIf, however, the inflammation on which the opacity depends \ntakes a permanently favorable turn, the vitreous may clear up \nand return to its normal condition \n\nAssociated with the diffuse form, we frequently meet with \nvarious circumscribed opacities, both filiform and membranous, \nconsisting of the debris of cells, or the remains of blood \neffusions, floating about in the vitreous, and assuming a great \nvariety of forms. Examined with the ophthalmoscope, they \nare seen to be dark, fixed or floating bodies, of a filiform, \n\n\n\n3l6 PRACTICE OF MEDICINE. \n\nreticulated or membranous character ; or they may be so fine \nand numerous as to give an obscure and hazy appearance to \nthe whole fundus. \n\nTreatment. \xe2\x80\x94 This to be successful must be directed to \nthe removal of the cause, which, as we have seen, is generally \nsome form of choroiditis, or other inflammatory affection of the \ndeeper structures of the eye. Arn., Gels., Ham., Kali iod., \nLach., Merc, and Sulph. have acted very favorably in many \ncases, and are worthy of special attention. Ars., Bell., Caust., \nKal., Lye, Phos., Prun., SiL, and Sol. n. have also been recom- \nmended, and deserve notice. The absorption of opacities \narising from extravasation of blood into the vitreous, has been \nhastened by the application of a compress bandage. Benefit \noften accrues, also, from attention to the general health, \nespecially when the affection is aggravated by some functional \nderangement of the system. \n\n12.-DETACHMENT OF THE RETINA. \n\nAMOTIO RETINA. \n\nDetachment of the retina occurs whenever serum is \neffused between it and the choroid. At first it is always \npartial, and confined to the periphery ; but it may afterwards \nspread in every direction, especially towards the optic disc. \nIt usually takes place in the lower half of the fundus, \nprobably in consequence of the fluid immediately gravitating \nto that part. The outline of the detachment, as viewed with \nthe ophthalmoscope, is generally somewhat irregular, varying \naccording to the amount of sub-retinal effusion. When the \ndetachment is large and prominent, it is frequently thrown \ninto folds, which are usually most conspicuous near the \ncircumference of the fundus, on which they sometimes cast a \ndistinct shadow. The color of the detached retina, which \n\n\n\nDETACHMENT OF THE RETINA. 317 \n\nchiefly depends upon that of the fluid beneath, is of a yellowish, \ngreenish, or bluish-grey tint, and often exhibits a marked \ncontrast with the usual bright red reflex of the normal retina. \nThese features of the disease are generally sufficiently \ndistinctive for the ready recognition of advanced cases ; but \nin very slight degrees of detachment, a much closer inspection \nis required to clear up the diagnosis. We notice, first, that the \nvessels are darker than those on the normal retina ; that they \nbend more or less abruptly over the border of the detachment, \nand pursue a crooked and tortuous course on the folds, \nbetween which they frequently disappear; that they quiver \nwith every movement of the undulating membrane ; and that \nthey are somewhat closer to the observer than those on the \nnormal retina. We notice also that those appearances are \ngenerally more conspicuous the nearer we approach the \ncircumference of the fundus. \n\nVision is impaired in proportion to the degree of detach- \nment. The patient first notices a faint cloud waving before \nhim, at a point in the field of vision corresponding to the \nsub-retinal effusion. Hence, if the detachment occurs in the \nlower half of the fundus, the obscurity will be in the upper \nhalf of the visual field, and vice versa. Objects generally \nseem more or less distorted, exhibit slight wave-like or undula- \ntory movements, and appear bordered with a colored ring. \nThe sight is likewise disturbed with photopsies, arising from \nretinal irritation; and also by movable opacities of the vitreous, \nwhich appear as black specks and spots, of various sizes and \nshapes, floating about in the field of vision. \n\nEtiology. \xe2\x80\x94 The causes which give rise to detachment \nof the retina are not always manifest. Sometimes it can \nbe traced directly to a blow or fall. In other cases it is \nfound to arise from intra-ocular hemorrhage, occurring in \nthe course of some inflammatory affection of the choroid \nor retina. Thus, we have seen it to occur very frequently \n\n\n\n3l8 PRACTICE OF MEDICINE. \n\nin the course of sclero-choroiditis posterior, in consequence \nchiefly of the elongation of the optic axis, which, by causing \na separation of the vitreous, favors the detachment of the \nretina. It is also frequently associated with retinitis, \nespecially the exudative variety. \n\nPROGNOSIS. \xe2\x80\x94 This is mostly unfavorable. Occasionally, \nslight detachments may remain stationary, or may even \ndisappear, the sub-retinal fluid becoming absorbed, and the \naffected membrane regaining its functions. But such favorable \nresults are not to be expected. In the vast majority of cases \nthe disease is progressive, the detachment slowly extending, \naccompanied by frequent inflammatory attacks and exacerba- \ntions, until finally it terminates in total blindness. When the \ndetachment is the result of accident, the disease is generally \nlimited to one eye, and is much more favorable;* but when \nassociated with myopia, or when it depends upon sclero- \nchoroiditis posterior, each eye is usually affected, the same \ncause operating in both. \n\nTreatment. \xe2\x80\x94 If seen shortly after the detachment \noccurs, the patient should be confined to his room, and if \npossible, to his bed. The eyes should also be carefully ban- \ndaged, as this not only serves to exclude the light, but hastens \nabsorption. Atropine should be immediately instilled, chiefly \nwith the view of preventing accommodation ; but its use \nshould not be pushed too far, as the sudden reduction of the \nintra-ocular pressure is liable to excite temporary hyperaemia \nof the vessels of the choroid and retina, and by causing an \neffusion of blood, increase the detachment. \n\nGelseminum is one of our most promising internal \nremedies for this affection, rapidly promoting absorption in \nrecent cases, both traumatic and inflammatory. Much benefit \nhas also been derived from the administration, in suitable cases, \nof Apis, Ars., Aur., Bry., Dig., Hep., Kali iod., Merc, and Rhus. \n\n\n\n*See Dr. Boynton\'s Case, p. 244, et. teg. \n\n\n\nHORDEOLUM. 319 \n\nTemporary improvement has been obtained by puncturing \nthe sac by means of a sickle-shaped needle, and permitting \nthe fluid to escape from beneath the retina. The needle is \npassed perpendicularly through the sclerotica behind the lens, \nand having penetrated seven or eight lines into the vitreous, \nits point is turned towards the detachment, which is then \ndivided as the instrument is withdrawn. Especial care must \nbe taken not to cause intra-ocular hemorrhage by wounding \nthe choroid. The operation, though unattended with any \nimmediate danger, is not always successful ; and as it appears \nin many cases to have "hastened the atrophy of the eye by \ninciting a degenerative irido-choroiditis," its usefulness as a \nremedial measure is, to say the least, very questionable. \n\n\n\nDIV. III. OPHTHALMIC TUMORS. \n\nIn the technical sense of the word, a "tumor" is "a cir- \ncumscribed substance produced by disease, and different in its \nnature from the surrounding Jparts." In a broader and more \ngeneral sense, however, the term may be used to denote any \nmorbid enlargement of a part, whether different in its nature \nfrom the neighboring tissues, or not ; and it is in this less- \nrestricted sense that we shall make use of it. \n\n1 -HORDEOLUM, OR STYE. \n\nThis miniature boil is too familiar to need particular de- \nscription. It is not, as was formerly supposed, an inflammation \nof a Meibomian gland, but of the connective tissue of the edge \n\n\n\n320 PRACTICE OF MEDICINE. \n\nof the lids. As a general rule, only one boil occurs at a time, \nbut in some cases there are several ; and it is no uncommon \nthing for one to follow another in regular succession, thus \nprolonging the disease for several months. The inflammation \nis generally confined to the immediate vicinity of the stye, but \nif highly acute it may extend to the entire lid, which becomes \nvery red and cedematous ; and even the ocular conjunctiva \nmay become inflamed and chemosed. In such severe cases \nthere is apt to be considerable feverishness and constitutional \ndisturbance. But generally the disease runs a less acute, and \nin some cases a chronic course ; and although the swelling is \nextremely sensitive to the touch, it soon terminates, either in \nresolution, or, which is more common, in suppuration, the pur- \nulent matter being discharged from the apex of the stye, \nmixed with small masses ol disintegrated connective tissue. \n\nHordeolum is generally regarded, and justly so, as an \nindication of an unhealthy state of the constitution. It is most \ncommonly met with in scrofulous and enfeebled subjects, or in \nthose whose health is broken down, especially individuals \nwhose constitutions are undermined by dissipation, or in whom \nthere co-exists some derangement of the digestive or uterine \norgans. \n\nTREATMENT. \xe2\x80\x94 If seen sufficiently early, we may bring \nabout resolution by the use of cold compresses and Aconite ; \nbut in most cases it is advisable to hasten the suppurative \nprocess by warm applications, giving at the same time Hepar \nor Pulsatilla internally, and subsequently, Graph., Staph., \nSulph., or Thuja. The following remedies are also useful in \npreventing the recurrence of styes : \xe2\x80\x94 Alum., Ambr., Caust, \nCon., Ferr., Lye, Merc, Nat. m., Phos. ac, Rhus, Seneg., Sep., \nSil., and Stann. \n\n\n\nDISEASES OF THE EYE. 32 1 \n\n\n\n2.-CHALASI0N. \n\n\n\nThis is a small tumor, or cyst, originating in the tarsus, \nand due to inflammatory or other changes of the Meibomian \napparatus. Its usual appearance is that of a small, rounded, \nisolated tumor, about the size of a pea, situated just beneath \nthe conjunctiva or skin, and at a little distance from the edge \nof the lid. It occurs most frequently in the upper lid, but \nsometimes in the lower one, and more rarely in both. It \noccasionally becomes inflamed and traversed by enlarged \nvessels ; and if the inflammation is very acute, it may give \nrise to suppuration and the formation of a small cystic abscess. \nIn most cases, however, the inflammation is of a chronic char- \nacter ; and the contents of the cyst, instead of being purulent, \nare sometimes glairy or gelatinous, sometimes curdy, and \nsometimes fatty or sebaceous. \n\nDebility seems to favor its development, as it is of frequent \noccurrence after confinement or prolonged nursing ; but its \nconnection with an impaired state of health is not so evident \nas in stye, with which it sometimes co-exists. It is of remark- \nably slow growth, many months elapsing before it attains its \nfull development. \n\nTreatment. \xe2\x80\x94 If the tumor is soft and recent, we may \nsometimes cure it by administering Merc, precip. rub., or Kali \niod., internally, at the same time that we use an ointment of \nthese remedies externally. We have known the tumor to dis- \nappear without treatment, but this is a rare occurrence. In the \nmajority of cases, even after the faithful use of indicated rem- \nedies and due attention to the general health, we have been \nobliged to resort to the knife. The operation is very simple. \nThe lid having been everted, a crucial incision is made into the \ntumor with a scalpel or narrow knife, and if the contents are \nnot sufficiently fluid to escape at once, they may be pressed \nout with the fingers, or scooped out with any convenient instru- \n\n\n\n322 PRACTICE OF MEDICINE. \n\nment. No after-treatment is generally required. It is well to \ninform the patient that he should not expect any reduction in \nthe size of the tumor for several days, and that the swelling \nmay even undergo a temporary increase, from bleeding within \nthe cyst. The inflammation excited by the operation will \ncause contraction, and in the course of two or three weeks, the \ncyst, and the thickened tissues around it, will disappear. If \nthe tumor return, which is very rarely the case, the operation \nshould be repeated, taking care to excite sufficient adhesive \ninflammation to insure the obliteration of the cyst, by lightly \ntouching its interior with a pointed crayon of nitrate of silver ; \nor, what is frequently more convenient, by dipping a silver \nprobe in nitric acid and cauterizing the cavity with the nitrate \nof silver thus extemporaneously prepared. \n\n\n\n3 -DERMOID TUMORS. \n\nThese were formerly called warts, moles and liorns. The \nformer are usually small, roundish and projecting. They are \nof various degrees of consistency, some being quite soft and \nfleshy, while others are hard and cartilaginous. They also \nvary greatly in color, being in some cases white, in others yel- \nlowish, red, reddish brown, or dark brown. The surface of the \nwart or mole is sometimes smooth, sometimes rough or granu- \nlar, and sometimes it has a number of short and delicate, or \nlong and coarse hairs springing from it. These tumors con- \nsist, according to Virchow, "of a pad of connective tissue and \nelastic filaments, covered by a thick layer of epithelium, in \nwhich are situated the hair-follicles, either with or without \naccompanying sebaceous glands." They may be confined to \nthe ciliary margin or to the outside of the lid, or they may \noccupy both. They also occasionally appear on the conjuncti- \nva, in the form of small, flesh-colored tubercles, either singly \n\n\n\nSEBACEOUS TUMORS. 323 \n\nor in clusters. These mucous warts bear a strong resemblance \nto those that occur on the prepuce. Dermoid tumors of a pale, \nwhitish-yellow color, one or two lines in diameter, smooth or \nlobulated, and either with or without projecting hairs, are also \nsometimes met with on the cornea. \n\nThe so-called "horns," according to Wilson, are "accretions \nof inspissated sebaceous matter on the edges of the lids, which \nowe their origin to the drying and hardening, as fast as it es- \ncapes, of the contents of the follicles that furnish the material \nfor their growth." \n\nTREATMENT. \xe2\x80\x94 Dermoid tumors are mostly congenital, and \ngenerally require excision. Warts on the lids are said to have \ndisappeared under the use of one or more of the following \nremedies, and if the patient is averse to having them snipped \noff, which is a very trifling operation, there can be no harm in \ntrying them : Bar. c, Calc. c, Caust., Hep., Nit. ac, Kali bic, \nLye, Sep., SiL, Sulph. and Thuja. \n\n\n\n4.-SEBACE0US TUMORS. \n\nThese are generally met with in infants and young child- \nren. They appear most commonly at the upper margin of the \norbit, near the external extremity of the eyebrow, but they are \nsometimes seen at the internal or nasal end. When first no- \nticed they are about the size of a small pea, and are so loosely \ncovered by the integument that the latter may be easily \npinched up into a fold. They always grow very slowly, are \nunattended by pain or redness, and seldom attain any consid- \nerable magnitude, the largest not exceeding an inch or so in \ndiameter. When opened they are found to consist of a com- \npact cyst, the posterior wall of which is somewhat thickened, \nand generally adherent to the periosteum of the orbit. The \ncontents of the cyst are sebaceous, containing fat molecules \n\n\n\n324 PRACTICE OF MEDICINE. \n\nand broken-down epithelial cells, mixed in varying proportions \nwith short and imperfectly-formed hair. The tumor appears to \nbe congenital. \n\nTreatment. \xe2\x80\x94 The proper treatment of sebaceous tumors \nis operative. Perhaps by a careful selection of our drugs, \nbased chiefly upon constitutional symptoms, we may, in some \ncases, effect their absorption ; but we have never witnessed \ntheir removal in this way, and unless the general health can \nbe benefited by it, it is not worth while to waste time by de- \npending upon medical treatment. If, however, the patient is \nopposed to operative procedures, we may try the following \nremedies, which have received the endorsement of able physi- \ncians : Bar. c, Calc. c, Graph., Hep., Nit. ac, Sil., and Sulph. \n\nSebaceous, like other subcutaneous cystic tumors, should \nbe carefully dissected out, or rather eneucleated, the handle, \ninstead of the edge, of the knife being used whenever practica- \nble ; for if the cyst be opened and its contents allowed to es- \ncape, the accident will greatly increase the difficulty of remov- \ning the whole of the tumor. If this should happen, however, \nit will be advisable to lighly cauterize the remaining portions \nof the cyst with nitrate of silver, in order to prevent the return \nof the tumor. \n\n5.-CYSTI0 TUHOBS. \n\nVesicular and other cystic tumors, the contents of which \nare sometimes watery and sometimes glairy, frequently occur \nabout the lids. When of long standing, they are often more or \nless pedunculated, and either overlap the edge of the lid or ex- \ntend back into the orbit. They are usually connected with \nsome portion of the conjunctiva, forming, for the most part, \nsmall, pinkish, translucent tumors, the walls of which are gen- \nerally very thin, and but loosely connected with the conjunc- \ntiva. \n\n\n\nCYSTIC TUMORS. 325 \n\nCysts of the iris are less frequently met with, and are \nusually the result of some injury to that membrane. They \ngenerally spring from the surface of the iris in the form of \nsmall vesicles, which may be either translucent or opaque. \nThe contents may be limpid and transparent, sebaceous and \nsoft, or hard and \xe2\x80\xa2cartilaginous. In most cases they excite \nconsiderable irritation and may even give rise to iritis. \n\nOrbital cysts also occur, some of which, as above stated, \nspring from the glandular structures of the conjunctiva, whilst \nothers are developed from the follicles of the lids. The \ncontents of these cysts are of the most varied character, serous, \nglairy, sanguinous, fatty, etc. Some also contain hair, others \nhydatids. The hydatids are the echinococci and the cysticerci. \nThe former, varying in size from a pea to a filbert, have been \nknown to exist in such quantities, that when emptied from the \ncyst they filled a tea cup half full. These tumors generally \ngrow very slowly, and when small are usually attended with \nbut little inconvenience ; but as they increase in size the \neyeball gradually becomes more and more protruded, and the \nsufferings of the patient are often most intense. \n\nThe cysticercus occurs most frequently within the eye. \nIt is occasionally seen in the anterior chamber, but its most \nfrequent seat is in or under the retina. At first it excites \nsevere irritation, but after a while the eye becomes accustomed \nto its presence, and it may remain for weeks and months \nwithout giving rise to any great inconvenience ; sooner or \nlater, however, it sets up violent inflammation, and the eye is \nfinally destroyed by irido-choroiditis. \n\nTreatment. \xe2\x80\x94 Vesicular and other small cystic tumors \ngenerally require nothing more than a simple puncture ; but \nwhen of a certain size the cyst must be removed or the tumor \nwill be pliable to return. Cysts of the iris will also require \nexcision, together with the portion of membrane to which they \nare attached, as simply puncturing or lacerating them proves \n\n\n\n326 PRACTICE OF MEDICINE. \n\nunsuccessful. \' It should be remembered, however, that this \noperation, even when combined with iridectomy, is not entirely- \ndevoid of danger, having in one instance given rise to severe \npurulent cyclitis. The greatest care should therefore be taken \nto guard against inflammatory complications, by removing \nevery portion of the cyst. Orbital cysts containing fluid \nshould be emptied of their contents, the operation being \nrepeated as often as may be necessary ; but other forms \nshould, if possible, be dissected out. \n\n\n\n6.-FATTY AND OTHER TUMORS. \n\n1. Milium. \xe2\x80\x94 This is a small white tumor, about the size \nof the head of a large pin, and is generally seated at or near \nthe edge of the lid. The cyst wall consists of a thin but \ndense membrane, containing a soft white substance like boiled \nrice. These tumors usually occur in elderly persons, and \noccasion little or no inconvenience, unless they happen to be \nnumerous, or appear in clusters. \n\n2. Moluscum. \xe2\x80\x94 This tumor is of the same nature as \nmilium, but larger, and generally seated a short distance from \nthe edge of the lid. It posseses little or no elasticity, \nretaining for some time any form into which it may be pressed. \nIn this respect it differs sensibly from the \n\n3. Fatty Tumor. \xe2\x80\x94 This is of frequent occurrence about \nthe eyelids, and is firm and elastic to the touch ; it is further \ncharacterized by being smooth, of a somewhat lobulated form, \nand of extremely slow growth. It is occasionally observed \non the ocular conjunctiva, especially in the vicinity of the \nlachrymal gland. In these cases it appears to be due to an \nhypertrophy of the adipose tissue of the orbit. Sometimes \nthese tumors attain such proportions as to displace the eyeball, \nand press injuriously upon the lachrymal gland. \n\n\n\nN^EVUS MATERNUS. 327 \n\n4. Polypi. \xe2\x80\x94 These are small condylomatous elevations, of \na pinkish color, attached to the conjunctiva by a distinct \npedicle, and generally seated near the semilunar fold They \nsometimes attain the size of a pea or hazel nut, and protrude \nbetween the lids. \n\nTreatment. \xe2\x80\x94 Milia and molusca simply require to be \npricked, and their contents squeezed out. In removing fatty \ntumors, care should be taken to sacrifice as little of the \nconjunctiva as possible, and to unite the edges of the incision \nby a fine suture. Polypi should be snipped off with scissors, \nand the hemorrhage arrested by touching the cut surface \nwith nitrate of silver, which will also be likely to prevent a \nreturn of the disease. \n\n\n\n7.-NJEVUS MATERNUS. \n\nTELANGIECTASIS. \n\nThis affection, the name of which is now restricted to \ncongenital tumors characterized by peculiar and excessive \nvascularity, is generally met with on the eye-brow and upper \nlid. It is also occasionally found on the conjunctiva, and \nvery rarely on the iris. These growths are generally divided \ninto an arterial or active, and a venous or passive form ; but \nthis distinction, is quite arbitrary, and we shall find it more \nconvenient to describe them according to the positions they \noccupy, as cutaneous, subcutaneous, and mixed. The cutan- \neous variety varies bqth in depth and extent, appearing in \nsome cases like a mere stain, and in others like a circumscribed \nmass of blood-vessels. The subcutaneous form, being deeper, \nis not so well defined, and is either colorless or of a light \nbluish tint, according to its depth from the surface. When \ndeep, it bears a close resemblance to the common fatty tumor. \n\n\n\n328 PRACTICE OF MEDICINE. \n\nMost naevi may be diminished in size by pressure, the blood- \nvessels being more or less emptied by it, but as soon as the \npressure is removed they refill. Some are firm and distinctly \npulsatile to the touch, while others are soft and impart no \narterial thrill to the fingers. They all become distended \nwhen the patient stoops, screams or struggles, and when \nsuperficial they assume at such times a very dark and tense \nappearance. On account of their vascularity, they also bleed \nprofusely on the slightest injury. \n\nTREATMENT. \xe2\x80\x94 Naevi after reaching a certain size frequently \nremain almost stationary ; in other cases they slowly diminish ; \nand sometimes they disappear altogether. Mere stains seldom \nundergo natural resolution, but the bluish superficial naevus is \nmore apt to disappear spontaneously than the scarlet variety. \nThe process is said to be hastened in some cases by the use of \nthe following remedies : \xe2\x80\x94 Calc. c, Carb. v., Cund., Fluor, ac, \nLach., Lye, Nux v., Phos., and Thuja. \n\nIf it becomes necessary to interfere surgically, the best \nplan is to endeavor to procure the obliteration of the naevus, \nby exciting adhesive inflammation in it. This may be readily \naccomplished by passing a number of fine silk threads, soaked \nin a solution of the perchloride or persulphate of iron, across \nthe tumor in different directions, and leaving them in for a \nweek or two. The subcutaneous ligature is a less convenient \nbut very effectual operation. The ligature is applied in \ndifferent ways, according to the size and situation of the tumor. \nIf large, it is best to divide it into sections, corresponding to \nthe peculiar shape of the tumor, and ligature each portion \nseparately ; but if small, a single thread may suffice. Another \nuseful plan is to break up the substance of the growth \nsubcutaneously, by means of a cataract needle, repeating the \noperation from time to time, and in the intervals to keep up \npressure upon it. But the most eligible method of operating \nis by electrolysis, inasmuch as it leaves no scar or disfigure- \nment, and is not attended with any pain or danger. \n\n\n\nDISEASES OF THE EYE. 329 \n\n8.-FIBE0US TUMORS. \n\nThese tumors are met with in the eyelids, conjunctiva and \norbit. In the eyelids they form small, hard, circumscribed \nelevations, which are sometimes painful to the touch. In \nsome cases they assume a cartilaginous or bony character. \nThey are mostly seated in the submucous tissue, and are \nreadily brought into view by everting the lid. \n\nIn the ocular conjunctiva these fibromata take the form of \nPinguecula. The latter consists of hypertrophied conjunctival \nand episcleral tissue, and is generally situated close to the edge \nof the cornea. It is a small, flat, roundish or triangular body, \nof a yellowish-white color, and bears a slight resemblance to \npterygium, for which it is sometimes mistaken. It does not, \nas might be inferred from its name and appearance, contain \nany fat, but is made up chiefly of epitheliel cells and connective \ntissue. Pinguiculae generally occur in old people, and are \nprobably due to a chronic irritation of the conjunctiva in \nconsequence of external injuries. \n\nFibrous tumors of the orbit spring from the periosteum, \nto which they often adhere by a broad base ; but the more \nmovable ones are usually attached to the edge of the orbit by \none or more pedicles. Some of them are hard and smooth, and \nsome are soft and lobulated. The former are generally \nsmall, circumscribed, and more or less movable. The latter, \nwhich sometimes attain a very great size, extend in some cases \ndeeply into the orbit, and may even involve the bones of the \nhead and face. \n\nTreatment. \xe2\x80\x94 The only successful treatment for fibrous \ntumors is operative. We are convinced that much valuable \ntime is often lost by practitioners of our school, in vain \nattempts to disperse such tumors by local applications and \nmedicines. Those attached to the orbit, if capable of being \nreadily extirpated, should be removed early, especially if they \n\n\n\n330 PRACTICE OF MEDICINE. \n\nencroach upon, or are actually within its cavity. No such \noperation should be undertaken, however, without duly \nweighing all the circumstances of the case, some of which \nmay render the case exceptional. Thus, the history \nand situation of a tumor may be such as not to threaten \nmischief, when its removal would in all probability \ninjure or destroy the sight. In this case, of course, no good \nsurgeon would undertake an operation. On the other hand, \nif the growth of the tumor gives rise to cerebral symptoms, \nthe surgeon should not hesitate to sacrifice the eyeball, if \nnecessary, in order to remove it, and even incur the risk of \nexciting considerable inflammation. \n\n\n\n9.-SAHC0MAT0US TUMORS. \n\nSarcoma occurs primarily in all parts of the eye and \nsurrounding tissues. It first appears in the form of nodules, \nwhich frequently become quite large, and give to the growth a \nvery irregular appearance. It is characterized by a prepon- \nderance of cellular elements, which vary greatly in form and \nsize, being spindle-shaped, stellate, oblong, circular, etc. \nSometimes the cells contain pigment, and then it is called \nmelanotic sarcoma. It is not of a benign character, neither \nis it so malignant as cancer, but rather between the two, \ndeveloping first in homologous, and afterwards in heterologous \ntissues. Its structure is equally diverse, sometimes approaching \none type and sometimes another of the connective tissue \ngroup, giving it at various times more or less of a fibrous, \nmucous, gliose, melanotic, medullary, cartilaginous, or bony \ncharacter. It appears much the most frequently in the \nchoroid, where it sometimes developes rapidly ; but generally \nits growth is very slow and interrupted, giving rise to symptoms \nof glaucoma, usually of a chronic character. Sometimes the \n\n\n\nGLIOMA RETINA. 33 1 \n\ndisease originates in the ciliary body, and when it has become \nsufficiently developed, makes its appearance in the anterior \nchamber, in the form of a dark brown tumor; or it may extend \nbackwards in the same manner into the vitreous. It is also \nfrequently found in the orbit, being, according to Virchow, \ngenerally developed from the adipose tissue behind the eye. \nAfter a time it pushes the eyeball out of the orbit, and \nappearing beneath the conjunctiva in the form of round, firm \nprotrusions, finally assumes a fungoid character. Or the \ndisease may grow inward, and after reaching the dura mater, \ninvade the cranium. After implicating the neighboring \ntissues, the disease generally ends in metastasis. \n\nSarcoma is less common in childhood than in adult life ; \nbut it frequently developed from warts or maculae in the \ninteguments of the lids, which were either congenital or \nobserved in infancy. These often remain unchanged till old \nage, when they suddenly become sensitive and painful, and \ngradually take on the character of sarcomatous tumors. \n\nTreatment. \xe2\x80\x94 The only safety in these cases is in complete \nextirpation. If the tumor is intra-ocular, the sooner the eye \nis enucleated after the disease is recognized, the better. \n\n\n\n10 -GLIOMA EETINJE. \n\nGlioma retinae is the name given by Virchow to the \nmedullary fungus of the retina, heretofore known as enceph- \naloid cancer, or fungus haematodes. It is mostly, and perhap? \nentirely, a disease of childhood ; for while it is not a very \nuncommon affection, not a single undoubted case of it, \naccording to Hirschberg, has, up to the present time, been \nobserved in persons over twelve years of age. \n\nSYMPTOMS. \xe2\x80\x94 The loss of sight is usually the first symptom \nthat attracts attention. The pupil is then seen to be some- \n\n\n\n332 PRACTICE OF MEDICINE. \n\nwhat widely dilated, and through it, upon careful examination, \nmay often be discerned a glistening-, yellowish reflection, \nformerly called the "amaurotic cat\'s eye." Examined with \nthe ophthalmoscope, we find the affected portion of the retina \nsomewhat mottled, thickened and opaque. As the morbid \ngrowth increases and becomes more prominent, it protrudes \nmore and more into the vitreous humor, where it presents the \nform of a nodulated yellowish-white mass, over which ramify \nnumerous blood-vessels. The latter inosculate freely with \neach other, and also with those more deeply seated, the growth \nbeing characterized by great vascularity. The tumor con- \ntinuing to enlarge, the lens becomes absorbed, or pushed \nforward along with the iris towards the anterior portion of the \nglobe, where sooner or later perforation usually takes place, \nand the morbid growth sprouts forth in the form of a dark-red \nand easily-bleeding fungus. (Fungus hcematodes). \n\nSometimes the glioma appears first in the external layers \nof the retina, and then it generally soon perforates externally. \nThis condition may be suspected if the movements of \nthe globe are much limited, and the eyeball protruded. \nWhen the tumor penetrates deeply into the vitreous \nhumor, the intra-ocular tension increases, and this \nfurnishes a diagnostic sign of great importance. Primary \nglaucoma being almost entirely a disease of adult life, \na marked increase of the intra-ocular tension occurring \nin young children, should always excite suspicion. As \nfor the differential diagnosis between simple detachment \nof the retina and that which occurs in glioma, we have only \nto remember that in the former the intra-ocular tension \nis often diminished. \n\nOccasionally the disease, at a certain stage of its progress, \nis very difficult to distinguish from simple choroiditis; in point \nof fact, the disease sometimes assumes the character of an \nirido-choroiditis, with commencing atrophy, the intra-ocular \n\n\n\nCARCINOMATOUS TUMORS. 333 \n\ntension being diminished, and the pupil obstructed by lymph. \nThese symptoms are generally due to suppurative choroiditis, \nbut in some rare cases they are said to be caused by suppuration \nof the cornea. But here the similarity ceases. The atrophy \nis often accompanied with severe paroxysms of pain, while \nthe eye is perhaps no more sensitive to the touch than usual. \nAt a later period the usual symptoms of glioma again manifest \nthemselves, and the disease progresses in the manner already \ndescribed. \n\nThat the disease is malignant we think there can be but \nlittle doubt. The optic nerve frequently becomes implicated, \nand in this way the affection may be propagated to the brain, \ngiving rise to secondary glioma or inflammation of that organ. \nWhen once the adipose tissue of the orbit becomes implica- \nted, the progress of the disease is very rapid. \n\nTREATMENT. \xe2\x80\x94 The only rational treatment for this, as well \nas every other malignant disease of the eye, is the immediate \nenucleation of the globe. Cases are on record in which, after \nthe lapse of several years, there was no return of the disease. \nCare should be taken in performing the operation to excise \nthe optic nerve as far back as possible, in order to include the \nwhole of the diseased structure ; and if the disease is found to \nhave extended to the orbit, it would be well to apply the \nchloride of zinc paste to the orbital cavity, as recommended \nunder \n\n\n\n11- CARCINOMATOUS TUMORS. \n\nCarcinoma differs but little in general appearance from \nsarcoma. According to Virchow, "the disease is recognized \nby the alveolar formation of its stroma, and the epithelial \ncharacter of its cellular elements." It may occur in any part of \nthe eye and surrounding tissues, but generally originates extra- \nocularly. It is of the most malignant and destructive nature, \n\n\n\n334 PRACTICE OF MEDICINE. \n\ninvading and destroying the most heterologous tissues, contam- \ninating the circulation, and spreading both by assimilation and \nmetastasis. It is also a very painful disease, being \nusually attended with more or less suffering from the \nvery commencement. It may be divided into three \nprincipal forms, namely : (a) the epitheliel, (b) the medullary, \nand (c) the scirrhus \xe2\x80\x94 melanotic cancer being only a variety of \nof the medullary. \n\nA.\xe2\x80\x94 Epitheliel Cancer. \n\nThis form of cancer, which is always supeiflcial, rarely \ncommences upon the lids or conjunctiva, but spreads to these \nparts from the skin of the nose, forehead or cheeks, invading \nmost frequently the lower lid, near the inner canthus. It \nseldom attacks the young, being much more common in those \nsomewhat advanced in life. It generally makes its appearance \nin the form of small, hard, circumscribed elevations, or \ntubercles, feeling like knots beneath the skin. These slowly \nenlarge and increase in number, until by coalescence they \nassume the form of warts or small thickened crusts. In this \ncondition they may remain for a long time, but sooner or later \nitching or uneasiness begins to be felt, the surface is rubbed or \notherwise irritated, and then ulceration sets in. A thin \nyellowish discharge oozes from the ulcerated surface, which \ndrys and forms a dark rough crust. The disease now begins \nto spread in every direction. Sometimes the ulcer becomes \ntemporarily healed over, but it soon re-opens, and the ulceration \nis renewed. In this way the malady proceeds, irregularly \nbut gradually eating its way along the surface and through \nthe lid, until ultimately it exposes the conjunctiva, and extends \nperhaps to the orbit. Up to this time the disease is generally \nattended with but little pain ; but as soon as it attacks the \ndeeper tissues, especially those of the globe, acute pain is felt, \n\n\n\nCARCINOMATOUS TUMORS. 335 \n\nresulting partly from exposure of the nerves, and partly from \npressure of the tumor upon them. \n\nA striking peculiarity of epitheliel cancer is the slowness \nwith which it advances. Several years may pass before \nulceration sets in, and many more may elapse before it makes \nany considerable progress, provided the general health of the \npatient remains good, and the sore is judiciously treated. \nUltimately, however, the cancerous cachexia is induced, and \nthen, if not before, the disease advances with the most \ndestructive rapidity. \n\nB\xe2\x80\x94 Medullary and Melanotic Cancer. \n\nMedullary cancer is distinguished as intra- or extra-ocular, \naccording as it makes its first appearance in the choroid, or on the \nwalls of the orbit. It is easily recognized by its soft consistence, \nand by the fungous character (f?mgns hcematodes) which it \npresents after the tumor bursts from the orbit, or is released \nfrom pressure by ulceration. When connected with the orbit, \nthe tumor may be closely adherent to the periosteum, or it \nmay be but loosely attached to it. It may increase rapidly in \nbulk, invade and destroy the neighboring tissues, and extend \ninto the adjoining cavities and along the optic nerve to the \nbrain ; or it may protrude externally, and form luxuriant \nfungous masses, giving rise to severe pain, and such a profuse \ndischarge and frequent hemorrhage, as to bring the \ncase to a speedy and fatal termination. On making a \nmicroscopical examination of the tumor, we discover large \nareolar spaces, filled with variously shaped cancer cells, similar \nto those described under the head of sarcoma. Unlike \nsarcoma, however, the medullary tumor makes a much more \nrapid progress, leads much earlier to metastatic affections, and \nis consequently far more apt to return after extirpation. (See \nGlioma Re tines). \n\nAs melanotic cancer is but a variety of the medullary, and \n\n\n\n336 PRACTICE OF MEDICINE. \n\ndiffers from it chiefly in containing a greater or less amount of \npigment in its cells, it is unnecessary to describe it in detail. \nThe amount of pigment may be so great as to give the tumor \na deep sooty-black color, streaked here and there with various \nshades of brown or gray. It is the most dangerous variety of \ncancer, and exceedingly prone to recur within a very short \ntime after extirpation. \n\nC\xe2\x80\x94 Soirrhus Cancer. \n\nScirrhus is so called from the stony hardness which \ncharacterizes it in whatever tissue of the body it may be found. \nIt seldom appears before the middle period of life, and generally \ndevelopes very slowly. Its occurrence in the orbit is \nprobably due to some injury or prior inflammation ; at least it \nhas been seen to follow a blow or other injury, but more \ncommonly it is preceded by repeated attacks of inflammation, \ngenerally of an intractable nature. \n\nTREATMENT OF CANCEROUS TUMORS. \n\nThe only proper treatment of any form of cancerous \ntumor of the eye, consists in prompt eneucleation of the \neyeball, and the complete extirpation of the morbid growth. \nIn order to destroy any portions of the tumor which cannot be \nreached with the knife, it is recommended to dress the raw \nsurface with the chloride of zinc paste, spread upon strips of \nlint. The paste may be prepared by rubbing up one part \nby weight of the chloride of zinc with four parts of flour, and \nadding sufficient tincture of Conium to make a paste of the \nproper consistency. \n\n\n\nDISEASES OF THE EYE. 33? \n\n\n\nDIV. IV.\xe2\x80\x94 CATARACT. \n\n\n\nCataract is a partial or general opacity of the crystalline \nlens, of its capsule, or of both the lens and capsule combined. \nThe first is called lenticular, the second, capsular, and \nthe third, capsulo-lenticular cataract. The term false cataract \nwas applied by the old authors to deposits of lymph in the \npupil which have become permanent. This condition, which \nis almost always associated with lenticular cataract, has already \nbeen sufficiently considered. (See Iritis) \n\nLenticular cataracts are divided into two general classes, \nnamely, (i) the cortical, or soft cataract; and (2) the nuclear, \nor hard cataract. This classification, though not strictly \ncorrect, is most convenient for obtaining a general notion of \nthe subject; while the exceptional forms will be best under- \nstood by considering them in connection with those to which \nthey are most nearly related. \n\n\n\n1 -SOFT CATARACT. \n\nCORTICAL OR CONGENITAL CATARACT. \n\nThe characteristic feature of soft cataract is, that, although \nthe whole lens may be opaque, it contains no hard nucleus. \nIt occurs in subjects under thirty-five or forty years of age, \nand is the most common form of congenital cataract. It is \ndivided into two principal varieties, the lamellar, and the \ncortical. \n\nA.\xe2\x80\x94 Lamellar Cataract. \n\nLamellar cataract is usually congenital, but as it interferes \nvery little with vision, it may long remain undetected. It is \ndistinguished by the fact that the opacity, which is generally \n\n\n\n338 practice of Medicine. \n\nof a delicate greyish, or bluish-grey tinge, is partial, central \nand uniform, being surrounded by a transparent or pellucid \nborder, and not increasing in density towards the pole, as \nwould be the case if the nucleus was affected. Examined by \nthe ophthalmoscope, when the light falls perpendicularly upon \nthe cataract, the opacity appears as a dark, sharply-bounded, \ncircular spot, through which the fundus presents a uniform \nreddish-brown appearance, and beyond the edges of which the \ndetails of the retina may be distinctly seen. But the diagnosis \nis best made out by oblique illumination. The cataractous \nportion of the lens then appears surrounded by a dark black \nring, caused by the heads of the ciliary processes shining \nthrough the transparent margin of the lens. But this uniform \nand sharply-bounded central opacity continues only so long as \nthe cataract is stationary. When progressive, the superficial \nlayers are affected with a cloudy or striated opacity, giving it \nmore or less of a radiated appearance, the striae extending \nfrom the central portion into the cortex, and marked here \nand there by various minute inequalities. The smaller the \nopaque specks, and the fewer and more delicate the streaks, \nthe slower is supposed to be the progress of the cataract, and \nvice versa. \n\nA fair degree of vision is usually enjoyed by patients \naffected with lamellar cataract ; but the sight is always greatly \nimproved by dilating the pupil with Atropine, in consequence of \nbringing into use the peripheral or unaffected portion of the \nlens. Thus, patients who, previous to dilatation of the pupil, \nwere barely able to make out the heaviest type, have after- \nwards been able to read with ease the finest print. \n\nB.\xe2\x80\x94 Cortical Cataract. \n\nThis "form of cataract may commence in any portion of \nthe cortical substance of the lens. Hence it may invade both \nsurfaces of the lens uniformly ; or it may commence at the \n\n\n\nCORTICAL CATARACT. 339 \n\nmiddle, or, which is more common, at the circumference, in the \nform of small, greyish-white streaks, or radii, running towards \nthe centre, the intermediate lens substance being at first \ntransparent, or but slightly opaque. Shortly, however, a \ngeneral opacity sets in, which may, or may not, render the \nstriae invisible. Sometimes the stellate figure may be observed \nin both the anterior and posterior cortical portion of the lens, \nthe remainder being transparent, or slightly dotted with opaque \npoints. This condition is easily recognized by lateral \nillumination, the anterior streaks appearing just behind the \npupil, and the posterior further back, and having a concave or \nmeridional appearance. These appearances are especially \nmarked through the opthalmoscope, the spots and stripes \nbeing projected in dark, well-defined opacities on the red \nsurface of the fundus. Unlike lamellar cataract, its progress \nis usually rapid, particularly in children, in whom it often \nmatures in the course of a few weeks or months. At a later \nperiod its rate of increase may be comparatively slow, \nespecially if the opacities are small and scattered. \n\nTotal or mature cortical cataracts are of a grey or bluish- \nwhite tint, the color being most intense at the centre, in \nconsequence of the increased density at that point. The \nstellate rays are broad, white, and sometimes slightly glistening. \nIf the cataract developes quickly, the lens swells so as to push \nforward the pupillary margin of the iris, which is frequently \nmore or less dilated and sluggish. Viewed obliquely, we \ndiscover that the more superficial layers of the cortical portion \nof the lens are less dense than the central, proving that, \nalthough soft, this is not a fluid cataract. In the latter the \nwhite opacity is equally as dense at the periphery as at the \ncentre. It is of a milky-white or greyish color, devoid of \nstriae, and extends quite up to the capsule, the interior of \nwhich is sometimes dotted with minute white opacities. \n\nThe consistency of cortical cataract, which is always soft, \n\n\n\n3 40 PRACTICE OF MKDICINE. \n\nis in infancy and childhood almost fluid. It increases in \ndensity up to the age of thirty or thirty-five, when the nucleus \nloses to a greater or less extent its soft, pulpy character, and \nbecomes somewhat hard. In the course of time, secondary \nchanges may set in, disintegration and absorption of the \naffected portions of the lens taking place, causing the latter to \ncontract, and the capsule to become more or less wrinkled. \nAfter the more fluid parts are absorbed, the shriveled capsube \ngenerally contains only broken-down lens substance, in the \nform of small, chalky-white chips In children, the process of \nabsorption may continue until nearly the whole of the over- \nripe cataract disappears, leaving only a small, hard, chalky \nlayer or disc, which, from its resemblance to a dried seed-shell, \nis called by the old writers "siliquose" cataract, (cataracta \nsiliqaata). After the age of twenty-five or thirty, the nucleus \nbecomes sufficiently hard to resist these secondary changes, \nand the softening is chiefly confined to the cortical substance. \nAs soon as the latter becomes fluid, the hard nucleus sinks \n\ndown in it, and thus is formed the so-called "Morgagnian" \n\ni \ncataract. \n\n\n\n2.-HABD CATABACT. \n\nNUCLEAR OR SENILE CATARACT. \n\nAs the name indicates, this form of cataract is characterized \nby the presence of a comparatively hard nucleus. It is \nappropriately called "senile," as the change that produces it \nnever begins to take place until after the age of from thirty to \nthirty-five, when the nuclear portion of the lens becomes \nharder, and assumes a yellowish tint. The consolidation of \nthe nucleus, which takes place gradually, is at first a purely \nphysiological process, and may exist for years without any \ndeterioration of sight. It is only when vision becomes \n\n\n\nHARD CATARACT. 341 \n\nperceptibly impaired in consequence of a certain increased \ndensity and opacity of the lens, that the process should be \nregarded as pathological, although the distinction between the \ntwo forms of hardness and opacity is merely one of degree. \nWhen this stage is reached, the nucleus exhibits a more or less \ngreyish-yellow or brownish-yellow color, quite distinct in \nappearance from the cortical portion of the lens, which at first \nretains its normal transparency, except in the immediate \nvicinity of the nucleus, where perhaps a so-called "arcus senilis \nof the lens" occurs. Subsequently the cortical portion also \nbecomes affected, constituting what is called "mixed" cataract. \n\nIf we view nuclear cataract by lateral illumination, it will \nappear as a yellowish, or more rarely as a brownish or black \nopacity, somewhat distant from the pupil, the latter, owing to \nthe transparency of the cortical substance, often throwing a \nshadow upon the surface of the opacity. Brown and "black" \ncataracts are due to the absorption of hematine from the \naqueous humor. These forms are liable to be overlooked, on \naccount of the dark color of the pupil, unless the examination \nis made with the ophthalmoscope or by lateral illumination. \n\nHard cataract at its commencement presents a stellate \nappearance very similar to that of the cortical variety already \ndescribed ; the opaque streaks being arranged in the form of \nradii, with clear portions of the lens between them. The \nopacity generally begins at the periphery, and may be confined \nto either surface of the lens, or may embrace both. The \ncentral portion, as well as the spaces between the rays, may \nremain for some time sufficiently transparent for the details of \nthe fundus to be seen ; but the opacity gradually extends \ntowards the centre of the lens, the intermediate spaces become \nmore and more clouded, and finally the entire lens becomes \naffected. \n\nSenile cataract occurs most frequently after the age of \nfifty, and is apt, sooner or later, to affect both eyes. Its \n\n\n\n342 PRACTICE OF MEDICINE. \n\nprogress is sometimes slow, at others rapid. In its earlier \nstages, it often remains for a long time almost stationary, and \nthen advances with great rapidity, reaching maturity perhaps \nwithin a few weeks. It is generally more rapid the larger, \nbroader, and more numerous are the opaque spots and \nstripes. Relatively, its progress is far more rapid in the \ncortical substance than in the nucleus. \n\nThe secondary changes that sometimes occur in senile \ncataract, are similar to those that take place in the cortical \nvariety, the chief difference being that the retrograde metamor- \nphosis is confined to the cortex. Partial absorption takes \nplace, and scattered chalk-like spots are formed, usually at the \nexpense of the cortical substance, which diminishes somewhat \nthe thickness of the cataract. These collect into small masses, \nand become attached to the inner surface of the capsule, which \nsometimes appears like a thin veil streched over the hardened \nnucleus and strewn with white granules. The softening of \nthe cortex may give rise to the so-called "Morgagnian" cataract, \nas mentioned under the previous head. \n\nThe impairment of vision is frequently much less than the \ndegree of opacity would lead us to suspect. This arises in \nsome cases from the cloudiness being confined to the portion of \nlens usually covered by the iris. The opacity being the same, \nthe clearness depends upon the nearness of the object, the \ndegree to which it is illuminated, and the amount of diffuse \nlight that is allowed to enter the eye. Hence, if the opacity \nis chiefly limited to the centre of the lens, the patient will see \nbest when the diffuse light is cut off, and the pupil dilated ; \nbut if confined to the margin, the reverse will occur ; he will \nsee best in a bright light, and with a contracted pupil. \n\n\n\nDISEASES OF THE EYE. 343 \n\n\n\n3.-CAPSULAE CATARACT. \n\nWe have already alluded to the fact that; during the \nsecondary changes which take place in lenticular cataract, the \nfluid and fatty elements become absorbed, and the harder \nportions become attached to the inner side of the capsule, thus \nrendering the latter apparently more or less opaque. But \nsince these white, chalky appearances are not situated in the \ncapsule itself, it is evident that the term "capsular" cataract \nis not, strictly speaking, correct. This does not, it is true, \ndisprove the possibility of the capsule becoming cloudy, but so \nfar it has not been observed. Indeed, it is almost certain that \ncapsular cataract never occurs except as a complication of a \nprevious opacity of the lens ; the deposit being intra-capsular, \nand depending on the condition of the lens substance. In \nmaking this statement we do not lose sight of the fact, that, in \ncertain cases, the hyaline membrane undergoes a sort of \nhypertrophy, or is apparently thickened by a deposit of trans- \nparent layers, which may subsequently degenerate and become \nopaque ; but as a general rule the capsule itself retains its \ntransparency. {Stellwag.) \n\nBy capsular cataract, therefore, we understand an opacity \nof the capsule, generally due to opaque deposits upon its inner \nsurface, consisting mainly of chalky incrustations, or fragments \nof cholesterine crystals, the capsule being somewhat wrinkled, \nand perhaps thinned. The opacity is seated chiefly behind \nthe pupil, sometimes on the posterior half, but generally on \nboth halves of the capsule. Sometimes it consists in a simple \nthickening and cloudiness of the capsule, dotted here and there \nwith small, chalky masses ; but in most cases the chalky \nopacities predominate, and form a more or less complete \nincrustation on the inner wall of the capsule. \n\n"Central" capsular cataract is sometimes congenital, but in \n\n\n\n344 Practice of medicine, \n\nmost cases it is the result of an iritis, or of a perforating ulcer \nof the cornea. When the latter is situated near the centre of \nthe cornea, the lymph effused in the ulcer comes in contact \nwith the corresponding portion of the capsule, in consequence \nof the lens falling forward upon the cornea during the escape \nof the aqueous humor, and a portion of the lymph adheres to \nthe capsule after the lens recedes from the cornea. This \ninterferes with the nutrition of the subjacent tissues, and the \nlatter become more or less cloudy and opaque. These \nfinally undergo the usual secondary changes, shrinking greatly, \nand forming a cartilaginous, or more frequently a chalky \nnodule, attached to the inner surface of the anterior capsule, and \nimbedded, so to speak, in the surface of the lens. Sometimes \nthe cataractous nodule, instead of being rounded, is of an \nirregular pyramidal shape, the apex projecting above the \nsurface of the capsule, and the base slightly imbedded in the \ncortical portion of the lens. This form is called "pyramidal" \ncataract. \n\nCapsular opacities occurring at the posterior pole of the \nlens, and hence termed "posterior polar" cataract, are some- \ntimes caused by changes in the contiguous cortical substance \nof the crystalline, or by deposits upon the internal surface of \nthe capsule, which take place in the manner already described. \nBut posterior polar cataract may also be due to inflammatory \nor nutritive changes in the anterior portion of the vitreous \nhumor. These are distinguished by their smooth and shining \naspect, whereas the former are usually rough and granular. \nThey are generally dependent upon chronic inflammation of \nthe deeper tissues of the eye, being frequently met with after \ncertain forms of choroiditis and retinitis. \n\n\n\nDISEASES OF THE EYE. 345 \n\n\n\n4 -TRAUMATIC CATARACT, \n\nWe shall devote this section chiefly to the etiology of \ncataract, beginning with the traumatic, Of the numerous \ncauses that give rise to its various forms, wounds and injuries \nof the lens and its appendages are among the most important. \n\nThe opacity generally commences within a few hours after \nthe receipt of the injury. If the latter is slight, such for \nexample as a very fine puncture that does not penetrate \ndeeply, it may cause only a superficial cloudiness in the vicinity \nof the wound, which may disappear, and leave no permanent \nopacity ; but more frequently, the parts surrounding the wound \nswell up, and if much aqueous humor is admitted, the whole \nlens may enlarge, causing the wound in the capsule to gape ; \nand if under these circumstances a portion of the cataractous \nsubstance protrudes and becomes absorbed, the edges of the \nwound may retract, so as to become cemented together by the \ndisintegrated remains of the cataract, and thus give rise to a \nsecondary traumatic cataract. Moreover, the swelling of the \nlens may cause it to press injuriously upon the ciliary body \nand iris, and thus lead, perhaps, to irido-cyclitis ; and if the \niris is badly lacerated, or if it becomes attached to the corneal \nwound, it may even excite a general irido-choroiditis, with its \nattendant consequences. The danger of secondary inflamma- \ntion is considerably less in children than in adults, in conse- \nquence of absorption being more rapid and the injurious \ninfluences of shorter duration. But no such differences exist \nin cases where the injury was caused by a foreign body, such \nas a bit of percussion cap, which still remains in the eye. \nHere the danger of destructive inflammation is always very \ngreat. In such cases the surgeon should not fail to keep a \ncareful watch over the eye, and promptly adopt such measures \nfor its safety, and for that of its companion, as the exigencies \n\n\n\n34^ PRACTICE OF MEDICINE. \n\nof the case may require. See Glaucoma, Sympathetic \nOphthalmia, etc. \n\nTraumatic cataract may also result from a blow or fall, \nwhich may or may not rupture the capsule of the lens, or \ndestroy the continuity of the ciliary processes. If the \nrupture is partial or incomplete, it may escape detection for \nyears. A careful examination, however, will generally result \nin discovering the mobility, oblique position, or sinking of the \nlens, the tremulousness of the iris, etc. If the lens has become \ncompletely dislocated, it may be forced into the anterior \nchamber, between the iris and cornea, where, inclosed in its \ncapsule, it may remain for years without exciting any particular \ninconvenience, though this is not generally the case ; or it may \nbe driven into the vitreous, where severe inflammation of the \ninternal tunics quickly occurs. Spontaneous and congenital \ndislocations also occur ; and although the luxated lens may \nremain transparent for years, it finally becomes cataractous. \n\nCataract has also been caused by entozoa perforating the \ncapsule and entering the lens. The monostoma lentis, the \nfilaria and distoma oculi humani, and the cystercercus, have all \nbeen found in the crystalline lens. \n\nRaphania, or ergotism, is an occasional cause of cataract. \nThe opacity developes slowly ; and as it generally affects the \nyoung, the cataract is usually soft. The same is true of \ndiabetes, which is a very common cause of cataract. \n\nFinally, while it most frequently results from the faulty \nnutrition incident to old age, cataract is often both hereditary \nand congenital, (cataracta adnata). The immediate cause in \nthese cases according to Stellwag, is supposed to be, "a faulty \ndevelopment of the lens, which prevents the elements from \nlong maintaining themselves at the height of evolution, and \ncauses their premature destruction ; a proceeding that is \nanalogous to the early fall of the hair and decay of the teeth." \n\n\n\nDISEASES OF THE EYE. 347 \n\nTREATMENT OF CATARACT. \n\nWhilst we are free to admit that the vast majority of \ncataracts, especially the hard, can only be removed by \noperative procedures, we see no reason to change the opinion \nwe have already expressed, namely, "that incipient cataract \nhas in some instances unquestionably yielded to homoeopathic \nmedication."* Even Stellwag, looking at the subject from the \nOld School standpoint, says that "medical treatment may be \nof service in so far as it is suited to remove direct or indirect \ncauses of cataract"; and adds, "it can scarcely be denied, that \nwith the removal of the cause, the development of the cataract \nmay be easily impeded, and its progress restricted. But if \nthis succeeds," he says, "it is evidently possible that the already \ncloudy portion may be caused to disappear by regressive \nmetamorphosis and absorption, and a relative cure thus brought \nabout." *f- He also admits that "several creditable authors," \nmeaning Tavigno, Arlt, Faye, Himly, and others, "say they \nhave seen existing cataractous opacities clear up under the \nsystematic use of mercury, after frictions of iodide of potassium \nointment about the eyes, after the internal and external use of \nPhosphorus, etc., etc." * Such admissions, coming as they do \nfrom such high authority in the old school, if they do not serve \nto convince, ought at least to render less positive the opinions \nof those of our own school who not only still cling to the old \nnotion of the incurability of cataract, but who even claim it to \nbe impossible, under any circumstances, to cure \xe2\x80\x94 what ? senile \nCataract ? no, but even "incipient" cataract, by therapeutic \nmeans. -|* Besides, it cannot be denied that a large \nnumber of such cases are to be found in our literature, and \nthat some of them are vouched for by several of our most \n\n\n\n*See Preliminary Observations. \n\nt u Treat. on Dis. of the Eye," Fourth Am. Ed., 1873, p. 624. \n\nLoc. cit. \n\n+See \' Medical Advance," vol. iv, p. 249. \n\n\n\n348 PRACTICE OF MEDICINE. \n\ndistinguished authors, including such names as Kafka, Quadry, \nKirsch, Lilienthal, and others of equal note. We are, \ntherefore compelled to admit that, under some circumstances, \ncataract is curable, or else of impeaching the integrity and skill \nof some of the most noted and reliable authorities of both \nthe allopathic and homoeopathic schools of medicine.* \n\nBut in order to succeed by medical treatment alone, it is \nrequisite that the cataract should be of a favorable character, \nthat the remedy should be rightly selected, and that its \nadministration should be neither irregular nor transient. No \none would expect to effect a cure by internal treatment after \ndegeneration of the lens fibres had occurred ; nor, supposing \nthe case to be a proper one, and the remedy to be rightly \nselected, would he look for a permanent and radical change \nunder several months. In all ordinary cases, therefore, we \nshall be obliged to resort to operative measures ; but in \ncomplicated cases, or those attended by circumstances contra- \nindicating an operation, which are by no means rare, we should \ngive the patient the benefit of our improved system of practice, \nand not, from any preconceived notions of its inefficiency, \ndeprive him perhaps of the only possible means of recovery. \nOur chief difficulty will consist in selecting the proper remedy. \nAside from the pathological condition of the lens, we shall be \nobliged to fall back upon the symptoms arising from complica- \ntions, if any, or from the state of the patients health, especially \nas regards any abnormal action of the heart, kidneys, or uterus, \nor any other derangement which may in any wise affect either \nthe circulation or nutrition of the organ of vision. In the \nabsence of any such indications, we shall be compelled to \naddress our remedies to the pathological condition itself, and \nfor this we have no other guide than experience. The \n\n\n\n*See a very able paper on this subject by Prof. Gilchrist, in the thirteenth volume of \nthe A merican Observer, p. 449, et seq. \n\n\n\nOPERATIONS FOR CATARACT. 349 \n\nremedies which have hitherto been employed with favorable \nresults, and which deserve special attention, are the following ; \n\xe2\x80\x94 Amm. c, Bary. c, Calc. c, Cann. s., Caust, Chim. u., Graph., \nIod., Kali iod., Lyco., Magn. c, Merc, Phos., Physostig., Sec. \nc, Sep., SiL, Sulph. \n\nOPERATIONS FOR CATARACT. \n\nBefore proceeding to describe the various methods now \npracticed for the removal of cataract by operation, we shall \nbriefly point out some of the principal circumstances and \nconditions which may render it necessary or advisable \nto either defer the operation, or abandon it altogether. \n\nI. The most favorable cataract for operation is one that \nhas just reached maturity ; that is, the cataract is ripe without \nbeing over-ripe. These terms are altogether relative. A cat- \naract is ripe for operation when the connection between the \ncortex and nucleus of the lens is stronger or more intimate \nthan it is between the cortical substance and capsule. For, if \nonly the external layers of the lens are in a soft or fluid con- \ndition, there can be no difficulty in removing the nucleus. \nNor can there be any great danger incurred, even if the cortical \nlayer is of normal consistency, provided the nucleus has ac- \nquired such a degree of density as to readily prevent its sepa- \nration from the cortex, for then the latter may be safely de- \ntached from the capsule. But if the superficial layers, without \nbeing abnormally hard, have lost their transparency, and have \nbecome intimately attached to the capsule, their separation can \nonly be effected by violent, and therefore dangerous means. \nHence such cataracts are said to be unripe for operation. For, \nif any portion of the cortex remains in the capsule, it not only \nswells up and irritates the iris, but is liable to proliferate, giv- \ning rise to a secondary cataract, if not to destructive inflamma- \ntion of the eye. \n\n\n\n350 PRACTICE OF MEDICINE. \n\nBut a cataract may be over ripe ; that is, the lens may- \nhave undergone such retrogressive changes that the cortical \nsubstance is either broken down into a creamy or chalky fluid \nor pulp, filled with minute sand-like grains, or transformed to a \ndry, cretaceous substance, portions of which are liable to re- \nmain in the eye, and thus render the operation extremely dan- \ngerous. \n\n2. Authorities differ as to the propriety of operating in \nmonocular cataract. All agree, however, that the operation \nshould not be undertaken unless a favorable result is almost \ncertain. The advantages, in case of success, are, first, the im- \nprovement in the personal appearance of the patient ; second, \nthe enlargement of the field of vision ; and, third, the preser- \nvation of vision in case the other eye becomes cataractous. \nOn the other hand, in case of failure, if the inflammation ex- \ncited by the operation should continue for a long period, or \nuntil the other eye has become affected, the patient would be \ndeprived during this period of any service from the sound eye ; \nthere is also the danger of the latter becoming sympathetically \ninflamed. \n\n3. Surgeons also differ as to whether, in binocular cata- \nract, only one eye at a time should be operated on, or both at \nonce. Our practice has been to operate on one eye at a time, \nand not to touch the other until the first has recovered ; thus \nlessening the danger of inflammation, diminishing the shock to \nthe system, avoiding the risk of any sympathetic influence of \none eye upon the other, and furnishing an opportunity to dis- \ncover any constitutional peculiarity or unfavorable tendency, a \nknowledge of which would be of service in the subsequent \nmanagement of the case. Of course, if only one cataract is \nripe, there is no occasion to wait for the other to mature ; but, \nif circumstances are favorable, we should promptly operate \nupon the former, so as to enable the patient to follow his usual \navocations whilst the other is maturing. \n\n\n\nOPERATIONS FOR CATARACT. 351 \n\n4. It is highly important not to operate unless the eye is \nin an otherwise healthy condition. The chief exception to this \nrule is where an inflammation is kept up by a swollen or dislo- \ncated lens, and then the urgency will depend upon the charac- \nter of the inflammation. Nor would it be safe to operate on \nan eye that had recently been in a state of inflammation, \nthough chronic inflammation of the surrounding parts some- \ntimes forms an exception. \n\n5. It is also important that the state of the patient\'s \nhealth should be such as to favor an operation, or at least such \nas not to endanger the result. Hence the various cachexia, \nsuch as scrofula, tuberculosis, syphilis, etc., as well as any other \ncondition, whether physical or mental, which greatly depresses \nthe vital powers, is to be regarded as endangering, and, to a \ncorresponding extent, contra-indicating an operation. It is es- \npecially important to determine whether the patient is suffering \nfrom diabetes, as this is a very frequent cause of cataract, and \nthe lens does not generally become affected until late in the \ndisease, when the health is seriously impaired. If diabetes is \nfound to exist, we should be careful to ascertain whether there \nis any co- existing affection of the retina or optic nerve, as this \nwould render the prognosis very unfavorable. \n\n6. The season of the year is of but little consequence, \nprovided we avoid thermometrical extremes, and these chiefly \non account of their interfering with the comfort or exercise of \nthe pat\'ent. Thus, in very hot weather the patient is apt to be \nrestless, and confinement in bed is much more difficult ; be- \nsides, wounds rarely heal as readily in July and August as they \ndo in cooler months. On the other hand, very cold weather is \nnot only unfavorable for regular exercise prior to the operation, \nbut, by confining the patient to his room longer than is neces- \nsary, often greatly protracts convalescence. \n\n\n\n352 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\n1.-DISCISSI0N. \n\n\n\nDIVISION OR SOLUTION OF CATARACT. \n\nThis operation is indicated in the cortical cataract of child- \nhood, in certain forms of lamellar cataract, and in opacities of \nthe posterior capsule, especially such as result from linear or \nflap extraction. \n\nThe operation consists in simply dividing or lacerating the \nanterior capsule with a fine needle, so as to break up the cata- \nract and facilitate its absorption in the aqueous and vitreous \nhumors. It may be performed either through the cornea (kerat- \nonyxis) or through the sclerotica (sclerotonyxis). The latter \nis generally done with a Beer\'s, or spear-pointed cataract needle. \n(PI. I., Fig. 10) ; but the former requires a round stop-needle \xe2\x80\x94 \nthat is, one the diameter of whose shaft gradually increases as \nit recedes from the point, in order to prevent the escape of the \naqueous humor. \n\nIf the operation by scleroto- \nnyxis is selected (Fig. 14, a.), \nafter dilating the pupil with \nAtropine, separating the lids \nby a stop-speculum (PI. IL, Fig. \n33), or by the fingers of an as- \nsistant, who also steadies the \nglobe with a double hook (PI. \nI., Fig. 6), or, what is better, a \npair of fixing forceps (PL IL, \nFigs. 36, 37), fastened to the \nlower part of the ocular con- \njunctiva, unless the eye can be \nfully controlled by the fingers, the operator enters the needle \nperpendicularly on the temporal side of the sclera, about a line \nand a half behind the border of the cornea, and the same dis- \n\n\n\n\nDISCISSION. \n\n\n\ndiscission. 353 \n\ntance below the horizontal diameter of the eye, the cutting \nedges of the needle being directed antero-posteriorly, in order \nto lessen, as much as possible, the danger of wounding any of \nthe larger vessels of the choroid. The point of the needle is \nthen pushed forward, with its side facing the cornea, through \nthe periphery of the lens into the anterior chamber, as far as \nthe upper and inner margin of the pupil. (See Fig. 14). Then, \nin order to tear away as large a piece of the anterior capsule \nas possible, and force it into the vitreous humor, where it will \ncreate the least amount of irritation while being absorbed, the \noperator lays the flat side of the needle directly over the center \nof the capsule, and presses it slowly backwards towards the \nvitreous. He then brings the needle back into the anterior \nchamber, in order to tear away and break up so much of the \nremaining portions of the capsule and lens as may be deemed \nadvisable. In infants and young children, in whom the lens is \nvery quickly absorbed, the capsule cannot be too freely divided ; \nbut in adults this is not the case, and in order not to cause too \ngreat a swelling of the lens, or the admission of too many frag- \nments into the anterior chamber, either of which may give rise \nto severe iritis or irido-cyclitis, it is best not to lacerate the \ncapsule too freely at one time, but to repeat the operation at \nintervals of a few weeks, or whenever the process of absorption \nrequires to be hastened. \n\nThe operation by keratonyxis (Fig. 14, d) is performed by \npassing the round stop-needle (represented in the cut), instead \nof Beer\'s, somewhat obliquely through the middle of the upper \nor lower outer quadrant of the cornea, in such a manner as to \navoid touching the margin of the iris during the division of the \nlens. Care should be taken not to make the track of the wound \ntoo long by entering the cornea too obliquely, as then the mo- \ntion of the needle in breaking up the cataract would strain and \nbruise the tissue of the cornea, and probably lead to more or \n\nless corneal opacity. The extent to which the laceration and \n\n45 \n\n\n\n354 PRACTICE Of MEDICINE* \n\n\xe2\x96\xa0 -m \n\ncomminution of the capsule and lens should be Carried, will \ndepend chiefly upon the age of the patient. Thus, in infants \nand young children, where, as above intimated, one operation \nmay be made to suffice, it should be much more extensive than \nin adults, in whom, for reasons already stated, it would be safer \nto repeat it. \n\nVery little after-treatment is generally required. The pa- \ntient should remain in a moderately darkened room for a day \nor two, with the eyes lightly bandaged, care being taken to \nkeep the iris well out of the way of the lens by the instillation \nof Atropine. If the lens should swell greatly, so as to cause \nmuch irritation, and especially if symptoms of severe inflam- \nmation should set in, the cataract should be immediately re- \nmoved by linear extraction. If this is rendered difficult or \nhazardous, in consequence of any considerable portion of the \nlens substance having fallen into the anterior chamber, or for \nany other reason, it will be best to combine an iridectomy with \nit, especially if the inflammation has already given rise to an \nincrease of intra-ocular tension, or impairment of vision. \n\n\n\n2.-DEPRESSI0N. \n\nRECLINATION OR COUCHING. \n\nThis operation, once so common, has deservedly fallen into \nvery general disrepute, and ought perhaps to be entirely aban- \ndoned. The danger lies in the depressed lens ultimately com- \ning in contact with the choroid, and exciting a destructive irido- \nchoroiditis. Stellwag, however, considers the operation "still \napplicable in cases of a very large sclerosed nucleus, and pro- \nportionately thin but tough cortex." \n\nDepression may be performed with a curved Scarpa needle \n(PI. I., Figs. 7, 8) or a Pancoast needle (Fig. 9). The prelimi- \n\n\n\nDEPRESSION. 355 \n\nnary steps of the operation are the same as for discission (which \nsee). The operator, holding the needle as a pen, with the con- \nvexity upwards, introduces its point exactly in the transverse \ndiameter of the globe, and one and a half or two lines behind \nthe cornea. The point is first directed inwards toward the \ncenter of the vitreous, but as it is carried forward it is made to \nappear directly behind the pupil, and in front of the anterior \ncapsule. The needle is then gently pressed backwards against \nthe cataract, so that the lens may become loosened from the \nzonula, and afterwards, by a half-circular turn, raised above the \nlens, with its convexity upwards. The lens is then pressed \nbackwards and downwards out of the line of vision, the needle \ngently rotated to disengage it from the lens, and then lifted a \nlittle to see if the lens is inclined to rise with it ; if not, the \noperation is finished, and the needle may be withdrawn. But \nif the lens should rise, it must be more completely separated \nfrom the zonula, or, if the operator piefers, he may rupture the \nposterior capsule with the needle, after which the lens should be \nagain depressed. \n\nReclination \xe2\x80\x94 This is a modification of depression, in which \nthe lens, instead of being pushed downwards in a straight direc- \ntion, is turned on its axis, so as to lie horizontally in the vitre- \nous humor, below the pupil. As it possesses no material advan- \ntages over the operation just described, it is unnecessary to \ndwell upon it. \n\nThe after-treatment for depression is the same as for flap \nextraction (which see). \n\n\n\n356 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\n3 -LINEAR EXTRACTION. \n\n\n\nThis operation, which is indicated in both congenital and \ntraumatic forms of cataract, when the lens substance is fluid or \npulpy, is now employed for the immediate removal of the \nlatter through a small linear incision. It may also be per- \nformed a few days after the ordinary operation of discission, \nwhen the lens has become softened and swollen, instead of \nleaving it, or its fragments, to be slowly absorbed by the \naqueous humor. It is also suited for the removal of siliculose \nand other forms of regressive and secondary cataracts, \nin which the capsule is greatly shrunken, and contains but a \nsmall portion of degenerated lens substance. \n\nIf the capsule is entire, the operation is performed by first \ndividing the anterior capsule and lens by a very fine curved \nneedle, (PL I , Figs. 8, 9), passed through the temporal side \nof the cornea, near its margin, without evacuating the aqueous \nhumor. This puncture is then enlarged in a perpendicular \ndirection, to the extent of about two lines, by a lance-shaped \nknife, or one similar to Fig. 13. The cataract, if fluid, will \nnow escape from the opening ; but if pulpy it will have to be \nassisted by the curette, or Daviel\'s spoon. (PL I., Fig. 31.) \nThe operator first presses the spoon against the posterior lip \n\nof the incision, so as to cause \nit to gap, at the same time \ngently pressing the opposite \npart of the globe with his \nfinger ; and if this does not \nsucceed in causing the lens \nmatter to escape, he endeav- \nors to effect its dislodgement \nby a circular motion of the \nends of his fingers upon the \nlids ; but if this also fails, he \n\n\n\nFig. 15. \n\n\n\n\nLINEAR EXTRACTION. \n\n\n\nSUCTION OPERATION. 357 \n\ncarefully introduces the spoon into the wound, and scoops out \nany remaining portion of the lens substance. (See Fig. 15.) \nIf any portions of opaque capsule still remain, they may be \nremoved by means of the canula forceps, (PI. I, Fig. 3), or by \none of the iris hooks, (Figs. 4, 5). Siliculose and other \nforms of secondary cataracts may also be removed in the same \nmanner ; but as it is very apt to set up severe and even \ndangerous inflammation, in consequence of coexisting synechias, \nor other complications, most operators now prefer to leave the \nmembrane in situ, and to make a small clear aperture in it by \nmeans of the round stop-needle, as this is found to give \nexcellent sight, and is attended with far less risk of exciting \ninflammation. The needle opening may be enlarged, if \nnecessary, by means of a pair of canula iris scissors, (PI. I, \nFigs. 1, 2, 18, 19), passed through a linear incision. After \nthe operation, the pupil should be kept well dilated with \nAtropine, and a light bandage should be applied to the eyes. \nIf inflammation supervenes, it should be subdued by ice-water \ncompresses, or other appropriate treatment. \n\n\n\n4.-SUCTI0N OPERATION. \n\nThis is an ancient mode of extracting soft cataract, \nrecently revived by Mr. Pridgin Teale. The instruments \nrequired are a broad needle for puncturing the cornea and \ndividing the anterior capsule, and a suction tube, (PI. II, Fig. 39), \nconsisting of a glass stem, (B), five or six inches in length, \nwith a silver tubular curette (A) at one end, five-eighths of an \ninch in length, and of the size of an ordinary curette, and an \nexhausting tube, (C), about twelve inches in length, with a \nmouth-piece at the other end. The tubular curette is \npassed through the incision made by the needle, as described \nunder the head of linear extraction, and carried through \n\n\n\n358 PRACTICE OF MEDICINE. \n\nthe pupil, previously dilated by Atropine, to the centre \nof the lens substance. Gentle suction is then made upon \nthe mouth-piece, and the lens matter is drawn into the \nglass tube, which allows the operator to watch its progress, \nand thus regulate the aspirative efforts. These should be \ncontinued as long as any opaque matter appears in the pupil, \nthe end of the curette being slightly moved about within the \ncapsule, so as to take up any portions of the crystalline \nsubstance which may be observed to remain. If any \nportions of the crystalline are too glutinous or tenacious to \nbe readily drawn into the curette, they may be left to dissolve \nin the aqueous humor, as after an ordinary operation for dis- \ncission ; or they may be removed by a subsequent suction \noperation, after having become sufficiently softened, provided \nthere has been no rupture of the posterior capsule, nor too \nmuch irritability of the eye, nor any iritis ; conditions which \nin the opinion of Mr. Teale generally render the operation \nunsuitable. \n\n\n\n5. -FLAP EXTRACTION. \n\nThis operation is most suitable for senile cataracts, but \nmay also be employed for the cortical variety, in cases where \nthe cortical substance has softened, and the nucleus is large \nand of more than normal consistence. The instruments \nrequired are : an ordinary cataract knife, such as Beer\'s (PL I, \nFigs. 28, 29) or White\'s, (Fig. 23) ; a pair of fixing forceps, \n(PL II, Fig. 36); a cystotome, (Fig. 12), for dividing the capsule ; \na curette, (Fig. 31), which, for the sake oi convenience, is \ngenerally attached to the other end of the cystotome ; and a \nblunt-pointed secondary knife, or pair of scissors, for enlarging \nthe corneal incision, or what is better, an instrument expressly \ndevised for the purpose, represented in PL I, Fig. 20. \n\n\n\nFLAP EXTRACTION. 359 \n\nThe patient being in a recumbent position, and the lids \nseparated by an experienced assistant, the operator, placing \nhimself in a convenient and unrestrained position behind the \npatient, fixes the globe by pinching up a fold of the conjunctiva \nwith the forceps, and then enters the cornea with the cataract \nknife about a quarter of a line from its outer edge, and in the \nline of its transverse diameter, taking care that the point of \nthe knife enters the anterior chamber, instead of between the \nlaminae of the cornea ; he then carries it steadily forward, with \nthe blade parallel to the surface of the iris, until its apex \nemerges from the cornea at a point diametrically opposite to \nwhere it entered, when the forceps are to be laid aside, as the \nglobe is now fully under the control of the operator. The \nblade is now carried steadily forward until it cuts its own way \nout ; or, when the section is nearly finished, the operator, \nfollowing the advice of Von Graefe, instead of carrying it \nstraight on, may complete the section by drawing it back from \nheel to point, thus diminishing the straining by causing a relax- \nation in the tension of the muscles of the eye, at a time when \nit would otherwise be at its maximum. The lids are now care- \nfully closed, so as not to cause an eversion of the flap. After \nresting a moment, the eye is again opened, the cystotome care- \nfully introduced, and the capsule freely lacerated, the operator \nbeing careful, in doing it, not to displace the lens into the vitre- \nous humor. We have now reached the third and most delicate \npart of the operation, namely, the removal of the lens. This \nwill require to be managed with particular care, in order to \nprevent the escape of any considerable quantity of the vitreous, \nan accident that may not only give rise to an insidious form of \nirido-choroiditis, but is likely to be followed by detachment of \nthe retina. After the eye is again opened, the operator places \nthe points of his index and middle fingers, or the end of the \ncurette, against the lid, on the side opposite the incision, and \nthe point of the other index finger on the other side of the \n\n\n\n36o \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\n\nFLAP EXTRACTION. \n\n\n\nglobe, so as to exercise a steady but gentle pressure upon it. \n\nThis generally causes the \nlens to advance through the \npupil into the anteriorcham- \nber, and to make its exit \nthrough the incision (see \nFig. 16) ; if not, we must \naid it with the curette, un- \nless the hindrance is behind \nthe pupil, when we must \nlacerate the capsule again, \nand proceed as before. Af- \nter resting the eye a few \nseconds, the vision may be \ntested by trying if the patient can count fingers ; and if he \ncannot, we should examine the pupil to see whether any por- \ntions of the lens substance have been stripped off and \nleft behind, in which case they should be removed with \nthe curette, or with the canula forceps (PL I., Fig. 3). \n\nAfter-Treatment. \xe2\x80\x94 After the operation the patient \nshould be placed in bed in a darkened room, and the bed cover \nfastened above his arms, so as to prevent his touching his eyes \nduring sleep. A binocular bandage should be lightly applied, \nand changed whenever it becomes very uncomfortable to the \npatient, The edges of the lids should be kept from sticking \ntogether, by sponging with luke-warm milk and water, after \nwhich they should be anointed with a little cosmoline, or cold \ncream, care being taken not to disturb the flap by opening the \nlids unnecessarily, or without due caution. After union of the \nflap occurs, which generally takes place within forty-eight \nhours, or less, after the operation, Atropine should be instilled \nbetween the lids, without widely separating them, in order to \ndilate the pupil and lessen the danger of secondary cataract. \nIf no untoward symptoms occur, the eye should not be opened \n\n\n\nPERIPHERAL LINEAR EXTRACTION. 361 \n\nfor several days, as an early or frequent movement is apt to \ninduce iritis. But if the eye becomes very hot and painful, it \nshould be examined, and if there is no protrusion of the iris, \nnor any marked suppuration of the cornea, cold water com- \npresses should be applied ; but if the iris is prolapsed, a firm \ncompress should be at once applied, which will not only pre- \nvent its increase, but will even cause it to shrink. Methodical \ncompression is also the best treatment for suppuration of the \ncornea, tending, as Wells truly observes, more than any other \nremedy, to diminish the swelling of the lids and the discharge, \nand to limit the suppuration of the cornea. \n\nIn this country, patients are seldom confined to the bed \nmore than two or three days after an operation for extraction. \nIn favorable cases a shade is generally substituted for the band- \nage in the course of a week or so, in order that the eye may \ngradually become accustomed to the light. In the case of \nchildren the bandage is frequently omitted altogether, the pa- \ntient being simply confined to a dark room. \n\n\n\n6.-PERIPHERAL LINEAR EXTRACTION. \n\nVON GRiEFE\'S MODIFIED LINEAR OPERATION. \n\nThe indications are the same as for the ordinary flap ex- \ntraction ; and it, or some modification of it, is now very gener- \nally substituted for that operation. The instruments employed \nare : A Graefe\'s cataract knife (PI. II., Fig. 34) ; a sharp and a \nblunt hook (Figs. 35 a: ond 35 \xc2\xa3); a delicate, sickle-shaped nee- \ndle (PI. I., Fig. 8) ; iris scissors (Figs. 1, 2, 18, 19) ; iris forceps, \n(Fig. 3) ; toothed forceps (PI. II., Fig. 36), and a stop-speculum \n\n(Fig. 33). \n\nVery few operators now adhere closely to Von Graefe\'s \nmethod of operating. We are in the habit of performing per- \nipheral extraction in the following manner . The patient hav- \ning been brought under the influence of an anaesthetic (we \n46 \n\n\n\n362 \n\n\n\nPRACTICE OF MEDICINE. \n\n\n\nFIG. 17. \n\n\n\ngenerally prefer a mixture of equal parts of chloroform and \nsulphuric ether), the eyelids separated with the speculum, and \nthe eye fixed and somewhat depressed with a pair of fixing \nforceps, as represented in the cut, the point of the knife, with \nits cutting edge upwards, is entered in the sclera, about one- \nthird of a line behind the upper and outer edge of the cornea, \nand cautiously pushed downwards and inwards until it pene- \ntrates about three lines into the anterior chamber, when the \npoint is raised, carried horizontally across the chamber, and \nmade to emerge at a point exactly opposite to that of entrance \n(see Fig. 17). \n\nThe edge of the blade is \nnow turned somewhat ob- \nliquely forwards, so as to \ncomplete the section at the \nupper margin of the cornea, \nby pushing the knife for- \nward until its length is near- \nly exhausted, and then \ndrawing it gently backwards \ntoward the point. After \ncompleting the section of \nthe cornea, but before sev- \nering the conjunctiva, the \nperipheral extraction. edge of the knife is turned \n\nforwards and somewhat downwards, so as to divide the \nconjunctiva in such a manner as to form a conjunctival \nflap of about a line in breadth. The prolapsed \niris is then exposed by laying back the little con- \njunctival flap over the cornea, seized with the forceps, \ndrawn out to the required extent, and excised close up to its \nciliary attachment. This requires extreme care, in order to \nprevent any portion of the iris remaining in the wound, which \nwould not only excite iritis, but retard cicatrization. We \n\n\n\n\nPERIPHERAL LINEAR EXTRACTION. 363 \n\nnow come to the laceration of the capsule, which should be as \nfree as possible. The sickle-shaped needle is passed flat- \nwise through the incision to the opposite side of the pupil, and \ncommencing as near as possible to the lower margin of the \ncapsule, the incision is carried beneath the iris, as recommended \nby Wells, to the upper border of the capsule ; another incision \nis made in a similar manner through the proximal side of the \ncapsule ; and then the upper border is freely lacerated in the \nline of the corneal incision, so as to unite the two former \nincisions. This forms a sort of flap in the anterior capsule, \nwhich greatly facilitates the escape of the lens. The stop- \nspeculum should now be removed, and gentle pressure made \nupon the lower margin of the cornea with the needle or \ncurette, when the upper edge of the lens will probably present \nat the section ; if it should not readily escape therefrom, its \nexit may be aided by introducing the two hooks, (PL II, Fig. 35), \none on each side of the lens, and scooping it out. After the \nlens engages in the section, its removal will be facilitated by \ngentle pressure with the curette upon the lower portion of the \ncornea. If it fails to engage readily, by showing a tendency \nto pass behind the upper lip of the incision, it should be tilted \nforward by making slight pressure above the wound, the edge \nof which should also be pressed backward, so as to cause the \nlens to enter the incision. If portions of the cortical matter \nshould remain behind after the nucleus is extracted, they \nshould be coaxed forward by gently rubbing the lids in a cir- \ncular manner with the ends of the fingers. \n\nAfter Treatment. \xe2\x80\x94 This is the same as that for flap \nextraction, except that after the first two or three days, if no \nunfavorable symptoms occur, the patient may be allowed much \ngreater freedom. Atropine should be instilled as early as \nthe second day after the operation. If inflammatory compli- \ncations occur, the case should be managed as directed under \nflap extraction, (which see). \n\n\n\n364 PRACTICE OF MLDICINE. \n\nDIV. V.\xe2\x80\x94 OPTICAL AIDS AND TESTS. \n\nBefore enterning upon the description of the anomalies of \nrefraction, accommodation, and other functional disturbances \nof the eye, it will be best to devote a few paragraphs to the \nconsideration of some of the more important of the optical \naids and tests relating to their discovery and correction. \n\nl.-THE OPHTHALMOSCOPE. \n\nThe reason that the pupil of a healthy eye usually appears \nblack, is not because all the rays of light that enter it are \nabsorbed, for some of them are always reflected, but because \nthe reflected rays, instead of returning to the eye of the \nobserver, are, in consequence of the refractive power \nof the dioptric media, reflected back to exactly the \npoint from whence they came ; that is, the incident and \nreflected rays exactly coincide. In order, therefore, that the \neye of the observer should catch the returning rays, it must be \nplaced between the source of light and the eye under examina- \ntion, and this, in consequence of the interposition of the observer, \ncannot be done without intercepting the illuminating rays. \nMoreover, it must be remembered that the examiner will be \nunable to perceive light emanating from the eye of another \nperson, when the latter is exactly accommodated for the eye of \nthe observer, since only a dark image will be formed on the \nretina of the eye under examination, and hence only a reflection \nof this dark portion of the retina can be returned to the eye \nof the observer. \n\nIn order, therefore, that the interior of the eye may be \ndistinctly seen, it is necessary (1) that it be sufficiently illumin- \nated ; (2) that the eye of the observer be situated in the \ndirection of .the reflected or emergent rays ; and (3) that these \nrays, which are convergent, be rendered divergent or parallel. \n\n\n\nTHE OPHTHALMOSCOPE. 365 \n\nNow, Prof. Helmholtz found that all this could be accomplished \nby simply allowing the light of a lamp to fall. on a polished \nplate of glass, in such a manner as to reflect the rays into the \neye to be examined, and then, after having made the con- \nvergent rays divergent by means of a concave lens, placing \nhimself on the other side of the glass plate, so as to catch the \nemergent rays as they passed through it. But this, the first \nand simplest form of the ophthalmoscope, is now seldom \nemployed ; highly polished mirrors, which possess much \ngreater illuminating power, having been substituted for the \nglass plate. These mirrors are provided with a small aperture \nin the centre through which the returning rays reach the eye of \nthe observer. \n\nAs our object is merely to illustrate the principle of its \naction, and not to describe with particularity the various forms \nof the instrument, we will simply add, that ophthalmoscopes, \nas now constructed, may be divided into four different classes. \nI. The portable or hand opthalmoscope, of which we have \nthree distinct forms, namely, (a) Liebreich\'s, which consists of \na slightly concave metallic mirror, attached to a convenient \nhandle, and provided with a small bracket or clip for holding \na convex or concave lens; (b) the ophthalmoscope of Coccius, \nwhich consists of a plane mirror combined with a double \nconvex collecting lens ; and (c) the ophthalmoscope of \nZehender, which differs from that of Coccius in being provided \nwith a slightly convex mirror, instead of a plane one. 2. The \nfixed ophthalmoscopes, which are especially suited for class \ndemonstrations, as their successful use does not depend on the \ndexterity of the observer. 3. The binocular ophthalmoscopes, \nby which we are enabled to use both eyes at once, and thus, \nby obtaining a stereoscopic view of the fundus, readily distin- \nguish any change of surface on the retina and optic disc. \n4. The aut-ophthalmoscope, by which the observer is enabled \nto examine the interior of his own eye. Of these, the most \n\n\n\n366 PRACTICE OF MEDICINE. \n\nuseful for the general practitioner is the ophthalmoscope of \nCoccius, which possesses the following advantages over that of \nLiebreich, which is the one in most common use : \xe2\x80\x94 first, we \ncan more fully concentrate the light upon any given part of \nthe fundus ; secondly, we can readily increase or diminish the \nfocal distance and illuminating power of the mirror ; thirdly, \nwe can generally obtain a much better view of the fundus \nthrough a contracted or natural sized pupil, in consequence of \nthe corneal reflex being considerably less ; and, fourthly, it is \nfar better adapted for the direct method of examination. \n\nMANNER OF USING THE OPHTHALMOSCOPE. \n\nI. Indirect Method. \xe2\x80\x94 The examination of the inverted \nimage, or the indirect method, as it is called, is conducted by \nseating the patient in a darkened room, with a lamp placed by \nthe side of and a little behind the eye to be examined. The \nsurgeon then seats himself in front of the patient, and holding \nthe ophthalmoscope in his right hand, places the aperture of \nthe mirror close to his eye, directing the instrument in such a \nmanner as to cast the reflection of the flame directly into the \npupil. To be able to do this with facility, and at the same \ntime keep the eye well illuminated while conducting the exam- \nination, requires considerable care and experience, as the slight- \nest movement of the mirror is liable to throw the reflection far \naway from the pupil. Having illuminated the eye, the surgeon \ntakes the rim of the object lens between the forefinger and \nthumb of his left hand, and holding the lens from two to three \ninches from the patient\'s eye, according to its focal length, at \nthe same time steadying the hand by placing one of his fingers \nupon the edge of the orbit, he endeavors to obtain an ophthal- \nmoscopic view of the fundus. This is somewhat difficult for \nthe beginner, who is apt while adjusting the lens to displace \nthe mirror ; and it is not until he learns to use the hands inde- \npendently of each other that he can make a proper examina- \n\n\n\nMANNER OF USING THE OPHTHALMOSCOPE. 367 \n\ntion of the eye. He then finds that the rays of light reflected \nfrom the fundus, after passing thrnugh the lens, form an in- \nverted image. If the eye of the observer is presbyopic or \nhypermetropic, the image is rendered more distinct by using a \nconvex glass in the clip behind the mirror. The same is true \nif the eye of the patient is hypermetropic. If the observer \nwishes to gain a view of the optic disc, he should direct the \npatient to look toward his (the surgeon\'s) right ear, if the right \neye is under examination, and vice versa, in order that the axis \nof vision may be turned slightly inwards, so as to bring the \noptic nerve entrance directly behind the pupil. If the patient \nlooks straight forwards, the surgeon will see the region of the \nmacula lutea, which is distinguished by being of a slightly \ndarker color than the rest of the fundus, and without any ap- \npearance of blood-vessels passing over it. The ophthal- \nmoscopic appearance of the optic papilla has already been \ngiven (see Fig. 10). The color of the fundus of the normal \neye differs according to the complexion of the individual. In \nlight-complexioned persons it is light or yellowish-red, while in \npersons of dark complexion it is dark red. \n\n2. Direct Method. \xe2\x80\x94 If the examination be made without \nthe lens in the left hand, the image will be erect and much \nlarger than when made by the indirect method As perfect \nrelaxation of the accommodation is required in order to render \nthe emergent rays parallel, and as this is difficult to obtain \nwithout the use of Atropine, in consequence of the close ap- \nproximation of the patient to the observer leading him, not- \nwithstanding he is directed to look at some distant object, to \naccommodate for a much nearer point, it is advisable to dilate \nthe pupil with Atropine, as this secures at once the needed re- \nlaxation, and at the same time increases the size of the field \nof vision, and also facilitates the illumination of the fundus. \nThe lamp should be placed on the side and a little behind the \nplane of the eye under examination, the surgeon seating him- \nself on the same side and examining with the corresponding \n\n\n\n368 PRACTICE OF MEDICINE. \n\neye \xe2\x80\x94 that is, using the right eye for the right eye of the pa- \ntient, and vice versa. If the image is indistinct, either in con- \nsequence of the surgeon being unable to fully relax his own \naccommodation, or in consequence of his eye or that of the \npatient being myopic, he will find it necessary to use a concave \nlens in order to render the rays parallel. But, if the eye of \none is myopic, while that of the other is hypermetropic, the \ndifference in the refractive power of the two eyes may be so \nfar neutralized as to enable the surgeon, by using his accom- \nmodation, to examine without the aid of a concave lens. As \nevery ophthalmoscope is supplied with a series of these lenses, \nof different focal lengths, fitting into the bracket or clip behind \nthe mirror, the surgeon will have no difficulty in selecting one \nto suit the condition of his own and the patient\'s eyes, whether \nemmetropic, myopic or hypermetropic. \n\nThe advantages afforded by the direct method of examina- \ntion are (i) that we are enabled to ascertain the optical condition \nof the eye independent of its visual power, or of the statements \nof the patient ; and (2) that we are enabled to measure defi- \nnitely the amount of elevation or depression of any portion of \nthe fundus ; such, for example, as the amount of excavation of \nthe optic disc, the height of tumors, the amount of swelling in \nthe retina, etc. On the other hand, the field of vision is more \nlimited, and the examination more difficult, than by the indi- \nrect method, the employment of which renders all nice dis- \ntinctions as to myopia, hypermetropia, and the state of the \naccommodation unnecessary \xe2\x80\x94 conditions which must always be \ntaken into the account in searching for the retinal image by the \ndirect method. \n\n2.-LATEEAL OR OBLiaUE ILLUMINATION. \n\nThis method of exploring the anterior and central por- \ntions of the globe is best conducted in a darkened room. The \nlight is placed in the same position with respect to the patient\'s \n\n\n\nSPECTACLES. 369 \n\nhead as in the ophthalmoscopic examination. A double con- \nvex lens is then. held between the lamp and the eye to be ex- \namined, in such a manner as to concentrate the light upon any \nportion of the cornea, iris, crystalline lens, or vitreous, that the \nsurgeon desires to illuminate. We may obtain a magnified \nimage of these parts, and thus give greater clearness to the de- \ntails, by holding a second bi-convex lens immediately in front \nof the eye \xe2\x80\x94 that is, directly between the patient\'s eye and our \nown. In this manner we may detect slight opacities or irregu- \nlarities in the cornea which would otherwise escape notice, ex- \namine minutely the texture and condition of the iris, discover \nthe faintest traces of cataract, or the presence of foreign bodies \nin the anterior chamber, observe various morbid changes in the \nvitreous, hemorrhagic effusions, floating opacities, etc., and, in \nsome cases, the projecting folds of a detached retina. It \nwill thus be seen that lateral illumination is oftentimes no mean \nsubstitute for the ophthalmoscope, while the ease and rapidity \nwith which it may be employed renders it doubly valuable as \na means of detecting many diseased conditions. A good rule, \ntherefore, and one that is generally observed in practice, is to \nbegin the examination with oblique illumination, and, if there \nis any remaining obscurity about the case, to clear up the diag- \nnosis with the ophthalmoscope. \n\n3-SPECTACLES. \n\nThese are generally employed for the purpose of correct- \ning such optical defects as cannot otherwise be rectified. They \nconsist of convex spherical lenses for the correction of hyper- \nmetropia, concave spherical for myopia, cylindrical for astigma- \ntism, and a combination of both spherical and cylindrical for \ncomplicated forms of ametropia. Besides these we have the \nfollowing special forms and combinations : \n\nPantoscopic Spectacles \\ termed by the French verres a double \n47 \n\n\n\n370 Practice of medicine. \n\nfoyer, consist of lenses the upper and lower half of which have \ndifferent foci. They are especially useful where the presbyopia \nis combined with myopia or hypermetropia. In the former \ncase the upper half should be concave to neutralize the myopia, \nand the lower half convex to neutralize the presbyopia. \n\nPeriscopic Spectacles, consisting of concavo-convex glasses, \nare constructed for the purpose of reducing the spherical aber- \nration to a minimum. When the concave surface is towards \nthe eye, the image is less distorted, on account of there being \nless irregular refraction at the periphery of the lenses ; conse- \nquently, the observer is enabled to look more obliquely through \nthem. \n\nPrismatic Spectacles, the glasses of which are ground either \nin the form of prisms, or of prisms and lenses combined, are \nused for relieving or strengthening certain muscles of the globe. \nThe bases of the prisms are generally turned inwards, for the \npurpose of relieving the internal recti muscles. (See Muscular \nAsthenopia). The same object may be accomplished by what \nare called decentered lenses. These are so constructed as to \nthrow the centre a little to the inner side of the visual axis in \nconvex lenses, and to the outer side in concave glasses, thus \nproducing a slight prismatic effect. \n\nCataract Spectacles consist of convex lenses of great \nrefractive power. The eye having lost the power of accom- \nmodation, two sets will be required, one for near objects, of \nabout two and a half inches focal length, and the other of \nabout four and a half inch focus for distant objects. The \nglasses should be small, as large ones, by admitting too much \nlight, generally cause more or less dazzling. They are, of \ncourse, adapted to every form of aphakia. \n\nStenopaic Spectacles are constructed for the purpose ot \nexcluding the peripheral, and permitting only the central rays \nof light to enter the eye. For this purpose, metallic plates \nwith small central apertures are used in place of glasses. \nThey increase the sharpness of vision for near objects, and are \n\n\n\nTEST TYPES. 37 1 \n\nalso useful in opacity of the cornea, but as they contract the \nfield of vision, they are not adapted for distant objects. \n\nProtective Spectacles, or eye protectors, are composed of \nvariously colored glasses, amber, brown, grey, blue, green, etc. \nThe majority of ophthalmologists recommend blue glasses, as \nthese exclude the orange rays, which are the most irritating to \nthe retina ; but Dr. Dobrowolski, of St. Petersburg, gives the \npreference to grey or smoke-colored glasses. He argues that \nin attempting to shield the eyes from too bright a light, we \nshould employ glasses which will diminish equally all the rays \nwhich constitute sun-light, and not confine the patient to blue \nglasses, which only exclude the yellow rays, nor to green ones, \nwhich only protect the eye from the red rays, but should use \nthe grey or smoked glasses, which not only diminish the \npassage of all the rays, but also enable the eye to readily \naccommodate itself again to ordinary sunlight, a matter of \nsome difficulty after wearing the blue spectacles.* \n\nThe most convenient instrument for ascertaining the focal \nstrength of lenses, is formed on the model of the ordinary \nmeasuring stick used by shoemakers. The stationary upright, \nor toe piece, is fitted to receive the lens, and the movable \nupright, or heel piece, has attached to it a card on which are \nsmall printed letters. Placing the card at the focal distance \nrequired, the power of glasses is readily ascertained by chang- \ning the lenses until a suitable one is found, or by selecting \nanother lens which, placed before the first, will render the \nletters distinct, and then adding or subtracting its power. \n\n4.-TEST TYPES. \n\nIn order to have some generally accepted standard by \nwhich the range and acuteness of vision may be readily ascer- \ntained, and referred to in published cases, Prof. Jaeger, Dr. \n\n\n\nAm. Horn. Obs., vol. xi, p. 555. \n\n\n\n372 PRACTICE OF MEDICINE. \n\nSnellen, and others, have published different series of test \nletters. Those of Jaeger begin with the smallest type used \nin printing, and gradually increase to letters of a size to be \neasily distinguished by a normal eye at a distance of twenty \nfeet. Dr. Snellen\'s test types extend the scale, by means of \nletters made up of squares, to two hundred Paris feet. These \ntwo scales, which are the ones in general use, do not exactly \ncorrespond, that is to say, No. 20 Jaeger does not represent \nprecisely the same point in the scale as Snellen, XX, and \nhence it is best to specify the particular scale employed in the \ntest when the lower Nos. are used. \n\nFigures are placed above each series of letters, indicating \nthe distance, in feet, at which they may be read by a normal \neye. Thus, No. 10 should be read with ease at a distance of \nten feet ; but if it can be read only at a distance of five feet, \nwe say V, which expresses the acuteness of vision, \n\n_5_ 1 \n\n10 2. \nIf No. 18, which should be read by an emmetropic eye at \neighteen feet, can be read only at a distance of twelve feet, \nwe say \n\nV = \xe2\x80\x94 = - \n12 3. \n\nThe numerical values found in thif manner do not always \n\naccurately represent the acuteness of vision, although sufficiently \n\nprecise for all practical purposes. For example, a sharpness of \n\n6 4 3 \n\n\xe2\x80\x94 \xe2\x80\x94 or - \n\n18, 12 9. \n\njs not necessarily the same as -J- ; for eyes that see No. 18 at \nsix feet, may not see No. 9 distinctly at three feet, or No. 3 at \none foot. Hence, as Stellwag points out, if we would represent \naccurately the state of vision, we must avoid all reduction of \nthe fraction. \n\n\n\nDISEASES OF THE EYE. 373 \n\n\n\nDIV. VL\xe2\x80\x94 FUNCTIONAL DISEASES. \n\nThe diseases which we propose to consider in this section, \nare those functional disorders immediately influencing the \naccommodation, more especially asthenopia, and paralysis and \nspasm of the ciliary muscle ; those of refraction, namely \nmyopia, hypermetropia and astigmatism ; those affecting the \noptic nerve and retina, particularly hyperaesthesia, anaesthesia, \namblyopia, hemeralopia, and amaurosis ; and those involving \nthe ocular muscles, especially nystagmus and strabismus. \nAssuming that the reader is already sufficiently acquainted \nwith the refractive properties of the different kinds of lenses, \nwe shall proceed at once to consider \n\nl.-THE THEORY OP ACCOMMODATION. \n\nIt is assumed, in the first place, that all rays emanating \nfrom distant objects, by which is meant all objects at or \nbeyond twenty feet from the observer, are parallel ; that is, \nthe divergence being too slight to be taken into account, the \nobjects are considered as if they were placed at an infinite \ndistance. Such rays the refractive media of an emmetropic \neye, when in a state of rest, are adapted to bring to a focus \nupon its retina, and thus to produce distinct images of the \nobjects from which they emanate. The eye is then said to be \naccommodated for its far point, (punclnm remotissimuni), \ndenoted by the letter r. Being thus adjusted for parallel \nrays, the normal eye perceives distant objects without any \neffort of the accommodation. And since the more distant \nthe object the more nearly are the rays from it rendered \nparallel, it follows that the furthest point of distinct vision \nmust be at an infinite distance. \n\nBut if the rays, instead of being parallel, are very diver- \ngent, as in the case of very near objects, the state of refraction \nof the normal eye is such that they can only be brought to a \n\n\n\n374 PRACTICE OF MEDICINE. \n\nfocus behind the retina, unless it can increase the amount of \nrefraction sufficiently to focus them upon the retina. Now the \nnormal eye is provided with an apparatus by which it is \nenabled, intuitively and unconsciously, to increase or diminish \nat pleasure the amount of its refraction, and thus to adjust \nitself for near vision. When thus adjusted, the eye is said to \nbe accommodated for its near point, (punctum proxirnum), \ndenoted by the letter/. \n\nThe distance between these two points is called the range \nof accommodation, and is expressed by the letter A. In the \nyouthful emmetropic eye, it extends from about three and a \nhalf or four inches, the nearest point of distinct vision, to the \nfurthest point, which, as we have seen, lies at an infinite \ndistance. Anywhere between these points objects may be \ndistinctly seen ; but beyond the point for which the eye is \naccommodated, circles of dispersion are formed upon the \nretina, and the images appear blurred. \n\nIf, as proposed by Prof. Donders, the range of accommo- \ndation be expressed by i, the distance of the near point (p) \nfrom the eye, measured from the nodal point, by h and that of \nthe far point (r) by \xc2\xa3, its value in any particular case may \n\nbe readily determined by the formula \n\ni 1 i \n\nA P R. \n\nThus, in an emmetropic eye, if the nearest point at which \n\nvision is distinct is 5", and the furthest point is an infinite \n\ndistance, qq, we have by the above formula \n\n1 1 1 1 \n\nA 5 00 5. \n\nHere the range of accommodation is represented by what \nis called a 5 inch lens ; that is, it would require a convex lens \nof five inches focus to be placed before the eye, to render the \nrays coming from an object placed at the near point (5") \nparallel, or what is the same thing, give them the direction \nthey would have if the object were situated at an infinite \ndistance. \n\nThe theory of accommodation upon which these con- \n\n\n\nTHE THEORY OF ACCOMMODATION. 375 \n\nelusions are based, and which is now generally accepted as the \ntrue one, though ably advocated by Thomas Young as early \nas the beginning of the present century, did not receive a full \nand satisfactory demonstration until Cramer and Helmholtz, \nworking independently of each other, furnished, by means of \ningeniously devised instruments, incontestable proof of the \nalterations of curvature in the crystalline lens, when the eye is \naccommodated for near and distant objects, and at the same \ntime proved that no change occurs in the curvature of the \ncornea. \n\nThe changes in question may be readily demonstrated, \nocularly, by placing a lighted candle at a certain distance to \nthe right of a given fixed point, P, towards which the observed \neye is steadily directed, while the eye of the observer is \nsituated at an equal distance to the left of the same point. \nFig. 18, representing the pupil of an eye \nthus observed in a state of rest, (r), \nshows the three images formed by reflec- \ntion from the cornea, (a), anterior capsule, \n(b), and posterior capsule, (c). Fig. 19 \nshows the same eye in a state of accom- \nmodation for the near point, (/); the \npupil is somewhat contracted, as shown by the circular white \nline, and the image forms by the anterior capsule, (b), is found \nto be changed both in size and position. The image is \n^^^ rendered smaller in consequence of the \n\nincreased curvature of the anterior \nsurface of the lens, which forms a convex \nreflector of less radius. The change of \nposition is due to the projection forward \nof the reflecting surface, in consequence \nof the lens being increased in thickness \nduring accommodation. The other images have undergone \n\n\n\n\n\n37^ PRACTICE OF MEDICINE. \n\nno perceptible change, showing that neither the curvature of \nthe cornea, nor the curvature or position of the posterior \nsurface of the lens, undergo any perceptible change during \naccommodation. \n\nFig. 20. \n\n\n\n\nIn full accom. Eye at rest. \n\nFig. 20 illustrates the changes which occur during accom- \nmodation. The right half of the figure represents the eye in \na state of rest, i, e., when accommodated for distance ; the left \nhalf shows it when fully accommodated for near vision. The \nrelative difference in curvature of the anterior surface of the \nlens, on the two sides, corresponds very closely with the \nmeasurements of Cramer and Helmholtz. According to the \nlatter, the changes that occur during accommodation for near \nobjects are, (1) contraction of the pupil; (2) the pupillary \nmargin of the iris is pushed forward ; (3) the peripheral \nportion of the iris moves backwards. (4) the anterior surface of \nthe lens becomes more convex, and is arched forward, so as to \nrender the lens considerably thicker in the antero -posterior \ndiameter, and give it much greater refractive power ; (5) the \nposterior surface of the lens is also rendered more convex, but \nnot to such a degree as to cause any perceptable change in its \nposition. \n\nIt was formerly supposed that whilst the chief influence \nconcerned in the function of accommodation is exerted through \nthe action of the ciliary muscle, the iris also materially assists \n\n\n\nTHE THEORY OF ACCOMMODATION. 377 \n\nin the process ; but as the accommodation has since been \nfound to remain unimpaired, in a case in which the entire iris \nwas removed after an accident, there can no longer be any \nroom for doubt that the change in the form of the lens is \nwholly due to the action of the ciliary muscle. But the \nmanner in which the muscle causes the change in question has \nnot yet been satisfactorily answered. The most probable \nexplanation is, that, so long as the ciliary mucles continues \npassive, the lens remains in its usual condition ; but as soon \nas the muscle contracts the suspensory ligament becomes \nrelaxed, and the lens then increases its convexity by virtue of \nits own elasticity. \n\nAnother factor in the procees of accommodation was, \nuntil recently, supposed to exist in the action of the internal \nrecti muscles, in causing the necessary convergence of the \noptic axes for binocular vision ; but a case of Von Graefe\'s, \nin which all the external muscles of both eyes were completely \nparalyzed, and yet the power of accommodation remained \nunimpaired, clearly proves the contrary. \n\nIt is thus seen that refraction and accommodation are \ntwo entirely different processes. The former is a passive \ncondition, depending wholly upon the focusing power of the \ndioptric apparatus, which is chiefly due to the form of the eye \nand of its different refracting media. In these respects the \neye does not essentially differ from any other optical instru- \nment, the images being formed agreeably to the well-known \nlaws of optics. Accommodation, on the other hand, is a \npurely physiological process, being the result of muscular or \nvital action, and is none the less real in consequence of being, \nfor the most part, unconsciously and involuntarily performed. \n\nThat the focusing power of the crystalline lens is \n\ncontrolled by the action of the ciliary muscle, is clearly \n\nproven by the suspension of the function whenever paralysis \n\nof the muscle occurs from disease, or whenever it is artificially \n\ninduced by the action of Atropine. \n48 \n\n\n\n378 PRACTICE OF MEDICINE. \n\n2.-AN0MALIES OF ACCOMMODATION. \n\nHaving shown that the function of accommodation is \ndependent upon the action of the ciliary muscle, it remains to \nconsider the principal causes which are known to limit or \ndisturb the process. These are, (i), presbyopia, which is a \nlimitation of the function due to advancing age ; (2), paralysis \nof the ciliary muscle, which is occasionally met with after \nsevere illness ; and, (3), spasm of the ciliary muscle, which is \nfrequently the result of over-working the muscle in accommo- \ndation. \n\nA.\xe2\x80\x94 Presbyopia. \n\nThis affection, which was formally supposed to arise from \ndeficient refractive power, is now known to have very little \neffect upon distant vision, the actual change consisting in the \nrecession of the near point, and consequently in a limitation \nof the range of accommodation. This removal of the near \npoint from the eye, is caused by senile changes in the crystalline \nlens, whereby its hardness is increased, so that its form becomes \nless and less susceptible of alteration from the action of the \nciliary muscle, and hence the function of accommodation \ncorrespondently impaired. As this increase in the density of \nthe crystalline is a purely physiological process, it may \ncommence at any age, and may affect both emmetropic and \nametropic eyes. In point of fact, it is found to begin very \nearly, gradually increasing with advancing years, until, at the \nage of forty or forty-five, the near point is at eight inches from \nthe eye, the distance which, for the sake of definiteness, has \nbeen selected as the limit from which to reckon the commence- \nment of presbyopia. As age advances the refractive power \nof the lens also suffers, so that the eye not only becomes \npresbyopic, but hypermetropic. \n\n\n\nPRESBYOPIA. 379 \n\nAs presbyopia diminishes the range of accommodation, \nit cannot be of benefit, as is frequently supposed, to the \nmyopic eye. It is true, the senile changes in the refractive \npower of the lens will have a slight tendency to diminish the \nmyopia, and if moderate may serve to correct it ; but as the \nfar point remains pretty much the same, the only effect will be \nto shorten the range of adaptation, which is already greatly \nreduced by the approximation of the far point. Presbyopia \nsupervening upon hypermetropia is, of course, still more \nserious, loss of accommodation being added to diminished \nrefraction. \n\nSince no effort of the ciliary muscle will render the lens \nsufficiently convex for near vision, it should be aided by suit- \nable glasses. The patient should be advised to commence \ntheir use as soon as the presbyopia begins to be noticed, and \nnot postpone wearing them under the mistaken notion that he \nmay thereby be enabled to dispense with them altogether, for \nthis will necessarily fatigue and strain the accommodative \napparatus, and may possibly result in even more serious \ndisability. \n\nThe strength of the required glasses may be easily found \nfrom the formula \n\nPr = i-\xc2\xb1 \n\n8 P\' \n\nwhere Pr donotes the degree of presbyopia, 8" the presbyopic \nnear point, and p\' the observed power of the presbyopic eye. \nFor example, if we find the nearest point of distinct vision to \nbe twenty-four inches, then the value of Pr will be \n\n8 24 12 > \n\nthat is, it will take a convex lens of twelve inches focal length \nto neutralize the presbyopia, and enable the patient to see \nclearly at the distance of eight inches. \n\nIf the presbyopia is complicated with myopia or hyper-^ \nmetropia, it may become necessary to supply the patient with \ntwo sets of glasses, the myope with convex glasses for small \n\n\n\n380 PRACTICE OF MEDICINE. \n\nobjects, to remedy the loss of accommodation, and concave \n\nglasses for distance, to neutralize the increased refraction ; \n\nwhile the hypermetrope will require two pair of convex glasses, \n\none for near vision, to compensate for deficient refractive power \n\nand the loss of accommodation, and the other far distant \n\nvision, to neutralize the hypermetropia. \n\nTo ascertain the range of accommodation for presbyopic \n\neyes, we may make use of the formula already given, namely, \n\ni i i \n\nA P R. \n\nThus, if the near point (p) be at fifteen inches, and the \n\nfar point (r) at infinite distance (oo ), we have \ni _i i j_ \n\nA 15 oo 15. \n\nIn choosing glasses it is well not to be governed too \nrigidly by Donder\'s near point (8"); but to be influenced to \nsome extent by the distance at which the patient has been \naccustomed to read or sew. If this has been at a considerable \ndistance, it will be more convenient not to have the near point \nbrought within ten or twelve inches. We should also be \nguided in this matter by the range of accommodation. If this \nis large, we may, if the patient prefers, bring the near point to \neight inches, or even less if the sharpness of vision is dimin- \nished ; but if the range of accommodation is greatly lessened, \nweaker glasses should be selected, as these will be less fatiguing \nto the eye ; such, for example, as will enable the patient to \nread No. I of the test types at about twelve inches. \n\nB.\xe2\x80\x94 Paralysis of the Ciliary Muscle. \n\nThis affection, which is not of very frequent occurrence, \nsometimes follows exhausting diseases, especially diphtheria. \nParesis, or partial paralysis, is occasionally associated with \ngeneral atony of the muscular system, and is then apt to be \nmistaken for amblyopia depending upon general debility. \n\nAs the paralysis lessens or destroys the power of accom- \n\n\n\nSPASM OF THE CILIARY MUSCLE. 38 1 \n\nmodation, emmetropic eyes are unable to accurately distinguish \nnear objects, though their ability to see distinctly at a distance \nis not impaired. But its effect upon vision is most marked \nin hypermetropic eyes, as these are obliged to exercise the \nfunction of accommodation even at a distance, and consequently \nlose the power of seeing any object with distinctness, whether \nnear or remote. The myope, on the contrary, only becomes \naware of the defect when looking at very near objects. If \nthe paralysis is incomplete, these effects will, of course, be less \nconsiderable. In the latter case the symptoms may be \nmistaken for those of asthenopia, unless the range of accom- \nmodation is also examined. This is all the more necessary \nin these cases, because, in simple paresis, the contractility of \nthe pupil and the various movements of the globe generally \nremain unimpaired ; whereas in complete paralysis of the \naccommodation there is almost always dilatation of the pupil \nand divergent strabismus. \n\nTREATMENT. \xe2\x80\x94 This consists chiefly in perfect rest of the \neyes, and the employment of such hygienic measures as are \nbest calculated to invigorate the general system. If the \npatient is obliged to exercise his accommodation, he should be \nsupplied with such convex glasses as will enable him to see \ndistinctly without exertion, being careful to gradually diminish \nthe strength of the lenses, in proportion as the accommodative \nfaculty improves. \n\nThe remedies which have hitherto proven most beneficial \nin this affection are : Caust., Physostig. ven. (used externally), \nand electricity ; good results have also been obtained in some \ncases from the internal administration of Arg. nit., Arn., Cup. \nacet., Euph., Gels., Kali iod., Opium, Paris q., and Rhus tox. \n\nC\xe2\x80\x94 Spasm of the Ciliary Muscle. \n\nThis is not, as was formerly supposed, a very rare affection, \nbeing sometimes associated with both myopia and hypermetro- \npia. It is most frequently met with in young subjects who \n\n\n\n382 PRACTICE OF MEDICINE. \n\nhave strained their eyes in reading or fine work, the spasm \nbeing the result of over-tasking the ciliary muscle, in accom- \nmodating the eye for near objects. This causes an apparent \nmyopia, so that the patient sees better through concave glasses ; \nbut if we paralyze the ciliary muscle by means of Atropine, we \nshall generally find that the eye is really hypermetropic. \nSuch persons perceive distant objects very indistinctly ; and \nalthough near objects may be seen clearly for a short time, \nthe effort at accommodation soon fatigues the eye. The pupil \nis generally contracted ; and the iris is bulged forward by the \nincreased curvature of the lens. If we examine with the \nophthalmoscope, we shall find that the refraction is highly \nhypermetropic, and that the optic disc and retina are more or \nless hyperaemic ; there is also, not unfrequently, a co-existing \nposterior staphyloma. \n\nTreatment. \xe2\x80\x94 The most speedy and effective treatment \nconsists in completely paralyzing the ciliary muscle with \nAtropine. For this purpose we require a strong solution, say \nfour or five grains to the ounce, which should be used three or \nfour times daily, until the spasm is entirely overcome. If it \nreturns we should enjoin complete rest of the eye, and endeavor \nto improve the general health by regular out-door exercise, \nand other hygienic means. If necessary, we should prescribe \nstrong convex glasses for near objects, and weak ones for \ndistance, the regular use of which will diminish the spasm by \nproducing complete rest of the accommodation. Internally, \nwe obtain the best result from the Physostigma ven. \n\n3 -ANOMALIES OF REFEACTION. \n\nAn emmetropic eye is one whose dioptric media possess a \nrefractive power just sufficient, when the accommodation is at \nrest, to form well-defined images of distant objects upon the \nretina ; it also possesses the power of increasing or diminishing \n\n\n\nMYOPIA, 383 \n\nthe refraction at pleasure, thus adapting itself to distinct \nvision at any distance. But there are eyes which do not \npossess these optically normal powers, namely, those in which \nthe optic axis is too long, constituting myopia; those in which \nit is too short, producing hypermetropic/, ; and those in which \nthe cornea or lens have an unequal curvature in different \nmeridians, giving rise to astigmatism. \n\nA.\xe2\x80\x94 Myopia, \n\nNEAR -SIGHTEDNESS. \n\nWe have already remarked, that in the myopic eye \nparallel rays are brought to a focus before reaching the retina. \nThis optical defect is due to the refractive power of the eye \nbeing relatively in excess ; that is, although the refractive \npower may not be too high for a normally constructed eye, it \nis so in relation to the myopic eye, the antero-posterior axis of \nwhich is too long. It was formerly supposed that in myopia the \ncornea or lens was too convex, or that the latter was misplaced ; \nbut exact measurements have shown this not to be the case, \nand that the lengthening of the optic axis is due to a bulging \nof the posterior portion of the globe, in consequence of which \nthe retina is situated too far back of the lens and cornea. \nThe consequence of this displacement is, that while divergent \nrays, or those coming from near objects, may be brought to a \nfocus upon the retina, and thus afford distinct vision when the \naccommodation is at rest, parallel rays, or those coming from \ndistant objects, form upon that membrane greater or less \ncircles of dispersion, which render the images indistinct. It \ndoes not necessarily follow, however, that because a patient \nholds small objects very near to his eyes, or because he cannot \nsee well at a distance, he is myopic, as similar symptoms may \noccur in hypermetropia. But if, in proportion as the object is \nremoved from the eye, the vision becomes rapidly indistinct, \n\n\n\n384 PRACTICE OF MEDICINE. \n\nand there is no other apparent cause, we may strongly suspect \nthe existence of myopia ; and if the vision is greatly improved \nby the use of weak concave lenses \xe2\x80\x94 say of thirty or forty \ninches focus \xe2\x80\x94 the myopic condition is rendered almost certain. \nBut, as slight changes in refraction may be overcome by the \naccommodative power, and also by extreme degrees of myo- \npia, it is better to ascertain at once the far point, and then, by \nplacing concave glasses of the corresponding number before \nthe patient\'s eyes, he will, if myopic, be able to see clearly at \na distance, and there will no longer be any doubt. \n\nWe may also determine the existence of myopia with the \nophthalmoscope. If we make use of the direct method of ex- \namination, we may be able to perceive the details of the fundus \nat some distance from the eye, and if we move our head to \neither side, we shall find that the retinal image moves exactly \nin the contrary direction. But in order to obtain a distinct \nimage of the fundus, we shall, if the eye is strongly myopic, \nrequire a concave correcting lens behind the mirror. We shall \nnow probably discover that the malformed eye is also a dis- \neased one, there being, in the majority of cases, a greater or \nless degree of posterior staphyloma. This condition, which \nexists chiefly in progressive myopia, is generally associated \nwith a sclero-choroiditis posterior. If the myopia is stationary, \nor but slowly progressive, it causes but little inconvenience in \nreading, sewing, etc ; but if rapidly progressive, it is apt, in \nconsequence of the choroiditis, to be accompanied with symp- \ntoms of high irritation and inflammation, and may even prove \na source of great danger to the eye. (See Sclero-choroiditis \nPosterior) \n\nMyopia is frequently congenital, and sometimes heredita- \nry, but the researches of Dr. Cohn and others show that, in all \nprobability, it is very often acquired. Dr. Cohn found that, of \none hundred and thirty-two compositors, more than half (51,5 \nper cent.) were myopic ; and of the sixty-eight myopes, not \n\n\n\nMYOPIA. 385 \n\nless than fifty-one (y$ per cent.) were possessed of normal \nvision in early life. It is almost certain that the continuous \nuse of the eyes for near objects, especially by the young, is a \nfruitful cause, if not of the origin of myopia, at least of its de- \nvelopment. Out of ten thousand and sixty school children \nexamined, this investigator found one thousand and four my- \nopes, the proportion increasing in the higher departments, ac- \ncording to the increased demand for study. Thus, of the four \nhundred and ten students in the University of Breslau nearly \ntwo-thirds were affected with a greater or less degree of myo- \npia. \n\nTreatment. \xe2\x80\x94 This will vary according as the myopia is \nstationary or progressive. The latter, if marked, and especially \nif occurring in youthful subjects, will require similar treatment \nto that recommended for Sclero-choroiditis Posterior (which \nsee). But if stationary, or if the progress is too slow to be \nperceptible, and especially if it does not give rise to any mark- \ned inflammatory symptoms, no preliminary medical treatment \nwill be called for, and we may immediately proceed to select \nthe requisite glasses. \n\nIt is very important that the strength of the glasses re- \nquired for correcting the refraction should be determined with \nthe greatest accuracy. As the degree of myopia (M.) is meas- \nured by the far point (r.) for distinct vision, we first determine, \nby means of the test types, the furthest point at which the \npatient can clearly distinguish the letters. For example, if \nhe reads No. 1 with facility at one foot, but is unable to distin- \nguish No. 2 clearly at two feet, or No. 3 at three feet, and so \non, and yet is able to read No. 2 easily, say at twenty inches, \nwe represent the degree of myopia by the formula, \n\nM = \xe2\x80\x94 > \n\n20 \n\ntwenty inches being the furthest point at which vision is dis- \ntinct ; it will, therefore, require a concave lens of twenty inches \n\nfocus to neutralize the myopia. But, although No. 20 is theo- \n49 \n\n\n\n386 PRACTICE OF MEDICINE. \n\nretically the proper glass, it is rarely the case that the strength \ncan be accurately determined in this manner; as a general \nrule the glass will be found somewhat too strong, and will re- \nquire to be corrected by subtracting the power of the weak \nconvex lens necessary to correct it. On the other hand, if the \noriginal glass is too weak, we should add the power of the weak \nconcave lens required to give it the appropriate strength. The \ncorrection is made according to the following formula : \n\na\xc2\xb1b \n\nx= , \n\nab \n\nthat is, the power of the required lens (x) is equal to the sum \nor difference of the powers of the two lenses divided by their \nproduct. Take, for example, the case above cited. We first \ntry the patient with a pair of 20-inch concave glasses, and di- \nrect him to read, say No. XX. Snellen at twenty feet. He will \nno doubt notice at once a marked improvement in his vision. \nWe now place in front of the former glasses a very weak pair, \nsay No. 60 concave, and, if his vision is still further improved, \nthe original pair are too weak. Suppose that upon repeated \ntrial this No. 60 concave is found to be the best corrective of \nthe first pair of glasses, then, according to the formula \n\na\xc2\xb1zb 20-J-60 \nx= = \n\n\n\n\xe2\x80\x94 \xe2\x80\x94 T5"J \n\nab 20X60 \n\n\n\nwhich gives concave 15 as the proper glass. But suppose, in- \nstead of a No. 60 concave, it takes a No. 60 convex to render \ndistant vision distinct through the original glasses. This proves \nthat the latter are too strong, and we have \n\na\xc2\xb1b 60 \xe2\x80\x94 20 \n\nx= === \xe2\x80\x94 tct > \n\nab 60X20 \n\nShowing that only a concave 30 would be required to correct \nthe myopia.* \n\n\n\n*Convex lenses are generally designated by the positive or + sign, and concave lenses \nby the negative or \xe2\x80\x94 sign. If two or more are used in conjunction, the power of the com- \npound lens will be represented by their sum, if the signs are alike, and by their difference, \nif unlike. \n\n\n\nMYOPIA. 387 \n\nIf the patient wishes to procure glasses for some special \npurpose, such as reading music, he will need a pair of less \npower than those required for distant vision. For example, if \nhis myopia =J-, and he wishes to read at twenty-four inches, \nthe formula will be \n\n~~ 6 "\xe2\x80\xa2" TZ J; \n\nHence a concave 8 will be required. \n\nIn order to decide the question as to whether or not it will \nbe proper to allow the use of glasses for near objects, it will be \nnecessary to determine the range of accommodation. For this \npurpose, we may make use of the method already given ; that \nis, we first find the nearest and furthest point at which No. I \nof the test types can be clearly distinguished, and then deduct \none from the other, according to the formula \n\n\n\nFor example, suppose the far point is at eight and the near \npoint at two inches ; then we have \n\nA 2 8 2-| \n\nBut this method is less certain than that of Prof. Donders, \nwhich only requires the patient to accommodate for his far \npoint. Having first neutralized the myopia, which is done by \nusing such concave glasses as render distant objects distinct \n(No. 20 at twenty feet), the near point is ascertained by requir- \ning the patient to read No. 1 of the test types. Suppose this \npoint is found to be at three inches ; then, as r=oo , and p=3 /r , \n\nwe have \n\n1 1 1 1 \n\na 3 <\xc2\xbb 3. \n\nIf only one pair of glasses is used, it is safest to wear \n\nthose which do not quite neutralize the myopia. If of full \n\nstrength they will be too strong for near vision, and will be \n\nlikely to overtask the accommodation. To prevent this, the \n\nconfirmed myope generally employs only one eye for near ob- \n\n\n\n388 PRACTICE OF MEDICINE. \n\njects, and thus avoids the convergence of the optic axes re- \nquired in binocular vision. But this leads insensibly to a still \ngreater evil, namely, divergent strabismus, which is found to be \nof very frequent occurrence in myopia. We should be careful, \ntherefore, to follow the advice of Prof. Donders, and prescribe \nonly "spectacles so weak as to avoid these results." \n\nB. \xe2\x80\x94 Hypermetropia. \n\nThis affection, the opposite of myopia, was formerly con- \nfounded with presbyopia ; or, rather, the condition now called \nhypermetropia was regarded as a particular form of presbyo- \npia. This opinion, however, was erroneous, the refractive \npower for distant objects being normal in presbyopia, whereas \nin hypermetropia it is deficient, in consequence of the shorten- \ning of the optic axis ; hence parallel rays are brought to a focus \nbehind the retina, and only convergent rays come to a focus \nupon it. And since in this affection even parallel rays require \nan effort of accommodation to concentrate them upon the re- \ntina, it follows that, although hypermetropic eyes may be able \nto accommodate themselves to distinct vision for a short period, \nthe constant use of them must soon become fatiguing and pain- \nful, especially for near objects. In fact, this is often the most \nobvious symptom in hypermetropic eyes ; for while there may \nbe no apparent disease existing, the vision being pt^fectly good, \nthe eyes are incapable of continued use, especially upon small \nobjects, without causing so much fatigue and confusion of sight \nas to compel the patient to desist from his employment, (as- \nthenopia). \n\nProf. Donders divides hypermetropia into three forms, \nnamely, the faculative y the relative, and the absolute. The fac- \nulative form is that in which the eye readily accommodates \nitself for all distances, and the patient experiences no fatigue \nwhile at work ; but presbyopia sets in early, accompanied by \n\n\n\nHYPERMETROPIA. 389 \n\nsymptoms of asthenopia. In the relative form of hyperme- \ntropia, the eye is also enabled to accommodate itself for any \ndistance, but only by great effort, and by a too strong con- \nvergence of the optic axes. This form, which generally oc- \ncurs soon after puberty, is always attended with more or less \nasthenopia. Absolute hypermetropia, on the contrary, is a \nform in which no effort of the accommodation will enable the \npatient to see distinctly, without glasses, at any distance. It \ngenerally occurs at a later period in life than either of the pre- \nceding forms. \n\nIf we examine the hypermetropic eye with the ophthal- \nmoscope, by the direct method, we get an erect image, con- \ntrary to what occurs in the myopic eye ; for if we fix our at- \ntention upon any of the details of the fundus, such as the optic \ndisc or retinal vessels, and move our head to either side, the \nimage is seen to move in the same direction. By the indirect \nmethod, the image appears much larger than it does in the em- \nmetropic eye, in consequence of its being formed further from \nthe object lens. \n\nAs the asthenopic symptoms depending upon hyperme- \ntropia may be cured by the use of spectacles, it is important, \nin order to select the proper glasses, to ascertain the actual de- \ngree of hypermetropia. This is often considerably greater \nthan the manifest hypermetropia, (Hm,) in consequence of a \ncertain amount being rendered latent by the accommodative \npower, (HI,) which, as we have seen, is exercised to some ex- \ntent at all distances. Hence it becomes necessary to paralyze \nthe ciliary muscle by Atropine, before we can estimate correct- \nly the amount of absolute hypermetropia, (Ha). If we then \ntest the vision for distance, we shall find that the patient re- \nquires the aid of a convex lens, or if presbyopic, he will require \nmuch stronger glasses than he did before the accommodative \nfunction was suspended. The power of these glasses being \nthe measure of the absolute hypermetropia, the latter may be \nexpressed by the formula, Ha = --- etc. \n\nr J 10. 16. 20, \n\n\n\n390 PRACTICE OF MEDICINE. \n\nHaving neutralized the hypermetropia by the proper \nglasses, we may readily ascertain the range of accommodation \nhy measuring the nearest point at which the patient can dis- \ntinctly read No. I of the test types with these glasses. In \nyoung individuals, in whom the accommodative power is gen- \nerally very strong, it often amounts to - or even - \n\nHypermetropia is of frequent occurrence in childhood, \nand is often hereditary. It is generally caused, however, by \nsenile degeneration of the lens, the latter becoming more and \nmore flattened and less susceptible of a change of form by the \naccommodative power. It may also be caused artificially, by \nremoving the lens from the optic axis, as in operations for cat- \naract. In these cases, the power of accommodation is entire- \nly lost, and the hypermetropia is always absolute. \n\nAccording to Dr. Cohn, nearly two-thirds of the cases oc- \ncurring in childhood lead to convergent squint. Later in life \nit causes accommodative asthenopia. As age increases, the \nrange of accommodation diminishes, and the patient can only \nsee large and remote objects. \n\nTREATMENT. \xe2\x80\x94 We have already pointed out the principles \nto be observed in the selection of the proper convex glasses, \nthe use of which constitutes the only scientific treatment of \nthis affection. They should be prescribed upon the first ap- \npearance of asthenopic symptoms. It is important that they \nshould not be too strong. De Wecker recommends the neu- \ntralization of the manifest, and about one-fourth of the latent \nhypermetropia, for near vision ; but even these glasses are \nsometimes found to be too strong for the patient. The only \nsafe rule is, to prescribe glasses which may be used for a length \nof time without causing any sense of fitigue or pain to the eye. \nThey will generally be found to be glasses of about thirty \ninches focus. \n\nIn order to cure the asthenopia, it will often become nec- \nessary, after a few weeks, to change the first pair of glasses for \n\n\n\nASTIGMATISM. 39 r \n\nstronger ones. If the hypermetropia is faculative, the cure is \ngenerally soon accomplished, and the glasses may then be dis- \npensed with ; but if the hypermetropia is relative or absolute, \ntheir use, even for distant vision, will require to be continued. \nThe main point in treatment is, to relieve, and at the same \ntime strengthen, the power of accommodation. Hence the \npatient should never attempt to read or work without the aid \nof glasses, and should always rest the eyes whenever they be- \ncome weary. He will find it beneficial, also, to follow the \nadvice of Dr. Dyer, and exercise the eyes for a few minutes \nevery day, at stated hours, in reading with proper glasses, grad- \nually increasing the time as the eyes improve, observing at the \nsame time not to overtask the accommodative power. \n\n\n\nC\xe2\x80\x94 Astigmatism. \n\nWe have hitherto regarded the dioptric apparatus as being \nperfectly symmetrical, and its different planes as having one \nand the same focus. But this is not the case even with the \nnormally constructed eye, as it is found that rays entering it \nin the vertical meridian are generally brought to a focus sooner \nthan those which enter it in the horizontal direction. This \nvariation in the refraction of the eye in different planes, which \nexists in nearly all eyes, is too slight to exercise any percepti- \nble effect upon vision. But abnormal astigmatism, which \ngenerally results from a marked want of symmetry in the curv- \nature of the cornea, makes the refractive power of the eye so \nunequal, in one or another of its meridians, as to confuse the \nretinal image and render it more or less indistinct. Similar \neffects may also be produced by a similar irregularity in the \ncurvature of the lens, but such cases are comparatively rare. \nNor is it every case of irregular corneal refraction that is in- \ncluded in our inquiry ; for such symptoms as occasionally re- \n\n\n\n392 PRACTICE OF MEDICINE. \n\n\xe2\x80\xa2 \nsuit from the cicatrization of corneal ulcers have already been \n\nconsidered. (See Keratitis, etc.) \n\nRegular astigmatism may be either simple, compound or \nmixed. It is called simple when one meridian of the cornea is \nnormal, or emmetropic, and the other myopic or hypermetropic. \nIt is compound when both meridians are myopic or hyperme- \ntropic, but in different degrees. It is termed mixed astigma- \ntism when one meridian is myopic and the other hyperme- \ntropic. \n\nOne of the most convenient tests of astigmatism is, to have \nthe patient look at the cross-bars of a window, and if he sees \neither the perpendicular or the horizontal bars more clearly \nthan the others, he is astigmatic. Or he may be examined \nin a similar manner at different distances with Snellen\'s large \ntest types, say No. LXX or C, and if a point can be found at \nwhich one portion of the letters appear clear and the other por- \ntions indistinct, the defect in vision is due to astigmatism ; \notherwise it must be referred to some other cause. \n\nThe readiest method of determining the exact direction of \nastigmatism, is, to require the patient to look through a steno- \npaic disc, which consists of a metal plate perforated with a \nnarrow slit. When this slit is held in a proper direction, that \nis, in a line with the emmetropic meridian of the cornea, the \nconfusion of vision disappears, and the patient can see clearly. \nThe degree of astigmatism may be ascertained by simply plac- \ning convex or concave glasses before the slit until we find the \nnumber which renders vision most distinct. \n\nTreatment. \xe2\x80\x94 Stenopaic spectacles will suffice to correct \nsimple astigmatism ; but the compound and mixed forms will \nrequire convex or concave cylindrical glasses, according as the \nastigmatism is hypermetropic or myopic. Cylindrical glasses \ncause no refraction in the plane of their axes, whilst those rays \nwhich pass through them at right angles to their axes are re- \nfracted most. Hence this line of the lens should be so placed \n\n\n\n} AMBLYOPIA. 393 \n\nas to correspond with the line of the greatest astigmatism. \nSphero-cylindrical glasses are required for compound astigma- \ntism, one surface being convex- or concave-spherical, to correct \nthe hypermetropia or myopia, and the opposite surface cylin- \ndrical to correct the astigmatism. Mixed astigmatism requires \nbi-cylindrical glasses for its rectification, one side of which is \nconcave, to suit the myopic meridian of the eye, and the other \nconvex, to suit the hypermetropic meridian. \n\nThe selection is best made by trial. We first ascertain \nhow much vision can be improved by means of the ordinary \nconvex or concave glasses. We then select a convex- or con- \ncave-cylindrical glass of corresponding strength, and rotate it \nbefore the eye until its axis is brought into the right direction \nto correct the astigmatism. If it is found too weak or too \nstrong we try others. \n\nHaving ascertained by trial the exact angles which the \ntransverse diameter of the glasses makes with that of the eye, \nthe greatest care should be taken to have them set in precisely \nthe same position in the frames, as the least deviation from \nthe proper plane will lessen or destroy their beneficial effect. \nFor the same reason, spectacles are to be preferred to eye- \nglasses, the latter being less nicely and less securely adjusted \nto the eye. \n\n\n\n^.-AMBLYOPIA. \n\nAmblyopia is a general name, used to denote any form of \nblindness not due to optical defect. Hence it embraces hy- \nperesthesia and anaesthesia of the retina, hemeralopia, or night- \nblindness, and even amaurosis ; though the latter term is some- \ntimes confined to cases of complete or absolute blindness, while \nthe various degrees of impaired vision, except such as arise \n\nfrom anomalous refraction, are included under the term ambly- \n50 \n\n\n\n394 PRACTICE OF MEDICINE. \n\nopia. In addition to the amblyopic affections above mention- \ned, which will be separately considered, we note two distinct \nforms, namely, such as are due to functional disturbances of \nthe circulation, and those which seem to depend upon a de- \npraved state of the blood, such as occurs in scarlet or typhus \nfever. Thus we have what is called ancemic amblyopia, from a \ndeficiency of blood. This may originate in any of the causes \nwhich give rise to general anaemia, such as excessive haemor- \nrhage, hyper-lactation, etc. Congestive amblyopia, on the other \nhand, generally results from a suppression of some customary \ndischarge, and is due to over-fullness of the vessels of the eye \nor brain. It is most apt to occur during gestation, amenorr- \nhcea, etc. Toxcemic amblyopia is commonly due to the pois- \nonous influence of such agents as tobacco, {amblyopia nicotiana), \nalcohol, {amblyopia potatorum), quinine, lead, etc. Urcemic \namblyopia has ^already been referred to under the head of ne- \nphrite ietinitis, (which see). Transitory amblyopia sometimes \noccup\xc2\xbb4n;tj^course of low diseases, such as diphtheria, scarla- \ntina, typhus fever, etc.; and it may also occur in connection \nwith derangement of the stomach from indigestion, disease of \nthe liver, etc. Finally, we have traumatic amblyopia, resulting \nfrom concussion, shock, lightning-stroke, etc. \n\nThe ophthalmoscope reveals at first no abnormal appear- \nance, unless a slightly hypersemic condition of the retina and \noptic nerve is regarded as such ; but even this is frequently \nwanting. Besides, the appearance in question is no greater \nthan is frequently met with in a normal state of vision, and \nmay therefore be regarded as physiological rather than patho^ \nlogical. Subsequently, symptoms of atrophy of the optic \nnerve make their appearance, and then the disease assumes the \ncharacter of amaurosis, (which see). \n\nPROGNOSIS. \xe2\x80\x94 This will depend chiefly on the nature of the \ncause, the length of time the disease has existed, and the age, \nhabits, and constitutional condition of the patient. In most \n\n\n\nAMBLYOPIA. 395 \n\ncases progressive atrophy of the optic nerve sooner or later su- \npervenes, and then the vision, although it may not be entirely \nlost, is seldom capable of being fully restored. Von Graefe \nfounds the prognosis upon the state of the pupil, especially in \nthe transitory form of the affection ; for if the pupil reacts un- \nder the stimulus of light, he- regards the prognosis as favorable, \neven though all perception of light may have been lost. Cases \nhave occurred, however, in which the pupils have retained their \nactivity, and yet the sight has never returned. This is espe- \ncially the case with the blindness of pregnancy, many instances \nof which have terminated unfavorably. \n\nTreatment. \xe2\x80\x94 The treatment of amblyopia should be \nchiefly directed to the removal of the cause. Thus, anaemic \namblyopia requires a liberal and nutritious diet, exercise in the \nopen air, and such internal remedies as Anac, Ars., Chin., Ferr., \nIgna., Nux v., Phos. ac, etc. Congestive amblyopia, on the \nother hand, is most frequently benefited by such remedies as \nare specially suited to the characteristic symptoms, as, for ex- \nample, Aeon., Puis., and Sep., in menstrual suppression ; Bry. \nand Cimicif., in rheumatic cases ; Cactus and Lycop. in heart \ntroubles ; Bell, Cact., Gels., Glon., Phos., and Zinc, in hyperae- \nmia of the optic nerve ; Nux v., Sec. c. and Zinc, in paralysis \nof the retina ; Bell., Glon., Phos. and Sang., in cerebral conges- \ntion, etc. Amblyopia potatorum et nicotiana require the im- \nmediate and complete abandonment of the use of spirituous \nliquors and tobacco, and the internal administration of such \nremedies as are best calculated to invigorate the general sys- \ntem, especially Ars., Chin., Igna., and Nux v. Amblyopia \nsaturnina has been greatly benefited by Opium. Traumatic \ncases, and such as result from fright or shock, are best treated \nwith Ars., Coff., Cyp., Hyos., Igna., Scut., etc. \n\n\n\n39^ PRACTICE OF* MEDICINE. \n\n5 -HYPEEJESTHESIA RETINJE. \n\nSYMPTOMS. \xe2\x80\x94 This affection, which is frequently mistaken \nfor inflammation of the retina, is characterized by symptoms \nof extreme irritation, such as severe photophobia, lachryma- \ntion and ciliary neuralgia, accompanied in some cases with \nspasmodic twitchings of the lids. The irritability of the retina \nis so intense as to give rise to painful photopsies, even in the \ndark. These generally take the form of spontaneous flashes \nof light, accompanied with sensations of dazzling before the \neyes ; and are greatly aggravated by the least exposure of the \neyes to light, or by motion, excitement, exertion, or pressure \nupon the globe. The sensibility of the retina is so much ex- \nalted, that former impressions are manifested for an abnormally \nlong period ; and even the power of seeing in the dark (nycta- \nlopia), or with an insufficient amount of illumination for normal \nvision, has in some rare instances been observed. The so- \ncalled phosphenes, or luminous rings, such as appear when the \nglobe is firmly pressed, likewise occur, either with or without \nthe dazzling sensations and photophobia. Moreover, the for- \nmer, like the latter, may appear even in complete darkness. \nIn some cases objects are seen as through a mist, or surround- \ned by circles of various colors (ckromopsia). \n\nExamined with the ophthalmoscope, the eye is found to \nbe free from every appearance of disease. The sight is good \nin a subdued light, but owing to an anaesthetic state of the pe- \nripheral portion of the retina, the field of vision is considerably \ncontracted. \n\nEtiology. \xe2\x80\x94 Hyperesthesia of the retina is most frequent- \nly met with in patients of an excitable, nervous temperament, \nespecially young and delicate females. It sometimes arises \nfrom irritation or congestion caused by exposure to very bright \nlights ; but the most common cause is straining or over-work- \ning the eyes by strong artificial light. It may also result from \n\n\n\nANESTHESIA RETINiE. 397 \n\n-a blow or other accident about the eye ; but in many cases it \ncan be traced to no apparent cause, unless it be an impaired \nstate of the general health, such as comes from a disturbance \nof the menstrual function, etc. \n\nTreatment. \xe2\x80\x94 Blue glasses, which diminish equally all the \nrays of the spectrum, should be worn as long as the eyes are \nsensitive and painful, especially in the open air, and when ex- \nposed to bright lights. If the photophobia is very severe, it \nmay be necessary for a time to exclude all rays of light from \nthe eyes ; but as the irritation subsides we should gradually ac- \ncustom them to bear the light, which in a mild form is not in- \njurious to the retina. \n\nInternally we should prescribe such remedies as will ben- \nefit the general health, and at the same time ameliorate the \nlocal symptoms. We have generally obtained the best results \nfrom Bell., Cimicif., Con., Gels., Merc, Nux v. and Puis,; but \nhave also derived benefit, in suitable cases, from Chin., Hep;, \nIgna., Nat. m., Sulph., and Tart. em. \n\n\n\n6.-ANJESTHESIA BETING. \n\nThis condition, which consists in a diminished excitability \nof the retina, is unattended by any objective symptoms. It \nis chiefly characterized by the very feeble impression which \nmoderate degrees of illumination make upon the eye ; and \nseems to arise from the blinding effect of intense light upon the \nnerve elements of the retina, whereby the latter appears to lose, \nto some extent, its power of responding to the stimulating effects \nof ordinary degrees of light. One of the most common forms \nof the affection, snow-blindness, is characterized by a dimness \nof vision which lasts as long as the affected eyes remain expos- \ned to the dazzling reflection of the bright sunlight upon the \nsnow or ice. \n\n\n\n398 PRACTICE OF MEDICINE. \n\nPartial anaesthesia generally results from direct or reflect- \ned sunlight, or other strong light, acting suddenly or continu- \nously upon the retina ; and usually takes the form of a dark \ncloud in the centre of the field of vision. This cloud is often \ntemporary, lasting but a few hours ; but it may continue for \nseveral weeks or months, and then, if circumstances favor, grad- \nually clear up and disappear. When confined to the periphe- \nry of the retina, the visual field is more or less contracted, \nwhile the degree of central vision is generally but little, if at \nall, diminished. \n\nThere is a monocular form of anaesthesia, usually called \namblyopia exanopsia, which results from disuse of the eye, as in \nstrabismus convergens, (which see). It is also frequently as- \nsociated with paralysis of the accommodative function. It is \ngenerally confined to the central portion of the visual field, and \nthis will commonly serve to distinguish it from other pathogen- \netic forms of anaesthesia, in which the periphery is mostly in- \nvolved. \n\nTreatment. \xe2\x80\x94 This should consist in attention to the gen- \neral health, regular exercise in the open air, rest and protection \nof the eyes, and the internal administration of Igna., Nux v., \nSec. c, and Zinc. \n\n7-HEMERALOPIA. \n\nNIGHT-BLINDNESS. \n\nSymptoms. \xe2\x80\x94 Hemeralopia is characterized by a state of \nvision in which the patient sees well during the early part of \nthe day, or when objects are brightly illuminated, but imper- \nfectly towards night. In high grades of the affection, the pa- \ntient is unable to distinguish even large objects towards the \nclose of the day. This is not simply owing to the time of \nday, as was formerly supposed, but chiefly to the diminished \nintensity of the light ; for it is observed that, cceteris paribus. \n\n\n\nHEMERALOPIA. 399 \n\nthe degree of amblyopia corresponds with the amount of illu- \nmination, the patient being able to see even at night, provided \nthe artificial light is sufficiently bright. It is true, however, \nthat the patient can always see best in the morning ; but this \nmay be accounted for, in part, by the reinforcement, so to \nspeak, of the retinal sensibility during the night. It appears, \ntherefore, that the dimness of vision is due to torpor of the re- \ntina ; an abnormally great amount of light being required in \norder to see distinctly. \n\nIn the morning, or when there is sufficient illumination to \nsee clearly, the pupil is generally of normal size and mobility ; \nbut as night approaches, and the illumination decreases, it usu- \nally becomes dilated and sluggish. In old and severe cases, \nhowever, the pupil is always enlarged and torpid, and it requires \nthe stimulus of a very strong light to excite contraction. \n\nHemeralopia is not always equally developed in both eyes, \nthe patient being able sometimes to discern objects with one \neye and not with the other ; or perhaps some parts of the \nvisual field may be clouded over, while in the other eye it may \nbe clear, and admit of a certain degree of indirect vision. \n\nETIOLOGY. \xe2\x80\x94 The chief predisposing cause of this affection \nis an impoverished state of the blood, in consequence of which \nthe nerve elements of the retina are insufficiently nourished. \nThis accounts for the fact that soldiers and sailors suffering \nfrom scorbutic diseases, are especially prone to be affected with \nthe disease. We also find that by far the largest number of \nhemeralopes are individuals whose constitutions have become \nimpaired by severe illness, or whose general condition is one \nof debility. It is likewise owing to this cause, doubtless, that \nthe disease sometimes prevails epidemically in camps, jails, \npoverty-stricken fever-districts, etc. \n\nThe principal exciting cause of night-blindness is pro- \nlonged exposure to intense and unaccustomed light. Hence \nits frequent occurrence in the spring and summer, increasing \n\n\n\n400 PRACTICE OF MEDICINE. \n\nin clear, and diminishing in cloudy weather. Hence, also, its \nfrequent appearance amongst harvest hands, soldiers who \nexercise much in the sunlight, and sailors who are similarly- \nexposed within the tropics. \n\nTreatment. \xe2\x80\x94 The chief indications are, to restore the \ngeneral health, and protect the eyes from bright light. If the \ncase is very severe, or very chronic, the speediest way to effect \na cure is, to apply a binocular bandage, or else confine the \npatient in a dark room, and feed him with the most nourishing \nand easily-digestible food, soups, etc. In this way, protracted \ncases have been cured in a very few days. \n\nInternally, the following remedies, which have given great \nrelief in some cases, may be prescribed, the selection depending \nmainly upon the general condition of the patient : \xe2\x80\x94 Arg. nit., \nChin., Hyos., Lyco., Ranun. bulb., Stram., and Sulph. \n\n8.-AMAUR0SIS. \n\nThe term Amaurosis was formerly used to denote any \nimpairment or loss of vision depending upon congestive, \ninflammatory, organic, or functional disease of the nervous \napparatus of the eye, whether seated in the retina, optic nerve, \nor brain. At present its signification is more restricted, the \nterm being mostly confined to cases depending upon degenera- \ntive atrophy of the optic nerve, while those arising from \nirregularities in the circulation of the nervous system, are \nincluded under the head of amblyopia, (which see). Amaurosis \ntherefore differs from other amblyopic affections in being both \nfunctional and organic. \n\nSYMPTOMS. \xe2\x80\x94 The only characteristic symptoms of amauro- \nsis are ophthalmoscopic. Of these, the most marked are : \na faint, white or bluish-white appearance of the papilla ; an \nabsence, or diminution in the size of the nutritive \nvessels of the disc ; a contraction and attenuation \n\n\n\nAMAUROSIS. 401 \n\nof the retinal vessels, especially the arteries ; and an \nopaque, somewhat irregular but sharply defined optic \ndisc, which is often slightly excavated. The amaurotic \nexcavation is liable to be mistaken for the physiological \nexcavation, which is congenital and frequently seen in the \nnormal eye, unless we bear in mind that in the latter the other \nsymptoms of atrophy above-mentioned are absent, the optic \nnerve being in its normal state. In the amaurotic excavation, \nthe retinal vessels are never displaced, as in glaucoma, the \ncavity being so shallow, and its edges sloped so gradually, that \nthe vessels appear to pass over a nearly level surface. In \nmany cases of spinal amaurosis, a bluish, or bluish-green \ndiscoloration of the papilla is especially marked, and is best \nseen by the direct method of examination. In other cases the \ndisc appears pale and white, sometimes as white as paper. \nThis is particularly the case in the form of cerebral amaurosis \ncaused by the excessive use of tobacco. In the first stage of \nthe tobacco amaurosis, which is one of congestion and very \ntransitory, the disc is abnormally red ; this is followed by \npallor of the outer half, or the part nearest the macula lutea ; \nfinally, the whole disc becomes pale, white, and in an advanced \nstate of atrophy. These changes all occur within a few \nmonths, during which the sight becomes progressively impaired, \nand often extinct. \n\nEtiology. - The most frequent cause of amaurosis is \nbasilar meningitis, especially the chronic form. It may also \nbe produced by chronic periostitis at the base of the brain, or \nby tumors within the brain or cerebellum. Other causes are : \ncerebral hemorrhages, epilepsy, and diseases of the spinal cord, \nespecially chronic myelitis and locomotor ataxy. \n\nPROGNOSIS. \xe2\x80\x94 This will depend mainly upon the cause, \nthe mode of attack, the state of the field of vision, and the \ncondition of the optic nerve. All cases, of course, are serious, \nand should be considered more or less doubtful ; hence the \n\n\n\n402 PRACTICE OF MEDICINE. \n\nprognosis should always be guarded. Sudden attacks are gen- \nerally less unfavorable than the more gradual, especially in the \ncase of children. Cases that remain stationary for a consider- \nable period are also hopeful, as they usually depend upon \ncauses which are removable, or which are more or less amena- \nble to treatment, such as the too free use of alcohol or tobacco, \nor some disorder of the stomach, liver, or uterine system, etc. \nSo, also, if the visual field remains uncontracted for a consid- \nerable time after the disease sets in, or if the edges of the field \nare regular and well-defined, the prognosis is not altogether \nbad. On the other hand, irregular contractions, occurring rap- \nidly in both eyes,are very unfavorable ; and so, also, are central \nscotomata, especially if the peripheral portions of the field are \nlikewise affected. Although the appearance of the optic nerve \nis not sufficient of itself to determine the result, yet atropic \nchanges in it are always of serious import, and, in most cases, \nrender the prognosis very unpromising. \n\nTreatment. \xe2\x80\x94 These cases will generally tax the skill of \nthe practitioner to the utmost. To be successful even in a \nsmall proportion of cases, he will need to pay particular atten- \ntion to the cause, and to select his remedies with the greatest \ncare. The hints and indications given under the head of Am- \nblyopia, are no less appropriate to the treatment of Amaurosis, \nand will be suggestive. In addition to electricity and the hy- \npodermic injection of Strychnia, both of which have been used \nwith benefit, the following remedies, which have proven suc- \ncessful in some cases, should be carefully studied : -Aeon., \nArs., Bell., Calc. c, Cimicif., Crotal., Gels., Glon., Hep., Igna., \nLycop., Merc, Nat. m., Nux v., Phos., Puis., Ruta g., Sant, Sec. \nc, Sep., Sulph., Zinc. \n\n\n\nDISEASES OF THE EYE. 403 \n\n9.-MYDRIASIS. \n\nABNORMAL DILATATION OF THE PUPIL. \n\nSYMPTOMS.-^-This is a functional disease of the iris, char- \nacterized by an abnormal dilatation and immobility of the \npupil. As slight degrees of dilatation seldom produce any \nspecial inconvenience, they are not apt to attract attention ; \nand hence the term is only applied to those cases in which the \ndilatation is well marked. The pupil is not always regular, \nthe opening being sometimes greater in one direction than in \nanother. Whatever may be its shape and size, the pupil is \ngenerally more or less fixed, varying but little, if at all \nunder the stimulus of light, or from use. It is also less black \nthan the normal pupil, in consequence of the increased illumi- \nnation of the fundus. The affection is generally confined to \none eye. \n\nVision is commonly more or less impaired, especially for \nnear objects. This arises partly from glare or dazzling, in \nconsequence of the dilated state of the pupil, and partly from \nthe circles of dispersion formed upon the retina, in consequence \nof the loss of accommodation. The latter, however, is not \nalways present, nor is there any fixed or necessary relation be- \ntween it and the degree of dilatation ; for this may be extreme \nand the ciliary muscle but little affected, and, on the other \nhand, if the mydriasis is but slight, the power of accommoda- \ntion may remain unimpaired. \n\nEtiology. \xe2\x80\x94 The causes of mydriasis, though numerous, \nmay be reduced to a very few heads. When binocular, the \ndisorder is due to some deep-seated intra-ocular disease affect- \ning the sensibility of the retina, or to certain diseases of the \nbrain, such as basilar meningitis, apoplectic effusions at the \nbase of the brain, chronic hydrocephalus, and diseases of the \ncerebellum. In the great majority of cases, however, the my- \n\n\n\n404 PRACTICE OF MEDICINE. \n\ndriasis is monocular, and is caused either by spasm of the dila- \ntor pupillae and of the vessels of the iris, arising from irritation \nof the oculo-pupillary branches of the sympathetic nerve \xe2\x80\x94 in \nwhich case the ciliary muscle, and consequently the power of \naccommodation, remains unaffected \xe2\x80\x94 or else it depends upon \nparalysis of the constrictor pupillae, in consequence of injury to \nthe conducting power of the third nerve. In these cases there \nis often more or less paralysis of the accommodation, and in \nsome instances the entire region supplied by this nerve is im- \nplicated, and then it is generally considered to be of rheumatic \norigin. In some cases, however, it is undoubtedly syphilitic. \nWhen due to irritation of the sympathetic ganglia, it can some- \ntimes be traced to helminthiasis, spinal irritation, derangement \nof the digestive organs, etc. To the same class, also, belongs \nthe ephemeral mydriasis which has been observed only at cer- \ntain hours of the day, and which, as pointed out by Von Grsefe, \nis sometimes premonitory of insanity. \n\nTreatment. \xe2\x80\x94 This should be especially directed to the \nremoval of the cause; foralthough Atropine, Bell, and other my- \ndriatic remedies are homoeopathic to the condition of the iris, \nthey cannot be expected to prove curative unless the cause it- \nself be removed. Hence, rheumatic cases call for such rem- \nedies as Bry., Cimicif., Colch;, Rhus., etc.; syphilitic cases for \nMerc, Kali iod.; traumatic cases, Arnica ; helminthiasis, Sant; \nparalysis, Nux v., Rhus., etc. When associated with paralysis, \nthe treatment should generally be similar to that recommended \nfor paralysis of the ocular muscles, (which see). \n\n10.\xe2\x80\x94 MIOSIS, \n\nABNORMAL CONTRACTION OF THE PUPIL. \n\nSymptoms. \xe2\x80\x94 This affection, the opposite of mydriasis, is \ncharacterized by extreme contraction of the pupil, which is \nsometimes reduced to the size of a pin\'s head, and even less. \n\n\n\nPARALYSIS OF THE OCULAR MUSCLES. 405 \n\nThe pupil is regular in form, black, extremely limited and slug- \ngish in its movements, and yields but slightly to the influence \nof Atropine. \n\nVision is generally impaired in proportion to the degree \nof contraction, the field of vision being greatly diminished and \nbut feebly illuminated. In some cases the patient can see \nonly during the middle hours of the day ; in other cases he \nmay be almost totally blind. \n\nETIOLOGY. \xe2\x80\x94 Myosis may be due to paralysis of the radi- \nating fibres of the iris, or to spasm of the constrictor pupillae. \nThe former is most frequently met with in disease or injury of \nthe cervical portion of the spinal cord ; the latter in iritis and \ninflammations accompanied by great irritation of the ciliary \nnerves. It may also be caused by too great and long contin- \nued use of the eyes in the examination of very small objects, \nas in watch-making, engraving, etc. \n\nTreatment. \xe2\x80\x94 As this disease is very rarely idiopathic, \nthe treatment, to be effective, should be especially directed to- \nwards the removal of the cause. Simple idiopathic cases \nwould probably be benefited by such remedies as Opium, Physo- \nstigma ven., etc. \n\n1L-PABALYSIS OP THE OCULAR MUSCLES. \n\nSYMPTOMS. \xe2\x80\x94 The symptoms vary according as the paraly- \nsis is complete or partial ; that is, according as it affects all or \nonly a part of the muscles supplied by a particular nerve. \nMost frequently the affection is limited to the muscles furnish- \ned by the third nerve, or motor oculi, namely, the rectus supe- \nrior, inferior, and internus. If the paralysis is complete, we \nhave, in the first place, ptosis, or dropping of the upper lid, \nwhile the motion of the globe is restricted in the upward, down- \nward, and inward directions ; but as the rectus externus still \nretains its power, the eye is readily turned towards the temple, \n\n\n\n406 PRACTICE OF MEDICINE. \n\nand may also be rolled somewhat downward and outward, \nthrough the action of the superior oblique. Subsequently, the \nsixth nerve generally becomes affected, and then the paralysis \nextends to the rectus externus. In this case the eye can no \nlonger be turned towards the temple, but looks directly for- \nward. Occasionally the fourth nerve becomes implicated, and \ngives rise to paralysis of the superior oblique. \n\nDiplopia, or double vision, is a very annoying symptom in \nthese cases, and is sometimes the only one of which the patient \ncomplains. This symptom is always experienced when the \npatient endeavors to look in the direction opposite to that as- \nsumed by the affected eye. Thus, in paralysis of the superior \nrectus, the inferior oblique muscle will cause the eye to deviate \noutward, and crossed double images will appear in the upper \nhalf of the field of vision. On the other hand, if the paralysis \naffect the superior oblique, the deviation of the visual line will \nbe but slight, the double images will be homonymous \xe2\x80\x94 that is, \non the same side \xe2\x80\x94 and will be confined to the lower half of the \nvisual field. \n\nEtiology. \xe2\x80\x94 Paralysis of the ocular muscles is most fre- \nquently found to be due to syphilis. Von Graefe refers nearly \none-third of all cases to this cause. Many cases, however, are \nof rheumatic origin, or arise simply from exposure to damp and \ncold. Others, again, may be produced by some centrally act- \ning cause, such as cerebral hyperaemia, effusion of blood, \nsoftening of the brain, hydrocephalus, etc. Occasionally, also, \nsyphilitic nodes, tuberculous deposits, and tumors of various \nkinds, are so situated at the base of the brain, or within the \norbit or cranium, as to press injuriously upon the affected \nnerves, and thus cause paralysis of the muscles to which they \nare respectively distributed. \n\nTreatment. \xe2\x80\x94 Recent cases, especially those of a rheu- \nmatic or syphilitic nature, are found to be the most amenable \nto treatment. Bry., Caust, Cimicif., Euphr., and Rhus, are \n\n\n\nPARALYSIS OF THE OCULAR MUSCLES. 407 \n\ngenerally indicated in the former, and Aurum, Kali iod., and \nMerc, in the latter. Of these, Causticum is the one most fre- \nquently and successfully employed, especially where the paral- \nysis is caused by exposure to cold. The following remedies \nhave also been recommended in particular cases : \xe2\x80\x94 Arnica for \nparalysis resulting from a blow or other injury ; Cup. acet. for \nparalysis of the nervus abducentis ; Senega for paresis of the \nsuperior rectus or superior oblique, especially when the diplo- \npia is relieved by bending the head backwards ; and Spigelia \nwhen accompanied with sharp, stabbing pains. Alum., Con., \nGels., Hyos., Igna., Nux v., Phos., and a few other remedies, \nhave also been employed with advantage, when indicated by \nconstitutional or other general symptoms, but not so frequent- \nly as those above mentioned. \n\nGalvanic electricity has relieved a large number of cases, \nand may often be advantageously associated with internal treat- \nment. According to Benedict, who cured no less than seven- \nteen out of twenty-seven cases by galvanization, the curative \naction takes place, not by the direct excitation of the paralysed \nnerve, but by a reflex irritation through the fifth nerve. The \nsame authority states, that in most cases a curative action is \nonly observed when the galvanic current is relatively weak. \n\nPrismatic glasses are sometimes used to neutralize the di- \nplopia, by making the double images to coincide. They may \nalso be used therapeutically, by adapting them to the eye in \nsuch a manner as merely to approximate the images, the para- \nlyzed muscles being benefited by the efforts to unite them. \n\nIf all other means fail, and the affected muscle is not too \nmuch disabled to be incapable of producing the requisite de- \ngree of contraction, the abnormal direction of the eye may \nsometimes be remedied by tenotomy of the opposing muscle, \nas described under the head of Strabismus, (which see). \n\n\n\n408 PRACTICE OF MEDICINE. \n\n\n\n12-NYSTAGMUS. \n\nThis affection consists in a tremulous or oscillatory move- \nment of the eye-balls. The oscillations, which are involunta- \nry and exceedingly rapid, vary in direction, being either hori- \nzontal, oblique, or rotatory. In most cases the movements oc- \ncur simultaneously in both eyes, and in the same direction ; \nbut sometimes they take place alternately, and in different di- \nrections. The oscillations are not generally perceptible to the \npatient, nor do they prevent his seeing objects in their true re- \nlations ; but they always impair the sight, rendering the retinal \nimages more or less confused, in proportion to the severity and \nextent of the movements. It is also observed that, although \nthe eyes appear to act in concert, and the movements take \nplace simultaneously, the condition of the sight is often very \ndifferent in the two eyes, and binocular vision is more or less \ndisturbed. It is especially difficult for the patient to obtain a \ncorrect view of small objects, and even large ones, if numerous, \nor in a state of motion, may produce confusion and uncertainty. \nThis is remedied to some extent by a habit which the patient \nacquires of involuntarily and unconsciously moving his head in \na contrary direction to the movements of his eyes, by which he \nis often enabled to keep the visual axes fixed upon the object \nunder examination. \n\nEtiology. \xe2\x80\x94 The chief cause of nystagmus appears to be, \nover exertion of the ocular muscles in maintaining the necessa- \nry convergence of the optic axes for very near vision. This \nover-taxing of the external muscles is generally produced by \nholding objects very near the eyes, in cases of myopia, central \nand other partial cataracts, opacities of the cornea, strabismus, \nfunctional diseases of the optic nerve and retina, etc. \n\nTreatment. \xe2\x80\x94 As nystagmus usually sets in during in- \nfancy, there is some chance for it to diminish or disappear in \n\n\n\nSTRABISMUS. 409 \n\nafter life ; but as a general rule it undergoes but little change \nor improvement, even under the most suitable treatment. This \nis due, no doubt, to the fact that a cure can only be effected by \nrestoring acuteness of vision to the diseased eyes, and this is \nseldom possible in this class of cases. But good results are \nsometimes obtained by diminishing or neutralizing the impair- \nment of vision, correcting errors of refraction, and employing \nthe eyes in such occupations as will avoid all straining of the \nocular muscles. We may also derive benefit in some cases \nfrom the internal use of Agar., Calab., Hyos., Igna., Kali brom., \nNux v., Puis., and Sant. \n\n12.-STRABISMUS. \n\nAlthough the various forms of squint and their surgical \ntreatment have been long known to the profession, yet it has \nbeen only within a comparatively recent period that our pres- \nent more accurate knowledge of the pathology of strabismus, \nthe result of a careful re-investigation of the whole subject, has \nbeen obtained. To Prof. Donders, especially, the profession are \nindebted for the first correct view of its nature, and of the inti- \nmate relations which it sustains to the eye as an organ of vision. \nHe has clearly shown that, in the beginning, it is in most in- \nstances only a symptom resulting from certain conditions of re- \nfraction ; but that after it has once become established it fre- \nquently proves highly injurious to vision, and may even lead to \nits entire destruction. We are also indebted to his investigations \nfor our knowledge of the highly important fact, that one form \nof strabismus frequently depends upon myopia, and the oppo- \nsite form upon hypermetropia. \n\nBy the term squint, or strabismus, (strabismus concomitans) \nwe understand an inability to direct both visual lines simulta- \nneously upon the same point. If the eye squints inward it is \ncalled convergent strabismus ; if outward, divergent strabis- \n\n\n\n4IO PRACTICE OF MEDICINE. \n\nmus; if the deviation is upward, it is called strabismus sursum- \nvergens ; if downwards, strabismus deorsumvergens. If con- \nfined to one eye it is monocular or monolateral; if it alternates \nbetween the two eyes it is alternating or bilateral. \n\nStrabismus is also divided into real and apparent, periodic \nand permanent. Apparent strabismus is a form in which, \nthough there is a well marked convergent or divergent devia- \ntion of the optic axis, as in real squint, both eyes are neverthe- \nless fixed upon the object, and neither of them undergo the \nslightest movement when the other is closed. Periodic squint \nis occasionally merely a reflex symptom, as in dentition, but \ngenerally its pathology is the same as that of confirmed stra- \nbismus, of which it is usually but the forerunner. \n\nA.\xe2\x80\x94 Convergent Strabismus. \n\nAs already defined, convergent strabismus is characterized \nby excessive convergence of the visual lines. The conver- \ngence takes place only during binocular vision ; for if the more \nhealthy eye is screened, the squinting eye changes its position \nand looks forward. This also proves that the squinting eye is \nbut little concerned in ordinary vision. In these cases, if the \nsquinting eye is covered, the more healthy one will be found to \nsquint. This is called the secondary squint, and is generally \nequal to that of the eye chiefly affected ; but in confirmed stra- \nbismus it is usually more difficult for the squinting eye to di- \nrect its visual line towards a given point than it is for the other. \nIn paralytic squint, on the contrary, the secondary deviation is \nthe greater. This serves as a ready means of distinguishing \nit from concomitant squint, in which, as we have seen, the pri- \nmary and secondary movements are equal. \n\nThe extent of the squint may be determined with sufficient \nexactness by first marking upon the lower lid the precise situa- \ntion of the pupil or edge of the cornea, when the squinting eye \nis turned strongly inward or outward, and then, having cover- \n\n\n\nCONVERGENT STRABISMUS. 41 1 \n\ned the healthy eye and fixed the other upon some convenient \nobject, measuring the distance between their present and for- \nmer position. \n\nConvergent squint is generally due to hypermetropia. \nThe latter is found to be present in about eighty per cent, of \nthe cases of convergent strabismus. The reason it is so often \noverlooked in these cases is, doubtless, because the majority of \nthe patients are too young to read. This will also account \nfor the fact that periodic squint generally first appears at about \nthe fourth or fifth year, or when the child is learning to read \nand spell. The explanation is this : In the hypermetropic \neye the refractive power is too low, parallel rays reaching the \nretina before being focused, thus creating circles of dispersion \nupon that membrane, and thereby rendering the vision indis- \ntinct. To remedy this defect, the hypermetropic eye is oblig- \ned to accommodate for distance, just as the normal or emme- \ntropic eye does for near objects. And since near vision re- \nquires a still greater strain of the accommodation, the accom- \nmodative faculty, which in hypermetropic eyes is never at rest, \nis soon over-worked. In order to lessen the strain, and at the \nsame time increase the power of accommodation, one eye \nsquints inward. At first it is periodic, occurring only when \nviewing near objects ; but as the habit becomes confirmed it \nbecomes more and more frequent, and finally it takes place at \nall distances, and the strabismus becomes permanent. It is \nnot surprising, therefore, that hypermetropia should be a \nfrequent cause of convergent squint. The only wonder is that \nit does not occur more frequently amongst hypermetropes than \nit does. Prof. Donders thinks it arises from an effort to avoid \ndouble vision ; for if one eye of a hypermetrope is screened, it \nwill soon turn inward when the other is fixed upon near objects. \nOn the other hand, if the degree of hypermetropia is greater \nin one eye than in the other, or if, in consequence of opacity, \nthe defect of vision is greater, the tendency to squint is \n\n\n\n412 PRACTICE OF MEDICINE. \n\nincreased, the annoyance from diplopia being no longer \nsufficient to prevent it. In fact, next to hypermetropia, no \nmore frequent cause of strabismus is known, than impaired \nvision. It is often seen in cases of opacity of the cornea and \nlens, or in some affection of the deeper structures of the eye in \nwhich the retinal image is rendered indistinct. In order to \navoid the confusion resulting from the difference in the visual \npower of the two eyes, the patient involuntarily squints with \nthe diseased or more defective eye. The strabismus soon \nbecomes confirmed, and finally amblyopia from non-use of the \neye is added to the defect of vision already existing. It \nshould not be forgotten, however, that in many of these cases \nhypermetropia is also present, and may constitute the chief \ncause of the complaint. \n\nB.\xe2\x80\x94 Divergent Strabismus. \n\nAs convergent strabismus is generally associated with \nhypermetropia, so divergent squint is most frequently met \nwith in connection with myopia. And as the latter is most \nmarked at a later period of life than the former, so divergent \nstrabismus generally occurs later, not manifesting itself in \nsome cases until after the formation of extensive posterior \nstaphyloma. In fact, this is the chief reason that myopes are \nso frequently subject to divergent strabismus. For, as we have \nseen, the elongation of the antero-posterior diameter of the \nglobe in myopic eyes, is due in a great measure to the yielding \nof the posterior portion of the globe, which gives it more or \nless of an ellipsoidal shape. In consequence of this extension, \nthe mobility of the globe is diminished, and the difficulty of \nrotating it in the orbital cavity is correspondingly increased. \nNow, as myopic vision requires a very great convergence of \nthe optic axes, and as this is rendered impossible by reason of \nthe ovoidal shape of the globe, it follows that binocular \n\n\n\nTREATMENT OF STRABISMUS. 413 \n\nvision for near objects cannot be maintained without extieme \nexertion. The internal recti muscles soon become fatigued in \nthe attempt to maintain the necessary inclination of the optic \naxes, and so to relieve the muscular weariness, and the asthen- \nopic symptoms arising from the strong efforts at accommoda- \ntion, one eye is allowed to diverge, giving rise to one of the \nmost common forms of divergent strabismus. But Prof. \nDonders has shown that divergent squint may also be produced \nwhenever the degree of myopia becomes so excessive as to \nrequire too great a convergence of the optic axes for distinct \nvision, or in other words, whenever objects have to be brought \nso close to the eyes that the requisite amount of convergence \nfor clear vision cannot be obtained. This is most likely to \nhappen if the internal recti muscles are relatively weak. \nDivergent squint is also apt to occur if one eye is amblyopic, \nor more myopic than the other, the diseased eye deviating \noutward, in consequence of the patient relinquishing all effort \nat binocular vision. This form of relative divergence may \ntherefore be denominated passive. \n\nTREATMENT OF STRABISMUS. \n\nThis will differ according as the squint is either paralytic \nor concomitant, convergent or divergent, periodic or permanent. \nIf dependent on nervous irritation, the removal of the \nprimary disease will be required. Thus, squint arising \nfrom dentition is best treated by such remedies as Aeon., \nBell., Cham., Coff., etc. If dependent on verminous affec- \ntions, we should give Cina, Cyclamen, Merc, Sant, Sep., \nSpig., Sulph., etc. Pertussis calls for such remedies as Bell., \nCast., Cin., Cupr., Dros., Phos., Verat., etc. When produced by \nspasm and convulsions, we may give Agar., Bell., Cic, Cycla., \nHyos., Stram., Tabac, etc. \n\nRecent cases depending on hypermetropia or myopia may \nbe frequently corrected by using suitable convex or concave \n\n\n\n414 PRACTICE OF MEDICINE. \n\nglasses, so as to neutralize the errors of refraction. If this is \nnot done, the squint will soon become permanent, and then \ntenotomy of the affected muscle will be required. \n\nAs true concomitant squint, when confirmed, can only be \ncured by an operation, the surgeon cannot insist too strongly \non its early performance, more especially as the neglect to \nperform it has, in thousands of instances, resulted in the loss \nof sight. The operation consists in dividing the tendon of \nthe muscle in whose direction the squint occurs, thus permitting \nit to recede slightly, so that it may reattach itself somewhat \nfurther back. As the pain is severe, nervous persons and \nchildren will require to be anaesthetized. Then, having separ- \nated the lids by the stop-speculum, (PL II, Fig. 33), an assistant, \nif the case is one of convergent strabismus, turns the globe \noutwards with a pair of fixing forceps, (Figs. 36, 37); and the \nsurgeon, seizing a small fold of the conjunctiva with a pair of \ndelicate forceps near the lower margin of the insertion of the \ninternal rectus, snips it through with the scissors, being careful \nto make the incision small, so as to obtain, as nearly as possible, \nthe advantages of a sub-conjunctival operation. Having \nseparated, to a limited extent, the sub-conjunctival tissue from \nthe muscle, the surgeon now inserts the strabismus hook \n(PI. I, Fig. 17), beneath the tendon, to hold it and raise it from \nthe globe, and it is then carefully divided close to its insertion \nin the sclerotic, unless we desire to increase the effect to be \nproduced, when the division may be made farther back ; but, \non the other hand, if we desire to limit the effect of the \noperation, the edges of the external wound should be brought \ntogether with a suture. It was formerly the practice in cases \nrequiring only a slight degree of correction, say of from one \nto one and a half lines, to sever the tendon only partially, \nleaving a few of the upper or lower fibres undivided ; but this \nis not found to answer the purpose. \n\nOwing to the great change in the form of the globe, and \n\n\n\nTREATMENT OF STRABISMUS. 415 \n\nthe consequent difficulty experienced by the internal recti in \novercoming the deviation, after section of the external rectus \nfor divergent strabismus, it is frequently desirable to keep the \neye in a position of forced inversion, until the rectus externus \nhas acquired a new union with the globe at a point further back \nthan would be the case if left to itself. This may be accom- \nplished by passing a suture through the conjunctiva near the \ninner edge of the cornea, and then attaching it to the skin \nnear the inner canthus. The suture will cut itself out in the \ncourse of two or three days, but if the patient is careful not to \nmake undue traction upon it, it will not do so until after the \nmuscle has formed the requisite attachment. \n\nThe question as to whether we should operate upon one or \nboth eyes does not depend upon whether or not both eyes are \naffected with squint, but solely upon its extent. It is found by \nexperience that a deviation of from two and a half to three \nlines is all that can be overcome by a single operation ; and \ntherefore if the deviation exceeds this amount, we should \ndivide it between the two eyes, assigning the greater amount of \ncorrection to the squinting eye, in order to diminish as far as \npossible the muscular effort. \n\nAfter the strabismus has been rectified by division of the \nmuscle, if there is any coexisting hypermetropia or myopia, it \nshould be immediately neutralized by the proper convex or \nconcave glasses, as already explained under the head of anom- \nalies of refraction. This is necessary in order to secure \nbinocular vision, to prevent a recurrence of the deformity, and \nto overcome the amblyopia due to the long disuse of the eye. \nThe amblyopia is often greatly improved after the operation, \nespecially if the sight is exercised with strong and suitable \nglasses. \n\n\n\n416 PRACTICE OF MEDICINE. \n\n14 -EXOPHTHALMIC BRONCHOCELE. \n\nMORBUS BASEDOWII, GRAVES\' DISEASE, ETC. \n\nSymptoms. \xe2\x80\x94 This disease, the pathology of which is not \nwell understood, is characterized by certain functional disturb- \nances of the circulation, which give rise to violent palpitations \nof the heart, bronchocele, and exophthalmos. The palpitations, \nand other cardiac symptoms, generally occur in paroxysms, \nand are usually accompanied by more or less nervous excite- \nment and dyspnoea. At first the patient may complain only \nof weariness and exhaustion; but the breathing is almost \nalways difficult ; the mucous membranes are pale and anaemic, \nespecially the conjunctivae ; digestion is apt to be more or less \ndisturbed ; and, if we notice particularly, we may observe a \npeculiar staring expression about the eyes. As the disease \nprogresses, the hearts\' action becomes strong and tumultuous, \nand is accompanied by loud systolic murmurs ; the paroxysms \nof dyspnoea increase in severity and frequency, during which \nthe vessels of the neck frequently beat with great violence ; \nthe pulse, which previously was large, full, and perhaps not \nmore than 80 or 100 per minute, now ranges from 120 to 150, and \nis irritable and jerking ; the thyroid gland becomes enlarged ; \nthe exophthalmos increases, so that the lids no longer cover \nthe globes ; the stomach becomes still more disturbed, and the \ndebility more marked ; and, as the disease reaches its height, \nthe respiration becomes shorter, more accelerated, and frequently \northopnceic. Some of these symptoms, however, are not always \npresent, especially those connected with derangement of the \nstomach. On the other hand, the digestive troubles may \nbecome still more pronounced, giving rise to dyspepsia, severe \n\n\n\nEXOPHTHALMIC BRONCHOCELE. 417 \n\nand even bloody vomiting, diarrhoea, hemorrhage from the \nbowels, etc. \n\nBronchocele is generally, but not always present in Base- \ndow\'s disease. An interesting case of this kind has been reported \nby Dr. J. E. Morrison. The patient was a woman, aged 33, of \nnervous temperament, inclined to hysteria; menses "interrupted" \nsince the third month after their first appearance. The cata- \nmenia usually appeared in the morning and flowed until noon, \nthen suddenly ceased, or they would last from half an hour to \nsix hours, intermitting in this manner for ten or twelve days. \nDuring the menstrual period there was active congestion of the \ngenital organs, with puffiness of the parts on and around the \npubis and vulva, exophthalmos, and forcible and tumultuous \naction of the heart, which could be heard several feet from the \nbed. \n\nThe exophthalmos is generally binocular, but does not \nusually become very manifest until some time after the \nappearance of the cardiac symptoms and goitre. Like the \nlatter it often varies considerably, especially during the first \nstage, sometimes almost disappearing, at others becoming so \nconsiderable that the lids cannot be closed. The protrusion of \nthe globe, which, as well as the swelling of the thyroid gland, \nhas been found to depend upon a dilatation of the vessels, \nparticularly of the veins, \xe2\x80\x94 generally occurs in an oblique \ndirection, and most frequently towards the inner or nasal side. \nIn consequence of the long-continued exposure of the cornea \nto atmospheric and other irritating influences, the epithelial \nlayers become dry and rough, the xerosis increasing with \nthe degree and duration of the exophthalmos. Sometimes, also, \nulcerations of the cornea occur, which if unchecked may even \nlead to perforation, and, finally, to atrophy of the globe. At \nthe same time the lids and conjunctivae become more or less \nswollen and inflamed, and in some cases there are disturbances \nof vision ; but the latter are generally caused by the coexisting \n\n\n\n418 PRACTICE OF MEDICINE. \n\nxerosis, dilatation of the pupil, etc., and very rarely by real \namblyopia or amaurosis. \n\nPATHOLOGY. \xe2\x80\x94 As already stated, the exopthalmos is found \nto be due, in the first place, to a hyperaemic swelling of the \nadipose cellular tissue of the orbit, which afterwards becomes \nmore or less hypertrophied. This swelling, which may \ngenerally be diminished by pressure, is said by Virchow to \nrapidly disappear after death. But the true nature of the \ndisease, and the relation which the cardiac affection sustains to \nthe bronchocele and exopthalmos, are still involved in much \nobscurity and doubt. Some have referred the disease to \nanaemia ; but anaemia, even when it gives rise to palpitations \nand cardiac murmurs, is not generally associated with goitre \nand exophthalmos, nor do these affections produce anaemia. \nOthers, again, have attributed the protrusion of the eyes to the \npressure of the enlarged gland upon the cervical vessels ; but, \nas we have seen, the disease may occur without any enlargement \nof the thyroid, and on the other hand very large bronchoceles \nexist without any exophthalmos. The most rational and \ngenerally received theory is that which refers the disease to \nfunctional disturbances of the central parts of the sympathetic \nnerve. Not only do the general symptoms point to disturb- \nances of the vaso-motor centres, but the almost numberless \ncomplications of the disease, many of which are of an extremely \nvariable and transient character, appear strongly to confirm \nthis view of its origin. \n\nETIOLOGY. \xe2\x80\x94 The disease is generally less severe, occurs at \nan earlier period, and much more frequently, in women than \nin men. It is often associated with disturbances of the uterine \nfunctions, especially chlorosis, menstrual suppression, etc, or \nwith some cutaneous neurosis, such as urticaria. It has also \nbeen caused by great mental depression, sudden fright, severe \nbodily exercise, hemorrhages, and other debilitating influences. \n\nPrognosis. \xe2\x80\x94 This should always be guarded, especially \n\n\n\nEXOPHTHALMIC BRONCHOCELE. 419 \n\nin the case of males, in whom the symptoms are usually more \nsevere and more permanent. The disease is generally slow \nin its progress, especially during the first stage, or before the \nappearance of the goitre and exophthalmos. The symptoms \nfrequently abate, or become less frequent ; but relapses often \noccur, and lead sooner or later to faulty nutrition, and in some \ncases to death. Complete recovery is unusual, occurring only \nin about one third of the cases. As a general rule the function \nof the retina remains unimpaired. \n\nTreatment. \xe2\x80\x94 Dr. Morrison\'s case, above-mentioned, was \ncured by the internal administration of Lycopus virg., a remedy \nwhich would seem from its provings to be pre-eminently \nadapted to the disorder. Cures, or beneficial results, are also \nsaid to have followed the use of Amyl nit., Brom., Cact, Fer., \nlod.,* Spong., Nat. m., and Bary. c ; the Amyl nit., being used \nby olfaction alone. Other remedies which deserve attention \nare : \xe2\x80\x94 Bell., Calc, China, Cimicif., Dig., Gels., Plat, Puis., Sep., \nSil., and Sulph. \n\nGalvanic electricity, applied to the sympathetic nerve, has \nbeen employed with good success in many cases, especially in \ncuring the goitre and exophthalmos, and also in improving the \ngeneral health. This agent is also highly useful in regulating \nthe menstrual function, upon the disturbance of which many of \nthese cases measurably depend. \n\nDiet and Regimen. \xe2\x80\x94 Experience shows that whatever \ntends to invigorate the general system and improve the health, \nusually exerts a beneficial influence upon the disease. Hence, \nthe patient should abstain from the use of stimulants, take \nregular but gentle exercise in the open air, make use of a plain, \nbut liberal, nutritious, and easily digestible diet, and, avoiding \nall emotional or other excitement, enjoy as much quiet cheer- \nfulness as circumstances will permit. \n\n\n\nSee Am. Horn. 05s., vol. xiii, p. 603. \n\n\n\n420 PRACTICE OF MEDICINE. \n\n\n\nIn closing the first volume of our work on the Homoeo- \npathic Practice of Medicine, we desire to add, that \nnotwithstanding it is confined almost exclusively to the \nconsideration of diseases of the brain and eye, the affections \ndescribed are amongst the most important that the general \npractitioner is called upon to treat. And if we have appeared \nto give undue prominence to those of the eye, it is because, in \nour opinion, the subjects discussed are too important to be \ndismissed in a few short sections. On the contrary, this \ndepartment of medicine, though somewhat extended, should \nno longer be excluded from our therapeutic treatises. For not \nonly are many diseases of the eyes, as we have seen, intimately \nrelated to those of other parts of the system, but their \ninvestigation, by throwing new light upon the latter, is full of \ninstruction to the general practitioner. Besides, he is frequently \ncalled upon to treat diseases of the eye under circumstances \nthat preclude their being referred to specialists, even if that \nwere the proper course to pursue. But as the majority of \nophthalmic diseases must necessarily be treated by the ordinary \nmedical attendant, the propriety of incorporating the requisite \ninformation in a work of this character, will, we doubt not, be \ngenerally conceded. \n\nFor reasons which will hereafter appear, we have post- \nponed the consideration of the various organic and functional \ndiseases of the brain, until we shall have occasion to take up \nthe corresponding affections of the nervous system generally. \n\n\n\nINDEX \n\n\n\nAbnormal astigmatism \n\ncontraction of pupil \n\ndilatation of pupil \n\nAbscess of cornea \n\nglobe \n\nlids \n\nlachrymal sac \n\norbit \n\nAbsolute glaucoma \n\nAbsorption, treatment of cataract \n\nby \n\nAccommodation, theory of \n\nanomalies of \n\neffect of atropine upon \n\nparalysis of \n\nrange of \n\nAcidum nit 130, 135, 143, \n\nAconitum 42, 50, 84, m, 117, \n\n157, 189, 231, \n\nAcute glaucoma \n\nAcuteness of vision 372, 403, \n\nAdditional therapeutic indications, \n\nAgaricus \n\nAilantus gland. \n\nAlbugo \n\nAlbuminuria \n\nAlternation of Medicines \n\nAlumina \n\nAmaurosis 256, \n\nspinal \n\nAmblyopia \n\nexanopsia 398, \n\nAmotio retinae \n\nAmyl nit \n\nAnatomy of the eye \n\nAnkyloblepharon \n\nAnaemia of the brain \n\nAnaesthesia retinae \n\nAneurism by anastomosis \n\nAnomalies of refraction \n\nApoplexy cerebral \n\nAnterior chamber of the eye \n\nAntimonium tart \n\nAnnular staphyloma \n\nApis mel Ill, 143, \n\nAphakia \n\nApthous ophthalmia \n\nAqueous humor, hypersecretion of \n181, \n\nArcus senilis of the lens \n\nArgentum nit \n\nArnica 43, 79, 189, \n\nArsenicum 39, 72, 96, 112, 143, \n\n157, 189, 220, \n\n\n\n77 \n\n\n\nPAGE \n\n391 \n404 \n403 \n159 \n231 \n152 \n277 \n270 \n213 \n\n352 \n\n373 \n378 \n377 \n380 \n\n374 \n158 \n\n236 \n216 \n\n4C5 \n281 \n281 \n281 \n116 \n\n257 \n18 \n281 \n400 \n401 \n\n393 \n412 \n\n3i6 \n282 \n103 \n293 \n\n38 \n397 \n328 \n382 \n\n74 \n107 \n\n84 \n3H \n231 \n37o \n145 \n\n196 \n\n34i \n118 \n231 \n\n232 \n\n\n\nArthritic foam \n\nophthalmia \n\nArtificial pupil, operations for \n\nAsafcetida \n\nAsarum \n\nAssalini, on Egyptian ophthalmia. \n\nAsthenopia \n\nArlt.Prof., on catarrhal ophthalmia, \nAstigmatism \n\nforms of \n\ntreatment of, by lenses \n\nAtresia pupillae 178, 183, \n\nAtrophy of the choroid. ..233, 235, \n\n249, \n\neyeball 215, \n\nretina 249, 257, \n\noptic nerve 216, 249, 263, \n\nAtropine, effect of, on the accom- \nmodation \n\non the iris \n\npurity of 161- \n\nAurum \n\nBandage, compress \n\nin keratitis 161, \n\nBaryta 79, \n\nBecker, Dr., on leucaemic retinitis, \n\nBelladonna, 43, 50, 79, 84, 96, \n\nill, 118, 143, 157, 189, 221, 232, \n\nointment \n\nBlear eye \n\nBlenorrhcea \n\nof lachrymal sac \n\nBlepharitis \n\nciliaris \n\nBowman, Mr., on corneal opacities, \n\nexcision of pupil \n\nBoynton, Dr., on choroido-retinitis, \n\nBronchocele, exophthalmic \n\nBryonia 43, 50, 85, 118, 189, \n\nBuphthaimos \n\nCactus grand 157, \n\nCalabar bean, effect of, on iris \n\nCalcarea carb 39, 51, 73, 112, \n\niod \n\nCalomel, insufflation of 167, \n\nCamphora 39, \n\nCanaliculi, division of \n\nCannabis sat 135, \n\nCantharis \n\nCanthoplasty \n\nCancer of the eye \n\nCapsules of Bonnet and Tenon, in- \nflammation of \n\n\n\nPAGE \n\n212 \n\n210 \n190 \n282 \n282 \n123 \n388 \n122 \n391 \n392 \n393 \n190 \n\n253 \n230 \n263 \n400 \n\n377 \n186 \nnote \n282 \n172 \n172 \n282 \n258 \n\n236 \n187 \n\n150 \n\n120 \n278 \n149 \n150 \n3C6 \n203 \n\n244 \n416 \n221 \n310 \n\n237 \n1 88 \n\n143 \n282 \n177 \n85 \n279 \n143 \n135 \n168 \n\n333 \n269 \n\n\n\n422 \n\n\n\nINDEX. \n\n\n\nPAGE \n\nCapsular cataract 343 \n\nCarcinomatous tumors 333 \n\nCaries of the orbit 274 \n\nCataract, classification of 337 \n\nadnata 346 \n\nanterior capsular 343 \n\nblack 341 \n\ncapsular 343 \n\ncongenital 337, 346 \n\ncortical 338 \n\ndiabetic 346 \n\nglaucomatous 214 \n\nhard 340 \n\nlamellar 337 \n\nmature 339 \n\nmixed 341 \n\nMorgagnian 340, 342 \n\nnuclear 340 \n\noperations for 349 \n\nposterior polar 239, 344 \n\npyramidal 344 \n\nsecondary 340, 342, 345 \n\nsenile 340 \n\nsiliculose 340 \n\nsoft 337 \n\nspectacles for 370 \n\ntraumatic 345 \n\nCataract, treatment of. 347 \n\nby division 352 \n\nby flap extraction 358 \n\nby linear extraction 356 \n\nby peripheral linear extraction 361 \n\nby reclination or couching 354 \n\nby solution 352 \n\nby suction 357 \n\nby Von Graefe\'s method 361 \n\nCatarrhal ophthalmia...... 109 \n\nCats-eye, amaurotic 332 \n\nCaustics, on the use of, in episcler- \nitis 174 \n\nin granular ophthalmia 130 \n\nin keratitis 156, 159 \n\nCaustics, on the use of, in purulent \n\nconjunctivitis 119 \n\nCaustic, special form of J30 \n\nCedron 221, 283 \n\nCerebral ancemia 38 \n\napoplexy 74 \n\nhypercemia 41 \n\nCellulitis of the orbit 270 \n\nCephalalgia 49 \n\nCerebritis 60 \n\nCharpie 172 \n\nChalazion 321 \n\nCh amomilla 51, 189 \n\nChemosis 176 \n\nChelidonium 283 \n\nChina . 40, 51, 97 \n\nCholesterine in vitreous humor 239 \n\nChoroid 104 \n\nChoroiditis 223 \n\ndisseminated or exudative 225 \n\nserous, simple 224 \n\n\n\nChoroiditis, syphilitic 225 \n\nsuppurative 227 \n\nChromopsia 229, 396 \n\nChronic glaucoma 213 \n\nCicuta 283 \n\nCiliary body 106 \n\ninflammation of 195 \n\nmuscle, paralysis of. 380 \n\nspasm of 381 \n\nneuralgia, 177, 189, 190, 196, \n\n197, 206, 211 \n\nprocesses ic6 \n\nCimicifuga 51, 157, 189, 221 239 \n\nCina 40 \n\nCinnabaris 153 \n\nClematis 153, 283 \n\nCoccius, Prof., ophthalmoscope of.. 365 \n\nCoculus 80 \n\nCoffea cr 43 \n\nColocynthis 98 \n\nConcussion of the brain 86 \n\nCohn, Dr., on hypermetropia 390 \n\non myopia 384 \n\nColchicum 175, 189 \n\nCollyria 113, 174 \n\nComocladia 283 \n\nConfirmed glaucoma 211 \n\nCongestion of the brain 41 \n\nConical cornea 307 \n\nConium 143, 158, 221 \n\nConjunctiva. 105 \n\ninflammation of, see Conjunctivitis \n\nxerosis of 300 \n\nConjunctival croup..... 136 \n\ndischarge, contagiousness of, \n\n"7, 123 \n\nConjunctivitis blennorrhoica 114 \n\ncatarrhal 109 \n\nexanthematous 147 \n\ndiphtheritic 136 \n\ngonorrhceal 132 \n\ngranular 126 \n\nneonatorum 114 \n\nphlyctenular 138, 145 \n\npurulent. : 114, 120 \n\nscrofulous 138 \n\nsimplex 109 \n\nvariolous 148 \n\nContagious ophthalmia 120 \n\nContraction of pupil, abnormal 404 \n\nConvergent strabismus 410 \n\nCoredialysis 194 \n\nCorelysis 194 \n\nCornea 104 \n\nabscess of 159 \n\nconical 307 \n\nherpes of 169 \n\ninflammation of 153 \n\nneuro-paralytic affection of.... 160 \n\nopacities of 1 15, 305 \n\npannus of 165 \n\nparacentesis of 162 \n\nperforation of 161 \n\n\n\nINDEX. \n\n\n\n423 \n\n\n\nCornea, perforating ulcer of 140 \n\nstaphyloma of 307 \n\nulcers of 1 15, 140, 159, 169 \n\nCorneitis, see Keratitis \n\nCouching 354 \n\nCoup de Soleil 81 \n\nCrocus 237, 284 \n\nCrotalus 284 \n\nCroton tig 284 \n\nCrystalline lens 106 \n\nCupping of the optic disc, 216, \n\n234, 235, 401 \n\nCyclamen 285 \n\nCyclitis 195 \n\nserous 196 \n\npurulent 197 \n\nCylindrical lenses 393 \n\nCyst, tarsal 325 \n\nin iris 325 \n\nin orbit 325 \n\nCysticercus in the anterior chamber 326 \n\nin the lens 346 \n\nunder the retina 326 \n\nDacryo-adenitis 275 \n\nDacryocystitis 277 \n\nDefinitions and aphorisims 9 \n\nDermoid tumors 322 \n\nDescemetitis , 181 \n\nDescemet, membrane of 105 \n\nDetachment of the retina 316 \n\nof the vitreous 234, 239 \n\nDigitalis 189 \n\nDilatation of pupil, abnormal 403 \n\nDiphtheritic conjunctivitis 136 \n\nDiplopia 406 \n\nDirect method of ophthalmoscopic \n\nexamination 367 \n\nDisease, analysis of 22, 23 \n\ncauses of 10 \n\ndefinition of. 9 \n\nsuppression of 10 \n\nDislocation of the lens 346 \n\nDistichiasis 298 \n\nDistoma oculi humani 346 \n\nDivergent strabismus 412 \n\nDivision of cataract 352 \n\nDixon on calcareous deposits in the \n\ncornea 306 \n\nDobrowelski, Dr., on protective \n\nglasses 129, 371 \n\nDonders, Prof., glaucoma of 215 \n\non hypermetropia 388 \n\non myopia 238 \n\non strabismus 409 \n\nDose, homoeopathic 15 \n\nrepitition of 17 \n\nDropsy of the brain 70 \n\nDrowsiness, morbid 48 \n\nDuct, lachrymal 107 \n\nnasal, stricture of 279 \n\nDouble sight 406 \n\nDuration of Medical action 20 \n\nDyer, Dr., on hypermetropia 391 \n\n\n\nPAGE \n\nEchinococcus, in orbit 325 \n\nEctropium 296 \n\nEczema of the lids 149 \n\nEgyptian ophthalmia 123 \n\nElectricity 381, 402, 407, 419 \n\nElectrolysis 329 \n\nEncephalitis 60 \n\nEncephalon, diseases of. 35 \n\nEmmetropia. 382 \n\nEngorged papilla 265 \n\nEntozoa in the lens. 346 \n\nin the orbit 325 \n\nEntropium. 294 \n\nEnucleation of globe 20S \n\nEpiphora 177 \n\nEpiscleritis 1 73 \n\nEpitheliel cancer 334 \n\nErysipelatous conjunctivitis 147 \n\nEuphorbium m \n\nEuphrasia in \n\nEvacuation of the aqueous humor.. 162 \n\nEversion of the lids 296 \n\nExanthematous ophthalmia 147 \n\nExcavation of optic nerve, amau- \nrotic 401 \n\nglaucomatous 216, 401 \n\nphysiological 216, 401 \n\nExcision of globe 208 \n\nof pupil 203 \n\nExhaustion, thermic 81 \n\nExophthalmic goitre 416 \n\nExternal applications 28 \n\nExtirpation of globe 208 \n\nExtraction of cataract, by flap \n\noperation 358 \n\nby linear incision 356 \n\nby peripheral linear incision... 361 \n\nby suction 357 \n\nby Van Graefe\'s method 361 \n\nEye, enucleation of 102 \n\ndiseases of. 208 \n\ngeneral inflammation of. 227 \n\nEyelashes, inversion of 298 \n\nEyelids, abscess of 152 \n\nadhesion of 293 \n\nto globe 29T \n\nerysipelas of 152 \n\neversion of. ;.. 296 \n\nfollicular inflammation of 150 \n\n.inflammation of edges of 150 \n\nEyelids, inversion of 294 \n\noedema of 152, 176 \n\nEye protectors 371 \n\nFace-ache 92 \n\nFar point 373 \n\nFar sightedness 378 \n\nFatty degeneration of retina, 247, 255 \n\ntumors 327 \n\nFibroma of eyelid , 329 \n\nof orbit 330 \n\nField of vision, state of in amauro- \nsis 402 \n\nin choroiditis 225 \n\n\n\n424 \n\n\n\nINDEX. \n\n\n\nPAGE \n\nField of vision, in detachment of \n\nretina 317 \n\nillustrations of 244, 245 \n\nin glaucoma 214 \n\nin hyalitis 239 \n\nin retinitis, 243, 248, 253, 256, \n\n260, 262 \n\nFilaria oculi humani 346 \n\nFistula of lachrymal gland 275 \n\nofthe sac 278 \n\nFlap extraction of cataract 358 \n\nFluoric acid 285 \n\nFomentations in suppurative kera- \ntitis 162 \n\nForeign bodies in the eye 206 \n\nFunctional diseases of the eye 373 \n\nFundus oculi, ophthalmoscopic ap- \npearances of 367 \n\nFungus heematodes of eyeball 332 \n\nGalazowski,Dr., on vitreous humor, 238 \n\nGelseminum 43, 98, 158, 222 \n\nin choroido-retinitis 244 \n\nGeneral observations Q \n\nGiddiness 47 \n\nGland, lachrymal 107 \n\ninflammation of 275 \n\nGlaucoma 209 \n\nacute inflammatory 210 \n\nchronic inflammatory.. 213 \n\nnon inflammatory 215 \n\nfulminans 213 \n\nhemorrhagic form 218 \n\niridectomy in 219 \n\nmyotomy in 219 \n\nnature of. 217 \n\nophthalmoscopic symptoms of, 216 \n\nparacentesis in 219 \n\npremonitory stage of 210 \n\nprognosis of. 218 \n\nsclerotomy in 219 \n\nsecondary 234 \n\nsimplex 215 \n\nsubacute 213 \n\ntreatment of 219 \n\nGlioma retinae 33 1 \n\nGlonoine 51, 64, 85 \n\nGoitre, exophthalmic 416 \n\nGonorrhceal ophthalmia 132 \n\nGraefe, Von, Prof., on bandages for \n\nthe eye 162 \n\non ephemeral mydriasis 404 \n\non fomentations 157 \n\non hypopya 183 \n\non irido-choroiditis 202 \n\non operation for cataract 361 \n\non optic neuritis 266 \n\non transitory amaurosis 395 \n\non trichiasis 299 \n\non sclero-choroiditis posterior, 235 \non structure of vitreous hu- \nmor 224 \n\non sympathetic ophthalmia 206 \n\nGranulations, chronic 129 \n\n\n\nGranulations, diaphanous 109 \n\nGranular ophthalmia 126 \n\nGraphites 130, 144 \n\nGraves\' disease 416 \n\nGummy tubercles of the iris 184 \n\nHamamelis 222, 285 \n\nHahnemann\'s law of cure II \n\nHeadache 49 \n\nHelleborus 73, 85 \n\nHemorrhage after enucleation 209 \n\nHelmholtz, Prof., on acccommoda- \n\ntion ofthe eye 376 \n\nhis invention of ophthalmo- \nscope 365 \n\nHemeralopia 398 \n\nHemiopia 285, 289 \n\nHepar sulph c, 98, in, 118, 135, \n\nH4, 158, 232 \n\nHerpes of the conjunctiva 145 \n\nofthe cornea 169 \n\nHerpetic bridge 170 \n\nHeymann, on retinitis apoplectica, 260 \nHirschberg, Dr., ou glioma retinae 332 \n\nHomoeopathic aggravation 14 \n\ndose 15 \n\nmateria medica 14 \n\nregimen 29 \n\nHordeolum 319 \n\nHorns 323 \n\nHyalitis 237 \n\nsimple 238 \n\nsuppurative 240 \n\nHydatids of orbit 325 \n\nHydrastis can 112 \n\nHydrocephalus, acute 65 \n\nchronic 70 \n\nHydrophthalmia, anterior 217 \n\nHypersemia of the brain 41 \n\nHyoscyamus 85 \n\nHypersesthesia of retina 396 \n\nHypermetropia..., 388 \n\ndiagnosis of 389 \n\nfrequent cause of asthenopia... 388 \n\nof convergent squint 390, 411 \n\nvarieties of 388, 389 \n\nHypopyon 159, 182, 228 \n\nposterior 240 \n\nIgnatia 52 \n\nIllumination, lateral 368 \n\nIndirect method of ophthalmosco- \npic examinations 366 \n\nInfinite distance, what is meant by 373 \nInflammation of orbital cellular \n\ntissue. 270 \n\nof the brain and its mem- \nbranes 56 \n\nof the substance of the brain.. 60 \nInflammation of capsule of Tenon.. 269 \n\nof choroid 223 \n\nof ciliary body 195 \n\nof conjunctiva 108 \n\nof cornea 153 \n\nof eyelids 150 \n\n\n\nitfDEX. \n\n\n\n42S \n\n\n\nInflammation of eyelids, edge of.... 150 \n\nof eye generally 227 \n\nof iris 175 \n\nof iris and choroid 198 \n\nof lachrymal gland 275 \n\nof lachrymal sac 277 \n\nof retina 241 \n\nof sclera 172 \n\nsympathetic 204 \n\nof vitreous humor 237 \n\nInsomnia 48 \n\nInduration of the brain 61 \n\nInsufflation 167 \n\nInterstitial keratitis 153 \n\nIntra-ocular tension, increase of, \n\nin glaucoma 213 \n\nInversion of lid 294 \n\nIodium 65, 112, 130 \n\nIpecacuanha 40, 52 \n\nIridectomy 190 \n\nin glaucoma 192, 219 \n\nin irido-choroiditis 202 \n\n\n\nin iritis , \n\nin keratitis 157, \n\nwhen indicated , \n\nIridenkleisis , \n\nIrido-choroiditis, simple \n\nglaucomatous \n\npseudo-membranous , \n\nIrido-cyclitis \n\nIiidodesis \n\nIridodialysis \n\nIridotomy \n\nIris \n\n\n\ncolor of \n\ninflammation ot \n\nprolapse of 1 16, \n\nversicolor \n\nIritis \n\nparenchymatous \n\nserous \n\nsimple \n\nsuppurative \n\nsyphilitic \n\ntraumatic \n\nIschaemia of the disc \n\nIwanoff on detachment of the vitre- \nous 234, \n\nJackson, Dr., on optic-neuritis \n\nJaeger, Prof., on posterior staphy- \nloma \n\ntest-types of \n\nKali iod 131, 158, 189, \n\nbich \n\nKalmia 99, \n\nKeratitis, diffuse \n\npannosa \n\npunctata 181, \n\nphlyctenular \n\nsuppurative \n\nsyphilitic \n\nvascular \n\nKerato-conus \n\n\n\n192 \n\n163 \n192 \n\n193 \n198 \n209 \n200 \n196 \n\n193 \n\n194 \n194 \n\n105 \n179 \n\n175 \n140 \n\n99 \n\n175 \n182 \n181 \n\n175 \n182 \n\n\n\n179 \n265 \n\n239 \n\n267 \n\n235 \n\n372 \n222 \n\n285 \n285 \n\n153 \n165 \n\n224 \n169 \n159 \n155 \n165 \n308 \n\n\n\nKerato-iritis 155, 177 \n\nKerato-globus 310 \n\nKeratonyxis 353 \n\nLachesis 80 \n\nLachrymal apparatus 107 \n\nfistula of. 275, 278 \n\ninflammation of 275 \n\nLagophthalmos 300 \n\nLateral illumination 368 \n\nLaurocerasus 80 \n\nLeber, Dr., on leucsemic retinitis.. 258 \nLens, crystalline , 106 \n\ndislocation of 224, 346 \n\nLenses 278 \n\ninstrument for ascertaining the \n\nfocal strength of. 279 \n\nLeucoma 116 \n\nLiebreich, Dr., ophthalmascope of 365 \n\non leucsemic retinitis 258 \n\nLippitudo 150 \n\nLinear extraction in cataract 356 \n\nperipheral 361 \n\nLong-sightedness 388 \n\nLycopodium 131 \n\nLycopus. 286 \n\nMacula lutea 106 \n\nophthalmoscopic appearance of 367 \nMackenzie, Dr., on post-febrile \n\nophthalmia 203 \n\nManz, Dr., on optic-neuritis 265 \n\nMateria Medica, homoeopathic, 14 \n\ndefects of 103 \n\nMeasles, ophthalmia of 148 \n\nMedical nomenclature S3 \n\nMedullar)\' cancer 335 \n\nMeningitis 56 \n\ngranular 56 \n\ntuberculous 65 \n\nMeissner, on neuroparalytic oph- \nthalmia 160 \n\nMercurius 44, 52, 73, 80, \n\n99, I", 131, \xc2\xbb35\xc2\xbb r 44, 158, \n\n189, 232, 280 \n\ncorrosivus 237 \n\nproto-iodatus 175 \n\nMezereum 99 \n\nMicropsia., 249-note \n\nMilitary ophthalmia 120 \n\nMilium 326 \n\nMoluscum 326 \n\nMonostoma lentis 346 \n\nMorbus Basedowii 416 \n\nMucous ophthalmia 109 \n\nMuriate of hydrastia 118 \n\nMuscles of the eye, paralysis of... 405 \n\nspasm of 408 \n\nMydriasis 403 \n\nMyopia 383 \n\nfrequent cause of divergent \n\nsquint 412 \n\nMyosis 404 \n\nMyotomy in glaucoma 219 \n\nNsevus maternus.. 327 \n\n\n\n426 \n\n\n\nINDEX. \n\n\n\nPAGB \n\nNasal duct, treatment of stricture \n\nof 279 \n\nNear point 374 \n\nNear-sightedness 383 \n\nNebulae of cornea : 154 \n\nNecrosis of orbit 274 \n\nNeonatorum, ophthalmia 1 14 \n\nNeuralgia trigemini 92 \n\nNephritic retinitis 254 \n\nNeuritis, optic, ascending 265 \n\ndescending 266 \n\nNighr-blindness 398 \n\nNomenclature medical 33 \n\nNux vomica 40, 44, 52, 80, 99 \n\nNyctalopia 396 \n\nNystagmus 408 \n\nOblique illumination 368 \n\nCEdema of conjunctiva 121, 132 \n\nof eyelids 152 \n\nof retina 242 \n\nOintment, belladonna 187 \n\nOnyx 159 \n\nOpacities of cornea 305 \n\nof lens 337 \n\nof vitreous 234, 238, 315 \n\nOphthalmia, arthritic 2IO \n\ncatarrhal . 109 \n\ndiphtheritic 136 \n\nEgyptian 123 \n\nexanthematous 147 \n\ngonorrhoeal 132 \n\ngranular 126 \n\nmilitary 120 \n\nneanatorum 114 \n\nneuro-paralytic 160 \n\nphlyctenular 138, 145 \n\npost-febrile 203 \n\npurulent 1 14, 120 \n\nrheumatic 180 \n\nscrofulous 138 \n\nsympathetic 204 \n\ntarsi .\xe2\x99\xa6. 150 \n\nvenous 210 \n\nOphthalmic symptoms, table of..... 288 \n\nOphthalmoscope 364 \n\ndirect method of examination \n\nby 367 \n\nindirect method 366 \n\nvarious forms of... 365 \n\nOphthalmoscopic appearances of \n\nthe fundus oculi 367 \n\nof the optic papilla, normal.... 216 \n\nOpium 44, 80 \n\nOptic nerve 106 \n\nOptic Nerve, atrophy of...257, 263 267 \ncupping or excavation of, 216, \n\n234, 235, 401 \ndisc, normal appearance of..... 216 \n\ndropsy of 265 \n\ninflammation of. 264 \n\nneuritis 264 \n\nascending 264 \n\ndescending 266 \n\n\n\nPAGB \n\nOptical aids and tests... 364 \n\nOra serrata 106 \n\nOrbit, abscess of 269 \n\ncaries of. 274 \n\ncellulitis of 270 \n\nhydatids in 325 \n\n\' necrosis of 274 \n\nperiostitis of. 273. \n\ntumors, cystic 325 \n\nfatty 327 \n\nfibrous 330 \n\nsarcomatous 331 \n\nvascular 326 \n\ncancer of 334 \n\nepithelial 334 \n\nmedullary 335 \n\nmelanotic 336 \n\nOscillation of eyeballs..... 408 \n\nPagenstecher, Dr., on vitreous hu- \nmor 237 \n\nPannus 128, 165 \n\nPanophthalmitis 227 \n\nPantoscopic spectacles 369 \n\nParacentesis cornese 162; 188 \n\nParalysis of ciliary muscle 380 \n\nof ocular muscles 405 \n\nParenchymatous keratitis 153 \n\nPassavant, Dr., on corelysis 195 \n\nPerforation of cornea 161 \n\nPeriostitis of orbit 273 \n\nPeripheral linear extraction of \n\ncataract 361 \n\nPeriscopic spectacles 370 \n\nPetroleum 253 \n\nPhlegmonous inflammation of eye- \nlids 152 \n\nPhlyctenular ophthalmia 138, 145 \n\nPhosphenes 304 \n\nPhosphorus 112, 222, 237 \n\nPhotophobia 177 \n\nscrofulosa 139 \n\nPhotopsia 229 \n\nPhysostigma ven 237 \n\nPhytolacca 222, 286 \n\nPigment degeneration of retina 261 \n\nPlatina....!. 100 \n\nPolypi, conjunctival 327 \n\nPlumbum 65, 73 \n\nPosterior chamber 107 \n\nPost-febrile ophthalmia 203 \n\nPosterior polar cataract 239, 344 \n\nPreliminary observations on the \n\neye 102 \n\nPresbyopia 378 \n\nPressure bandage 172 \n\nPrisms 407 \n\nPrismatic spectacles 407 \n\nProlapse of iris 116, 140 \n\nProsopalgia 92 \n\nProsopon, diseases of the 92 \n\nProtrusion of globe 270, 331, \n\n333, 4i6 \nPrunus sp 286 \n\n\n\nINDEX. \n\n\n\n427 \n\n\n\nPAGE \n\nPsora 10 \n\nPsorinum \xc2\xbb 224 \n\nPsorophlhalmia 149 \n\nPterygium 301 \n\noperations for 303 \n\nPtosis 405 \n\nPulsation of retinal vessels 217 \n\nPulsatilla 44, 52, 8t, 144 \n\nPuncta lachrymalia, eversion of... 150 \n\nPunctum proximum 374 \n\nremotissimum 373 \n\nPupil, artificial, operations for 190 \n\nadhesions of 178 \n\ncontraction of. 178, 404 \n\ndilatation of 181, 186, 403 \n\nexclusion of. 199 \n\nocclusion of 200 \n\nPurulent cyclitis 197 \n\nophthalmia 114, 120 \n\nof adults 120 \n\nof infants 114 \n\nchronic 126 \n\nPustular ophthalmia 143 \n\nRange of accommodation 374 \n\nReclination of cataract 355 \n\nRecklinghausen, on leucsemic re- \ntinitis 258 \n\nRefraction, anomalies of 382 \n\nRegimen, homoeopathic 29 \n\nResults of ophthalmic inflammation 291 \n\nReichert, membrane of 105 \n\nRetina 106 \n\nanaesthesia of. 397 \n\natrophy of. 243, 249 \n\ndetachment of 239, 316 \n\nfatty degeneration of ..247, 255 \n\nglioma of 331 \n\nhyperassthesia of 241, 396 \n\ninflammation of 241 \n\ncedema of 242 \n\noperation in detachment of.... 319 \n\npigment degeneration of 261 \n\nsclerosis of 247, 256 \n\nRetinitis 241 \n\nalbuminunca 254 \n\napoplectic 259 \n\nexudative 247 \n\nleucsemic 258 \n\nRetinitis, nephritic 254 \n\nparenchymatous 247 \n\npigmentosa 261 \n\nserous 242 \n\nsyphilitic 251 \n\ntraumatic 244 \n\nRheumatic iritis 179 \n\nRhododendron 222 \n\nRhus tox...45, 100, 113, 118, 144, 232 \n\nRuta 286 \n\nSac, lachrymal, inflammation of.... 277 \n\nfistula of 278 \n\nSaemische, Dr., operation for ulcus \n\nserpens cornese 163 \n\nSanguinaria 53 \n\n\n\nPAGB \n\nSantonine 287 \n\nSarcoma 331 \n\nScarlatina, ophthalmia of 148 \n\nSchlemm, canal of 105 \n\nScirrhus 336 \n\nSclerectasia posterior 233 \n\nSclera, sclerotica.., 104 \n\ninflammation of 172 \n\nSclerotomy in glaucoma 219 \n\nSclero-choroiditis posterior 233 \n\nScotomata 225 \n\nScrofulous ophthalmia 138 \n\ninflam. ofbrain 66 \n\n. Sebaceous cysts 323 \n\nSecale cor 41 \n\nSecondary cataract 340 \n\nSelection of remedies ^ 24 \n\nSenega 287 \n\nSepia 53, 100 \n\n.Shields, glass, in symblepharon 292 \n\nShort-sightedness 383 \n\nSilicea 73, 85, 144 \n\nSimilia Similibus \xc2\xa3urantur II \n\nSleeplessness 48 \n\nSmall-pox, ophthalmia in 148 \n\nSnellen, Dr., test-types of 372 \n\nSnow-blindness 397 \n\nSoftening oi the brain 60 \n\nSolio ictus 81 \n\nSolution of cataract 352 \n\nSpasm of ciliary muscle 381 \n\nSpectacles 369, 370, 371 \n\nSpier\'s lachrymal catheter 280 \n\nSpigelia 100, 158, 190, 222, 237 \n\nSquint see Strabismus \n\nStaphyloma 307 \n\nof cornea and iris 311 \n\noperations for 313 \n\nannular 314 \n\nanterior 173, 314 \n\nposterior 233 \n\nracemosum 133 \n\ntreatment of 309, 312 \n\nStaphysagria 112, 144, 287 \n\nSteilwag, on curability of cataract, 347 \n\non post-febrile ophthalmia 204 \n\non syphilitic retinitis 251, 252 \n\nStenapaic spectacles 370 \n\nSticta 287 \n\nStrabismus 409 \n\napparent 410 \n\nSti-abismus, concomitans 409 \n\nconvergent 410 \n\ndivergent 412 \n\nmonolateral 410 \n\npassive 413 \n\nperiodic 410, 41 1 \n\ntreatment of.., 413 \n\nStramonium 53> 81 \n\nStupor 48 \n\nStye 319 \n\nSubstitution of medicines 25 \n\nSuction operation for cataract. .... 357 \n\n\n\n428 \n\n\n\nINDEX. \n\n\n\nSulphur 53, 73, 112, 131, 144, \n\nSunstroke \n\nSuppurative cyclitis \n\niritis \n\nkeratitis \n\nSymblepharon \n\noperations for 292, \n\nSympathetic ophthalmia \n\nSymptomatology \n\nSymptoms \n\ntotality of \n\nSynchysis \n\nSynechia, ann ular 178, \n\nanterior \n\nposterior 180, \n\nSyphilitic iritis \n\nkeratitis \n\nretinitis \n\nSyringe, suction, for cataract \n\nTable I. Analysis of Disease, 22, \n\nII. Substitution \n\nIII. Cerebral regions \n\nIV. Cerebral sensations.... \n\nV. Cerebral congestion \n\nVI. Cephalalgia, its causes, \n&c \n\nVII. Cephalalgia, its seat \nand character \n\nVIII. Meningitis \n\nIX. Acute hyrocephalus \xe2\x80\x94 \nsymptoms 68, \n\nXI. Concussion \xe2\x80\x94 synopsis \nof treatment \n\nXII. Cerebral diseases \n\nXIII. Prosopalgia \n\nXIV. A. Ophthalmic symp- \ntoms \n\nXV. B. Ophthalmic Inflam- \nmation \n\nTable A. \xe2\x80\x94 Ophthalmic symptoms.. \nB. \xe2\x80\x94 Ophthalmic inflammation \n\nTarsal cysts \n\nophthalmia \n\nTarsoraphia \n\nTeale, Mr., on suction operation \n\nfor cataract \n\nTelangiectasis \n\nTenon, inflammation of capsule of, \n\nTenotomy for strabismus \n\nTension, intra-ocular, in glaucoma, \n\nTest-types \n\nTherapeutic indications, 39, 42, 50, \n\n72, 79, 84, 92, m, 118, \n\ni35\xc2\xbb \'43, J 57. 189, 22o f \n\n236, \n\nThuja 112, 118, \n\n\n\n223 \n81 \n\n197 \n\n182 \n\n159 \n291 \n\n293 \n205 \n\n12 \n9 \n\n13 \n239 \n198 \n116 \n194 \n184 \n155 \n251 \n357 \n\n23 \n\n27 \n\n.36 \n\n37 \n46 \n\n54 \n\n55 \n58 \n\n69 \n\n\n\n90 \n101 \n\n288 \n\n290 \n288 \n290 \n321 \n149 \n297 \n\n357 \n327 \n269 \n414 \n213 \n37i \n\n231, \n281 \n\n131 \n\n\n\nTic douleureux , 92 \n\nTobacco amaurosis 401 \n\nTracoma 126 \n\nficosa 129 \n\nTraumatic cataract 345 \n\nTrichiasis 298 \n\nTumors, ophthalmic 319 \n\ndermoid 322 \n\ncarcinomatous 333 \n\ncystic 324 \n\nfatty 326 \n\nfibrous 329 \n\nsarcomatous 330 \n\nsebaceous 323 \n\nUlcer, resorption 169 \n\nof the brain 61 \n\nof cornea 140, 159, 169 \n\nUveal tract 196 \n\nVariolous ophthalmia 148 \n\nVenous circle 211 \n\nophthalmia 210 \n\npulsation of central vessels... 217 \n\nVeratrum album 41 \n\n(( viride 45, 85 \n\nVerbascum 100 \n\nVertigo 47 \n\nVesicular tumors 325 \n\nVirchow, Prof., on Bright\'s disease 257 \n\non dermoid tumors 323 \n\non glioma retinae.. 332 \n\non vitreous humor 238 \n\nVitreous humor..... 107 \n\nchloresterine crystals in 239 \n\ndetachment of 234, 239 \n\n\n\nfluid \n\n\n\nidition of. \n\n\n\n239 \n\n\n\ninflammation of 237 \n\nopacities of 238,240, 315 \n\nWalton, Mr. Haynes, on symble- \npharon 292 \n\nWarts 323 \n\nWeakness of sight 388 \n\nWeber, Dr.. canaliculus knife of... 279 \n\non vitreous humor 238 \n\nWecker, De, Dr., on hypermetro \n\n\n\npia. \n\n\n\n390 \n\n\n\n137 \n260 \n\n\n\nWells, Dr 157, 161, 174, \n\nWilliams, Dr \n\n207, 251, \nWordsworth\'s glass shields in sym- \nblepharon 292 \n\nXerophthalmia 300 \n\nZehender, Prof., ophthalmoscope of 365 \n\nZinc 73, 81 \n\nZinc, chloride of, paste 336 \n\nphos 237, 287 \n\nZonule of Zinn 106 \n\n\n\nX 2345^789 *o n la i3 14 xs 16 17 \n\n\n\n\nPLATE I. OPHTHALMIC INSTRUMENTS. \nAll these Instruments, 0/ the best make, are furnished by J. H. Gemrig, jog South 8th St., Philadelphia. \n\n\n\n33 \n\n\n\n\n36 \n\n\n\n\n\n\n\nPLATE IT. OPHTHALMIC INSTRUMENTS. \nAll these Instruments, e/the best make, are furnished by J. H, Gemrig, log South %th St., Philadelphia \n\n\n\nLIBRARY OF CONGRESS \n\n\n\n\nQQOlfiHZISbl \n\n\n\n'