LIBRARY OF CONGRESS. Chap.Aj.6 Copyright ]so Shell.. UNITED STATES OF AMERICA. OPHTHALMIC DISEASES AND THERAPEUTICS. BY A. B. XORTOX, :M. D. Professor of Ophthalinolog>- in the College of the New York Ophthalmic Hospital ; Surgeon to the New York Ophthalmic Hospital : Yisiting. Oculist to the Laura Franklin Free Hospital for Children; Ex-President American Homoeopathic Ophthalmological. Otological and Lar^-ngological Society : First Yice-President American In- stitute of Homoeopathy : President Homoeopathic Medical Society of the State of New York ; Editor Homoeopathic Eye. Ear and Throat Journal : Associate Editor. Department of Ophthalmology, North American Journal of Homoeopathy, etc. With Xixety Illustrations and Eighteen Chromo-Lithographic Figures. SECOND EDITIUX REVISED AND ENLARGED. PHILADELPHIA : BOERICKE & TAFEL. 1S9S. i 'fi ,v Is- 14S34 Copyrighted, 1898, By A. B. Norton, M. D. PRINTED BY T. B. & H. B. COCHRAN, LANCASTER, PA. find COPY, 1898. DEDICA TION. TO THE MEMORY OF MY BROTHER, Author of the Ophthalmic Therapeutics. This Book is Affectionately Dedicated as a Tribute to His LiFE-WORK in OPHTHALMOI.OGY. PREFACE TO THE SECOND EDITION. The indorsement extended the first edition of this book by the leading speciahsts of our school, as evidenced b}" the fact that it has been made the text-book on ophthalmology in twenty one of the twenty-two homoeopathic medical colleges, and by the pro- fession at large, as shown by its rapid sale, is extremely gratifying to the author and seems to warrant its continuance. To bring this edition thoroughly up to date, it has been neces- sary^, owing to the marked and rapid advancements in the domain of ophthalmology, to make very extended revisions, a number of subjects having been wholly rewritten. The object of its inception, " to furnish the student and general practitioner with a concise practical manual," has been continually kept in view. In order to accomplish this end without too greatly enlarging the size of the book, many of the illustrative cases in Part II. have been stricken out; the repetition of the indications for various remedies in the different diseases has been avoided by grouping under one general heading, as, under ** Indications for Remedies in Conjunctivitis" will be found the remedies for all the different varieties of conjunctivitis; by these changes much valuable space has been saved for new matter. The remedies given under the treatment of the various diseases have been arranged, so far as possible, in the order of their most frequent use by the author, instead of alphabetically as in the first edition. Over one hundred pages of new matter have been added cover- ing the following subjects, viz.: The Examination of the Eye; The Use of the Ophthalmoscope; The Hygiene of the Eye, a subject of everyday practical value that has never before been written upon in any text-book of the eye; Refraction and Ac- commodation, two chapters that have been kindly prepared for me by- Dr. Charles H. Helfrich, professor at the college of tht New York Ophthalmic Hospital; A Tabulated Statement of Dis- VI PREFACE TO THE SECOND EDITION. eases with More or Less Characteristic Eye Symptoms, a most excellent resume of the eye in its relation to general diseases, pre- pared by Dr. B. H. Linnell for his valuable work, " The Eye as an Aid in General Diagnosis," and published by courtesy of the author. Many new and original illustrations have been prepared for this edition by Dr. A. H. Hart; of these the additional plate of six chromo-lithographs illustrating external diseases of the eye is an unusual and valuable addition. To these gentlemen, and to my assistant, Dr. Edwin S. Mun- son, for aid in revision of proof, the preparation of the index, etc., the author desires to acknowledge his great indebtedness. 1 6 West Forty-fifth Street, New York, September, i8g8. FROM PREFACE TO FIRST EDITION. The scope of the work as originally planned has been followed out closely, and was to give as concisely as possible all the essential features necessar}^ to a thorough knowledge of the diseases of the eye, commencing with sufficient anatom}^ of the various structures to aid in an understanding of their diseases. In treating of the different diseases it has been our aim to follow a definite and systematic order, taking up successivel}^ the pathol- ogy? symptoms, course, causes, diagnosis, prognosis, and treat- ment of each separate disease. As the object of the work has been to furnish the student and the general practitioner with a concise, practical manual, all use- less verbiage has been discarded and the effort made to present a practical condensation of all important facts, believing such a book to be of more value to the student than one which hides the kernel under a profuse, even though interesting, envelopment. Special attention has been devoted to the homoeopathic treat- ment of diseases; at the same time, knowing the importance of both local and operative measures, it has been our aim to omit nothing that may be of value in these methods. The homoe- opathic treatment has, of course, been practically that of the last edition of the Ophthalmic Therapeutics, to which several new remedies and mau}^ new symptoms of old ones have been added; on the other hand, some of the old remedies have been cut down by dropping out the reports of some of the clinical cases and occasionally some general symptom of the drug. In the revision of this department of the work all homoeopathic publications of the last ten years, together with copious case records of my brother's as well as my own, have been carefully scrutinized and sifted. New York, August, i8g2. CONTENTS. CHAPTER I. EXAMINATION OF THE EYE. Examination of the Outer Structures — Examination by the Oblique Illumi- nation — Method of Determining the Tension — The Field of Vision, 17 CHAPTER II. THE USE OF THE OPHTHALMOSCOPE. The Art of Using the Ophthalmoscope — The Indirect Method — The Direct Method — The Fundus of the Eye as Seen by the Ophthalmoscope, . 27 CHAPTER III. REFRACTION AND ACCOMMODATION OF THE EYE. Normal Refraction and Accommodation — Convergence — Accommodation and Convergence Associated — The Angle Alpha and Angle Gamma — Abnormalities of Refraction and Accommodation — Hypermetropia or Hyperopia — Myopia — Astigmatism or Astigmia — Irregular Astigmatism — Anisometropia — Presbyopia, ... 35 CHAPTER IV. DIOPTOMETRY. Subjective Dioptometry — Cycloplegics — Estimation of Refraction by the Direct Method — Indirect Method — Skiascopy (Retinoscopy, or the Shadow Test) — Ophthalmometry — General Considerations, 59 CHAPTER V. HYGIENE OF THE EYE. School Hygiene- -Examination of the Eye Upon Entrance of School — The Construction of School Buildings — School Furniture, 84 X CONTENTS. CHAPTER VI. A TABULATED STATEMENT OF DISEASES WITH MORE OR LESS CHARACTERISTIC EYE SYMPTOMS. Abdominal Growths to Urticaria, 94 CHAPTER VII. DISEASES OF THE EYELIDS. Anatomy — Blepharitis— Abscess of the Lid. — Hordeolum — Ptosis — Blepharo- spasm — Nictitatio — Blepharophimosis — Symblepharon — Ankyloble- pharon — Lagophthalmos — Epicanthus — Trichiasis and Distichiasis — Entropium — Ectropium — Molluscum Contagiosum — Xanthelasma — Milium — Papillomata — Dermoid Cyst — Naevi — Chalazion — Epithelioma Lupus and Sarcoma — Syphilitic Ulcers, Chancre and Gummata — Herpes Zoster Ophthalmicus — Contusions — Wounds — Burns and Scalds, 102 CHAPTER VIII. AFFECTIONS OF THE LACHRYMAL APPARATUS. Anatomy — Dacryoadenitis — Hypertrophy of the Lachrymal Gland — Tumors of the Lachrymal Gland — Anomalies of the Puncta and Canaliculi — Strictura Ductus Lachrymalis — Dacryocystitis Catarrhalis — Dacryocys- titis Phlegmonosa — Fistula Lachrymalis, 132 CHAPTER IX. DISEASES OF THE ORBIT. Anatomy — Cellulitis Orbitae — Tenonitis — Periostitis Orbitae — Caries and Necrosis — Empyema of the Frontal Sinus — Tumores Orbitae — Wounds and Injuries of the Orbit — Morbus Basedowii, 141 CHAPTER X. AFFECTIONS OF THE OCULAR MUSCLES. Anatomy — Paralysis of Ocular Muscles— Paralysis, External Rectus — Pa- ralysis, Superior Oblique — Paralysis, Internal Rectus — Paralysis, Superior Rectus — Paralysis, Inferior Rectus — Paralysis, Inferior Ob- lique — Complete Paralysis of the Third Nerve — The Localizing Value of CONTENTS. XI Paralyses of Orbital Muscles in Cerebral Disease — Strabismus or Squint — Strabismus Convergens — Strabismus Divergens — Strabismus Sursum and Deorsum Vergens — Nystagmus — Muscular Asthenopia — Hyperphoria — Bsophoria — Exophoria, 152 CHAPTER XI. DISEASES OF THE CONJUNCTIVA. Anatomy — Hypersemia — Conjunctivitis Catarrhalis — Conjunctivitis Puru- lenta — Ophthalmia Neonatorum — Conjunctivitis Gonorrhoica — Conjunc- tivitis Diphtheritica — Conjunctivitis Crouposa — Conjunctivitis Follicu- laris — Conjunctivitis Trachomatosa — Papillary Trachoma — Conjunc- tivitis Phlyctenularis — Conjunctivitis Vernalis — Amyloid Degeneration of the Conjunctiva— Pemphigus Conjunctivae — Xerosis Conjunctivse — Pterygium — Sub-conjuuctival Ecchymosis — Sub-conjunctival Emphy- sema — Tuberculosis Conjunctivae - Lesions of the Conjunctiva — Tumors of the Conjunctiva, 191 CHAPTER XII. DISEASES OF THE CORNEA. Anatomy— Inflammation of the Cornea — Keratitis Phlyctenularis— Keratitis Fasicularis — Keratitis Pannosa — Keratitis Vesiculosa — Ulcus Corneae — Hypopyon Keratitis — Ulcus Rodens — Asthenic Ulcer — Marginal Ring Ulcer — Keratitis Dendritica — Keratitis Neuro-Paralytica— Keratitis Bullosa — Abscessus Corneae — Descemetitis — Keratitis Parenchymatosa — Opacities of the Cornea — Staphyloma Corneae — Keratoconus — Kerato- globus — In juries and Wounds of the Cornea — Tumors of the Cornea, 235 CHAPTER XIII. DISEASES OF THE SCLERA. Anatomy — Episcleritis — Scleritis — Staphyloma Sclerae — Injuries of the Sclera, 277 CHAPTER XIV. DISEASES OF THE IRIS. Anatomy — Hyperaemia Iridis — Iritis — Iritis Syphilitica — Iritis Rheumatica — Iritis Spongiosa — Iritis Parenchymatosa — Iritis Serosa — Tumors of the Iris — Mydriasis — Myosis — Hippus — Iridodonesis — Iridoncosis — Hy- paemia — Iridodialysis — Coloboma Iridis — Irideraemia— Membrana Pupil- laris. Persistans — Heterochroma — Operations on the Iris, 283 Xll CONTENTS. CHAPTER XV. DISEASES OF THE CILIARY BODY. Anatomy — Cyclitis — Cyclitis Plastica — Cyclitis Serosa — Cyclitis Purulenta — Injuries Implicating the Ciliary Region — Paresis Musculus Ciliaris — Spasmus Musculus Ciliaris — Irido-Choroiditis, 310 CHAPTER XVI. SYMPATHETIC OPHTHALMIA. Symptoms — Causes — Prognosis — Treatment, 321 CHAPTER XVII. DISEASES OF THE CHOROID. Anatomy — Hyperaemia — Choroiditis — Choroiditis Serosa — Choroiditis Dis- seminata Simplex — Choroiditis Areolaris — Choroiditis Circumscripta — Choroiditis Syphilitica— Choroiditis Suppurativa — Sclerotico-Choroidi- tis, Anterior — Sclerotico-Choroiditis, Posterior— Senile Changes of the Choroid — Albinism — Tumors of the Choroid— Ossification of the Choroid — Haemorrhages in the Choroid — Detachment of the Choroid — Rupture of the Choroid — Coloboma of the Choroid, 327 CHAPTER XVIII. DISEASES OF THE RETINA. Anatomy — Hyperaemia Retinae^ — Retinitis Simplex — Retinitis Albuminurica — Retinitis Diabetica — Retinitis Leukaemica — Retinitis Haemorrhagica — RetinitisSyphilitica — Retinitis Punctata Albescens — Retinitis Proliferans — Retinitis Pigmentosa — Detachment of the Retina — Ischaemia Retinae — Embolus of the Arteria Centralis Retinae — Thrombus of the Vena Centralis — Hyperaesthesia Retinae — Commotio Retinae — Glioma Retinae, 354 CHAPTER XIX. DISEASES OF THE OPTIC NERVE. Anatomy — Opaque Nerve Fibres — Coloboma of the Sheath — Hyperaemia of the Disc — Haemorrhage of the Optic Nerve — Neuritis Optica — Neuritis Retrobulbaris — Atrophy of the Optic Nerve — Injury of the Optic Nerve — Tumors of the Optic Nerve, 387 CONTENTS. Xlll CHAPTER XX. AMBLYOPIA AND AMAUROSIS. Amblyopia Ex-Anopsia — Traumatic Amblyopia — Amblyopia from Light- ning — Amblyopia from Loss of Blood — Hysterical Amblyopia — Pre- tended Amblyopia — Hemeralopia — Snow Blindness — Color Blindness — Hemianopsia, 408 CHAPTER XXI. DISEASES OF THE VITREOUS BODY. Anat< my — Hyalitis Suppurativa — Opacitates Vitrei — Hsemorrhage into the Vitreous — Foreign Bodies in the Vitreous — Cysticercus in the Vitreous — Persistent Hyaloid Artery — Detachment of the Vitreous, 420 CHAPTER XXII. DISEASES OF THE CRYSTALLINE LENS. Anatomy — Cataract — Varieties of Cataract — Complete Congenital Cataract — Cataracta Lamellaris — Cataracta Zonularis — Cataracta Polaris Anterior — Cataracta Pyramidalis — Cataracta Polaris Posterior — Cataracta Trau- matica — Cataracta Secondaria — Cataracta Capsularis — Operative Treat- meat of Cataract — Aphakia — Luxatio Lentis, 428 CHAPTER XXIII. GLAUCOMA. Anatomy — Physiology of Secretion and Excretion — Pathology — Symptoms — Course — Causes — Diagnosis — Prognosis — Varieties of Glaucoma — Glau- coma Acuta — Glaucoma Chronica — Glaucoma Simplex — Glaucoma Haemorrhagica — Glaucoma Absolutum — Glaucoma Consecutiva — Treat- ment, 460 PART SECOND. Acetic Acid to Zincum, 485 PARX I OPHTHALMIC DISEASES. OPHTHALMIC DISEASES. CHAPTER I. Examination of the Eye. The importance of a thorough and systematic examination, not only of the eye itself, but of co-existent general conditions, in order to determine the underlying states and to make a correct diagnosis, cannot be overestimated. Every patient should be examined systematically for both an accurate understanding of the case and for the preservation of careful records for subsequent use. The necessity of a thorough general examination varies with different cases. There is, of course, not the same necessity for an examina- tion into the family and personal history, occupation, habits, con- dition of the various organs, such as heart, kidneys, nervous system, etc., etc., in cases of simple conjunctivitis as there is in the more grave ocular diseases. Furthermore, as the method of general examination or " taking the case " varies with different physicians, it will not be entered into here. In the examination of the e^^e itself, we cannot emphasize too strong!}^ the value of systematic methods. Many times has the ophthalmoscope revealed a retinitis or an optic neuritis in cases with a normal acuteness of vision, and no s3'mptoms indicative of an intra- ocular disease. The records of a thorough examination to-day may be of the utmost value in the prognosis of some con- dition that ma}' arise five, ten or twenty 3'ears later. Full records of each passing condition will often prove of great service in the treatment of subsequent similar conditions, and much of one's success in diagnosis depends upon careful routine observation and record. Therefore, we would urge, the thorough examination and the full recording of all eye cases. The author's method is in every instance to first determine the visual acuteness and any re- fractive error that may be present, the range and power of the ac- l8 EXAMINATION OF THE EYE. commodation, and the strength and balance of the extra-ocular muscles. The appearance of the lids, lachrymal sac, conjunctiva, sclera, cornea, iris, aqueous humor and lens are carefully noted; following this, a thorough ophthalmoscopic examination of the entire fundus should be made. The examination as to the field of vision and color-perception is not necessary except in more rare instances, and is therefore only made when the previous results indicate the necessity. To avoid useless repetition, the method of determining the refraction and accommodation, the muscular balance, and the color-sense will all be detailed later on in the chapters devoted to these subjects. Examination of the Outer Structures. — Much can often be learned before touching the eyes for an examination of the in- dividual structures by noting the general appearance of the patient and of the eyes. One important factor in children which is often neglected by many physicians is to first secure their aid and con- fidence. A few moments spent in acquiring the child's trust and attention will give better results and save time later on. We can detect from a casual glance as the patient enters the room the presence or absence of photophobia, lachrymation and discharge from the eye — the character of the discharge, if purulent or mucus, thick or thin, bland or excoriating. A paralysis of the muscles can often be recognized by the inclination of the head, and the deviation of the eye will denote either a paralysis or strabismus. Twitchings of the lids, the face or other parts of the body will indicate nervous disorders. The expression of the face and the general physical condition are also to be noted. The lids first attract our attention when we come to examine the eye proper. If swollen — whether hard and tense, or soft and cedematous— their mobility and position; their edges for distorted cilia, the presence of parasites or inflammation; their inner sur- face for granulations, cicatrices, secretions and foreign bodies. To examine the inner surface of the upper lid and the superior cul-de-sac, which, as a rule, gives more characteristic indications than does the lower, and to remove foreign bodies it is frequently necessary to evert the upper lid. This procedure is quite simple after one acquires the knack or practice, but to the unaccustomed often difficult. The eyelashes of the upper lid are seized by the index finger and thumb of the left hand, the lid is then drawn Fig. I. Method of examining the 63*6 in children. EXAMINATION OF THE OUTER STRUCTURES. 1 9 downward and away from the ball, the point of the thumb of the right hand or a pencil is then placed above the tarsal cartilage of the lid and by a quick downward pressure of the thumb and a simultaneous upward movement of the left hand grasping the cilia the edge of the lid is turned over the point of the thumb. During the entire manoeuvre you must insist upon the patient's keeping the e3^e downward, if not the eversion of the lid becomes unneces- sarily difl&cult and painful. When everted the thumb of the right hand presses the edge of the lid backward against the eye- ball and holds it for examination. The lachrymal piinda and sac should be examined for any ob- struction, and by pressure over the sac notice whether any mucoid material or tears can be expressed from the puncta. The inspec- tion of the conjunctiva shows us the presence of phlyctenules, pterygium, growths, adhesions, etc. The vascular condition of the eye affords most important information, and it should derive careful attention. Note if the redness is due to the large, tortu- ous, bright red superficial vessels of the conjunctiva, which are especially numerous toward the peripher}^ and looser portion of the membrane, or if fine, radiating lines, pink in color, confined to the ciliary region and due to the episcleral vessels. The charac- ter of the congestion can be determined by gently rubbing the lower lid over the eyeball, when it will be seen that the coarser conjunctival vessels will glide over the deeper episcleral ones. In some cases we may note a leash of vessels, more or less pyra- midal in shape, with the apex toward the cornea, indicative of an ulceration. Again, we may see a marked enlargement and tortu- osity of the episcleral veins, pointing out a glaucoma. ■The thorough examination of the conjunctiva and cornea in young children where there is much photophobia and inflamma- tion is usually a matter of great difficult^^ When, owing to these causes, there is a spasmodic contraction of the lids, their forcible separation can be best accomplished as shown in Figure i. The nurse or attendant seated at your side lays the child across her lap with the head held firmly between the surgeon's knees. The attendant in this way can readily hold the child's hands, feet and body while the head is held as within a vise by the surgeon's knees. A towel should first be placed across the lap of the sur- geon to prevent the staining of the clothes from any solutions that 20 EXAMINATION OF THE EYE, may be used. The surgeon then grasps the ciliary border of the upper lid with the index finger of the right hand and with the thumb of the left hand the border of the lower lid. In opening the eye the pressure must be mainly upward toward the supra- orbital ridge and just sufficiently backward to prevent the e version of tie lid. Great care must be used 7iot to make too great pressure backward or downward upon the eyeball, because in an ulceration of the cornea (which is so apt to be present in cases where this method has to be resorted too) the pressure is liable to cause a rupture of the cornea with loss of the eye. Many an eye has un- doubtedly been lost through careless and severe handling in an effort to examine the same. You will often have to hold the eye open for several minutes before a clear view of the cornea can be had, as it will roll so far upwards that the cornea cannot be seen until the muscles have become tired out and allow it to resume the direct position. In some cases, when one has become especially dexterous in this manipulation, they can open the lids by the use of the thumb and index finger of the same hand, leaving the other hand free to make any necessary applications. As the examination of the cornea is greatly facilitated by the use of the oblique illumination, it should always be employed. This cannot be too strongly emphasized, as we have frequently seen our students by neglect of this method overlook s^ome minute yet important diagnostic sign which was readily discernible by its employment. Make it, therefore, a routine practice in all cases when examining the anterior part of the eye. Its use aids the minute examination of the lids and conjunctiva, as well as the cornea, iris, lens and aqueous. By it we may often determine small superficial ulcers and abrasions, commencing interstitial infil- trations, faint opacities or nebulae, and particles of foreign sub- stances imbedded in the cornea. The discovery of minute tears or abrasions of the corneal epithelium ma}^ be aided by the instillation of a drop of a two per cent, solution of the potassium or sodium salt of fluorescin. This should be dropped upon the cornea and followed by a washing with distilled water; any break of the epi- thelium will be made apparent by a deep greenish stain, which remains for about two hours. Oblique illiunination , or, as it is sometimes called, /"^(f^/ ox lateral ilhimijiation^ is used as shown in Fig. 2. The patient is placed two Fig. 2. Method of oblique illumination. EXAMINATION OF THE OUTER STRUCTURES. 21 feet from the gaslight iu a darkened room, as preferable to daylight, the light is then brought to a focus upon the cornea with a two or three inch lens, the surgeon may at the same time observe the surface under examination through another magnifying lens held before the eye. In order to focus the light upon the different structures, the illuminating lens will have to be moved slightly, according as the pencil of light is made to play over the cornea, iris, or lens. Inspection of the iris may frequently reveal normal ph3'siologi- cal differences in color or shade of the two irides; and we may also have instead of the uniform pigmentation one or more irregu- lar spots of different color. We can also detect hy the oblique illu- mination swelling, discolorations and vascularity of the iris tissue; the loss of lustre or the presence of gumma, foreign bodies, etc. ; the shape and size of the pupil, the presence of adhesions to either the cornea or lens. The mobility of the iris should be carefully studied, as the pupils of the two e3'es should act consensually; to examine, the patient is placed before a window in da3dight and directed to look at a distance; one eye is then covered, the other exposed eye will contract to the bright light, while the covered eye acts in harmony. If both eyes be now shaded dilatation en- sues, and if t'.ien again exposed to the light contraction immedi- ately follows, succeeded in a moment by slight dilatation and again a contraction; thus oscillating for a moment it finally settles down to its original size. This action is called hippus, and is sometimes present in a marked degree in cases of hysteria, mania, and other nervous disorders. As the pupils contract under the influences of accommodation and convergence, care must be taken during the examination that the eyes are constantly fixed on a distant object. Dilatation of the pupil occurs in glaucoma, atrophy of the optic nerve, from fright, in anaemia, nervous conditions, etc., in young people and from the use of mydriatics. According to McEwen dilatation in diseases of the nervous system, w^hen of cerebral origin, indicates extensive lesion, and when of spinal origin irrita- tion of the part. Contraction of the pupil occurs in old people, from the use of myotics, is present in inflammation of the iris, in some fevers, in mitral disease and pulmonary congestion, and in paralysis of the sympathetic. If of cerebral origin, as in meningitis, it indicates 22 EXAMINATION OF THE EYE. an early irritative stage of the disease; if of spinal origin, a de- pression, paralysis or even destruction of the part (McEwen). The Arg341-Robertson pupil is the small, contracted pupil which affected little, or none at all, by light and shade, responds by con- tracting still farther under the influence of convergence. This action of the pupil is found in degeneration of the posterior col- umns of the cord and indicates a serious central lesion. The examination of the ante^dor chamber and lens also, by the aid of the oblique illumination, shows if the former is more shal- low or deeper than normal, the presence of any exudation, etc., while in the lens the faintest trace of disturbance or change can be detected. Proptosis, or protrusion of the eye, if unilateral, may be noted by comparing the position of the corneae with each other and with the brows. It is present in Graves's disease, orbital diseases, in- traocular tumors, paralysis of the ocular muscles, etc. Finally the tension of the eye should be noted. To estimate the tension of the eyeballs the patient should be made to look downward and to gently close the eyes, for, if squeezed tightly together, that alone may slightly increase the tension. The index fingers of both hands should be applied to the lids, as there is not the same delicateness of touch between the first and second fingers of the same hand, and press gently first with one finger and then the other. The tension should always be estimated from palpa- tion on the sclera some distance back of the cornea. Estimate according to the resistance or indentation of the globe. Tonom- eters, or instruments devised for estimating the tension have been employed, but are hardly practical for general use. The following signs are used for designating the degree of the tension, viz.: Tn, tension normal; T+?orT — ?, a doubful increase or decrease of tension; T+ i, a marked increase as compared with normal; T -f- 2, a greater increase, but the globe admits of some dimpling; T -f 3, stony hardness, or no impression from firm pressure; T — i, a decrease as compared with normal; T — 2, greater loss of tension, and T — 3, eye very soft, no tension at all. The tension differs physiologically in different eyes; the sclera is more elastic in young than in old people; a large eye yields more than a small one, and variations in the form of the eye affect the tension. Diseases of the sclera might increase or decrease the tension. Fig. 3. il^'^ -m>^if Method of determinin^i the tension. THE FIELD OF VISION. 23 Variations in the curvature of the sclera at the point of impression will cause a slight difference in the tension, the greater the curva- ture the softer the e\'e. The tension of one eye should alwa3'S be compared with its fellow, and when in doubt with an eye known to be normal, in a person of the same age as the patient. The Field of Vision. — By the field of vision is meant the space, when the visual axis of one eye is fixed upon some stationar}^ point, in which all other objects are visible. This space is large or small, in proportion to the distance at which the fixation point is from the eye. The object fixed imprints its image upon the macula lutea, while the image of all other objects fall upon some peripheral portion of the retina. Peripheral vision is of value, in that while we only see objects iudistinctl}" upon which the visual axis is not fixed, it attracts our attention to other objects which we maj^ desire to see, and the eye is then turned in that direction. As, for example, in crossing a street our peripheral vision is attracted b}^ the approach of a team within the field of vision and our attention is turned to it that we ma}^ avoid an accident. In many diseased conditions of the fundus a knowledge of the field of vision is of the greatest importance both in diagnosis and prognosis. T/ie 7iormal field of vision varies indifferent directions, being greatest toward the temporal side, where it has an extent of over 90° because the rays from such a point, owing to the strong re- fraction at the surface of the cornea, can still enter the pupil. The field at the nasal side and above is of much less extent, be- cause of the limitation caused b}^ the nose and brow. The normal field for colors is found practically to be more contracted than that for white, and to vary with the different colors— blue being the least contracted, red next and green the most contracted. Pathological changes in the field of vision are both numerous, varied, and, in many diseases, are quite characteristic. Altera- tions in the visual field may be concentric, uniformh' drawn in at all points; sector-shaped, where it has the shape of a triangle whose base corresponds to the periphery; hemiopic, one-half of the field wanting; in addition to these more or less regular and frequently found forms of contraction there are many irregular shaped notches in the normal field. Scotomata, or blind spots in the visual field, when found as the result of disease, are classed 24 EXAMINATION OF THE EYE. as central or peripheral. A central scotoma involves the point of fixation, and means that direct vision is either diminished or wholly lost. Peripheral scotoma, on the other hand, do not involve direct vision and cause but little disturbance; in fact, are often not known to the patient until found in examining the field. An annular scotoma is one that more or less completely surrounds the point of fixation like a ring, the direct vision being left intact. In the healthy eye we have a scotoma, known as Mariotte's blind spot, which corresponds to the entrance of the optic nerve and lies about 15° to the outside of the point of fixation. Concentric conti^action with central vision impaired, may be found in atrophy of the optic nerve or retina; with central vision good, in retinitis pigmentosa and sometimes in the early stages of glaucoma. Sector-shaped alterations may be found in atrophj^ of the optic nerve, in occlusion of one of the retinal arteries, in de- tachment of the retina, and in glaucoma the nasal side is con- tracted. Scotomata are found in choroiditis disseminata and other choroidal diseases, in haemorrhages, especially when in the macula lutea, in toxic amblyopias, etc. The importance of a careful study of the field for colors, as well as for white, is well illustrated in atrophy of the optic nerve, as in this disease the color field is more constantly involved than that for white, and in some cases will be the first sign of the disease. In glaucoma the field for colors is lost with that for white, and they bear the same concentric arrangement throughout. In toxic amblyopia there is frequently found a central scotoma for red and green. These few illustrations are merely suggestive as to the impor- tance of perimetry in the study of intraocular and cerebral con- ditions, further reference to the pathological involvements of the field of vision will be found under the various diseases. ' . Examination of the Field of Visioji. — This must be made for each eye separately; the eye to be examined is directed at a fixed point, as it must remain steadily in the same position, while the other eye is closed. There are three methods of determining the field of vision; the simplest, and, at the same time the poorest, is that by using the hand as a test-object. The physician stands in front of the patient, who directs his left eye to the right ej^e of the physi- cian, the other eye of each being closed. The physician then THE FIELD OF VISION. 25 moves his hand in a plane midwa}^ between the patient and him- self from the periphery inward over the limits of the field of view. The patient is to tell as soon as he sees the hand, and if his field is normal he should see the hand at the same time as does the physician. This method is onh' adopted to determine large de- fects and in those where the central vision is too poor to see smaller test-objects. The field in patients wnth cataract is usualh^ tested in this way, using a candle-flame in place of the hand. The blackboard is the second method of determining the field. In this the patient's head is rested on a support 30 cm. from the board. x\ chalk mark is made directly opposite the eye to be ex- FlG. 4. Skeele's perimeter. amined, on which he is to fix his gaze. The chalk is now gradu- ally approached from the edge to the center, and the patient tells at the moment he first sees it. By marking this spot where he first sees the chalk in all directions of the field, and then connect- ing the points thus determined, we have the field of vision. By using colored chalks we can determine the field for the various colors. This method is also inexact. 26 EXAMINATION OF THE EYE. The only exact and scientific method of determining the field of vision is that where the projection is upon a hollow sphere. This is now determined by means of an instrument known as the perimeter. The patient's head is supported on a chin rest, which is so placed in front of a semi-circle that the eye to be examined is situated in the centre of the curvature of the latter. The eye is then fixed upon the middle point of the semi-circular arc, while a test-object, a small white or colored square, is carried along the arm of the semi-circle. The semi-circular arc is marked with a scale of degrees which can be read off, or in the best perimeters is self-registering on a chart attached. i THE USE OF THE OPHTHALMOSCOPE. 27 CHAPTER II. The Use of the Ophthalmoscope. In all the realm of modern medicine there has probably been no one discover}' of greater beneficence to humanit}' than the in- vention of the ophthalmoscope b}' Helmholtz in 1851. Through its use the mj-steries of the interior of the e3'e stand revealed and many conditions that previously resulted in blindness are now made remediable. With it we are able to study changes in the circulatory system, as exhibited in the retinal vessels; and in the optic nerve and retina we have, under the eye of the surgeon, direct communication with the brain and spinal system. The ophthalmoscope, therefore, has become of the greatest value in general medicine as an aid to diagnosis, for in the fundus of the eye are found many characteristic changes of disease of the various organs. Helmholtz 's discovery was not a matter of chance, but resulted from a careful study of the laws of optics, one of which is that light follows the same lines in returning through a lens (in case it can return) as when entering. The rays of light returning from the eye must go direct to the luminous source from which they emanated, and in order to fall upon the retina of the observer his eye must be in the path formed by the source of the illumination and. the eye under ex- amination. The device used by Helmholtz consisted of a trans- parent mirror formed of three slips of plane glass. The present principle of a perforated metallic mirror w^as first proposed b}?- Ruete, in 1852. In examining the interior of an eye, light is thrown into the eye by the mirror, and in order to see the fundus we must receive in our own eye the light reflected from the fundus and unite its rays to form a sharp image. The mirrors used may be either plane or concave. The concave mirror by converging the rays from the source of light gives a stronger illumination and is therefore generally used. The modern ophthalmoscope, of which Loring's is one of the best 28 THE USE OF THE OPHTHALMOSCOPE. consists then of a concave mirror, silvered on the back, for illuminating the eye and a series of lenses for measuring the refraction, and for diagnosing pathological changes by the direct method. The art of using the ophthalmoscope is one much more difficult Fig. 5. Loring's ophthalmoscope. to acquire than that of any other instrument of precision and is only accomplished after long and persistent practice. Every physician realizes the months or years of practice required to detect with the stethoscope the finer shades of sounds due to varying diseases of the heart and lungs. In one case the ear and THE USE OF THE OPHTHALMOSCOPE. 29 in the other the eye has to be trained by long experience before the examiner can become expert. The beginner is apt to think that after he has acquired a few details of the nerve and vessels that he can see all that is to be seen. At this stage we have often told our students that they have as yet not crossed the threshold of that vast storehouse of beautiful pictures formed by diseases within the eye. Even after years of daily use this little instru- ment reveals significant and often important variations of patho- logical states not heretofore seen, the meaning of which the observer is often at a loss to understand. The first and most essential point in order to become a skilled ophthalmoscopist, and which is often neglected, is familiarity with the healthy fundus. The student should first practice over and over again upon every healthy eye-ground he can before attempting to study diseased states. This necessit}^ becomes apparent from the fact that the normal fundus in health varies with the age, condition and complexion. What a large range of physiological pigmentation ma}^ be found from the negro to the albino. The skilled use of the ophthalmoscope is in the deter- mination of the very slightest changes from normal, as the detec- tion of gross pathological conditions does not present the impor- tance that does the recognition of the incipient stages of disease. In making an ophthalmoscopic examination artificial light is generall}' used and is preferable to daylight. We therefore darken the room and use a vsingle light, the best being that from an Argand burner or a student's lamp. The e3'e is first illumi- nated from a distance of about eighteen inches, and as the light plays over the cornea we note any opacities that may be present in the cornea or lens. Occasionally when there is a marked error of the refraction the retinal blood-vessels will be seen. If the eye is highh' far-sighted the vessels will move in the same direction as the head of the observer, while if it is a very near-sighted e3^e the vessels will move in an opposite direction. There are two methods of examining the fundus of the eye: First, the direct method, so called because the eye-ground is studied by rays coming directly from it, and by this method we have an upright image; and second, the i?idirect, because the rays are received from an aerial image, or indirectly from the observed eye, and the image seen is inverted. The latter method will first 30 THE USK OF THE OPHTHAI^MOSCOPK. be considered because it is more frequently employed and because it is the more natural order after the preliminary examination of the cornea and lens. The indited method, or the method of examination by the divert- ed image, is made as shown in Figure 6. The patient is seated in a darkened room with the light from an Argand burner about eighteen inches behind, on the same side, and level with the eye to be examined. He should be instructed to fixate the unused eye upon some distant object. The observer sits about eighteen inches in front of the patient and holds the ophthalmoscope in the hand corresponding to the eye to be examined. A convex lens, about thirteen to eighteen diopters, is held between the thumb and forefinger of the unused hand, before the eye of the patient. By resting the middle, third and little fingers upon the outer part of the supra-orbital ridge of the patient's eye the lens is held steadily and focused upon any part of the fundus desired, and the middle finger may also be used if necessary to raise the upper lid for a better view. In all ophthalmoscopic work the student should learn to keep both eyes open, as the effort to close one eye tires the eye and prevents the complete relaxing of the accommo- dation. He should also accustom himself to using the right ej^e and holding the ophthalmoscope in the right hand when examin- ing the right eye of the patient, and the left eye and hand when examining the left eye. The first objective point is the optic nerve head, and this is brought into view b}^ having the patient look at the right ear of the observer, and vice versa, when examin- ing the left eye, the patient should be told to look at the left ear of the surgeon. From this point he may be told to look directly at the centre of the observer's forehead, which gives a view of the macula lutea, and then, up and down, to the right and left, in order to examine all parts of the fundus. If the image of the disc when first brought into view appears dim and ill-defined, the lens and the ophthalmoscope should be moved slightly forward or backward until the image is as clear and distinct as possible. The student must always remember that by the indirect method he sees the aerial picture of the fundus and that it is inverted and reversed. The image by the indirect method is magnified about four or five times, while by the direct method we get a picture magnified about fourteen times. The extent of the field of vision Fig. 6. Opthalnioscopic examination by the indirect method. Fig. 7. Opthalmoscopic examination by the direct method. < i THE USE OF THE OPHTHALMOSCOPE. 3 1 on the contrary is about four times greater in the indirect than it is by the direct method. The intensity of the ilhimination is also greater with the indirect than with the direct, hence a view of the fundus can often be had by the indirect method when, owing to haziness of the refracting media, it is no longer visible by the direct. The indirect method gives then a larger view and better general relation of the fundus, while the direct method is particu- larly adapted for the recognition of the finer details. The direct method, or the examination with the erect image, is shown in Figure 7. The patient and light are placed in the same positions as in the indirect examination. The surgeon seats himself by the side of the patient and again uses his right eye in examining the right eye of the patient, and vice versa. The ophthalmoscope is held in the same hand as the eye to be ex- amined and brought up to about one inch from the eye of the patient. Both eyes are to be kept open so as to avoid as much as possible the impulse to accommodate. Ao the field is enlarged, and the examination by this method greatly facilitated b}' a dilata- tion of the patient's pupil, the use of a mydriatic is to be recom- mended to the student when first learning to use the direct method. "The dilatation of the pupil can be increased also by having the room as dark as possible, by closing the other eye, and lowering the light from which the illumination is received. If a still larger pupil be required for an examination of the fundus a 4 per cent, solution of cocaine should be used, as it will give the neces- sary dilatation in from twenty to thirty minutes and its effect passes away in a few hours. By the direct method, if both the eye of the observer and of the patient be normal in refraction, and the accommodation at rest in both, the details of the fundus are readily seen. If, how- ever, either the surgeon or the patient be m^^opic, or if hyper- metropic in excess of the power of accommodation to overcome, the refractive error must first be corrected. The power of relax- ing one's accommodation comes by practice. The primary ob- jective point in the examination is, as by the indirect method, the optic disc, and this is brought into view b}^ having the patient look straight forward w^hile the surgeon looks into the eye slightly from the temporal side. 32 THE USE OF THE OPHTHALMOSCOPE. The Fundus of the Eye as Seen by the Ophthalmo- scope. — (See Figures i and 2, Plate II, Chromo-Iyithographs.) As already mentioned, the first objective point in all examina- tions of the interior of the eyeball is the optic disc, or papilla. The term papilla is somewhat inaccurate, as the inference drawn from the word papilla would be that it was an elevation or something protruding from the surface of the fundus. This is not the case, as there is no prominence, and hence the term papilla is misleading; as, however, it is so generally employed, we shall use the word interchangeably with the more correct term disc. The optic nerve appears usually as a circular or slightly oval shaped disc, but may be quite irregular in outline. Its color varies from a pinkish white to a deep red, and may vary in different parts of the disc, often paler at the centre than at the circumfer- ence, or the nasal side a more decided red than the temporal. The tint also varies wnth the age and complexion of the patient, and the contrast with the color of the surrounding fundus. The white appearance of some portion of the disc is due to a depres- sion at that point, the floor of which is composed of an interlacing opaque fibrous tissue called the lamina cribrosa, through which the nerve fibres pass, and it is here they lose their medullary sheath and become transparent axis cylinders. This white spot, varying in size, is seen usually at the centre of t-he papilla, or, rarely, more at the temporal side is called the physiological cup or excavation. Care must always be taken to differentiate this physiological cupping from the excavation found in glaucoma and in optic nerve atrophy. A description of the different forms of cupping of the disc will be found under the study of glaucoma. The border of the optic disc is well defined, being sharply outlined by a double ring. The inner, or scleral ring, appears as a faint white streak, especially distinct in elderly people, and indicates the opening of the sclerotic coat through which the optic nerve enters the eyeball. Jaeger has called this the connective tissue ring, formed by the junction of the connective tissue elements of the inner sheath of the nerve with layers of the sclera. The outer, or choroidal ring, usually seen as a slight black crescent upon one side of the disc and often wholly absent, bounds the opening in the choroid. The next most noticeable feature in the examination of the FUNDUS OF THE EYE AS SEEN" BY THE OPHTHALMOSCOPE. 33 fundus is the blood-vessels. The arterial trunk usuall}^ divides, just before emanating from the bottom of the disc, into an up- ward and downward branch, each of these branches generally dividing again as the}^ pass off from the optic disc. These arteries as they spread out above and below continue to divide dichoto- mously into numerous branches, supplying all parts of the fundus, excepting a small area at the temporal side of the optic nerve. This area is called the viacula hctea, or yellow spot, and at its centre is the point of most distinct vision, the fovea centralis. The temporal half of the retina is more freely supplied with blood-vessels than is the nasal side. The retinal veins follow the same general course and parallel to the arteries, and empty by two large branches into the centre of the disc. From this general arrangement of the retinal vessels we maj^ have manj^ variations in the normal fundus. The arteries and veins are distinguishable by their size and color, the veins being larger in proportion of about three to two and of a dark red as contrasted with the bright color of the arteries. The veins are also more tortuous in their course and spontaneous pulsation is not infrequently seen in the veins. The so-called reflex or light streak, which runs along the crest of the vessels, covering about one-third of their diameter, is of a pale straw color, and is more brilliant, broader and more sharply defined upon the arteries than veins and may be entirely absent in the veins. The cause of this reflex is unsettled, some claiming it to be a reflex from the vessel wall, others from the blood column. The appearance of the macula lutea is as difiicult to describe as it is to the student to see. No two observers seem to illustrate or describe it in the same coloring. In many cases while we ex- amine the macular region we see nothing, and often we are but conscious of a luminous oval ring, the centre of which is marked by a small spot of a darker color. This phantom-like reflex, or, as it is sometimes called, halo, varies in size, though usually of an oval or circular shape. The inclosed space seems to be more of a grayish or brown color than the 3'ellow we should naturally expect from the macula lutea being commonh^ spoken of as the j^ellow spot. The examination of the region of the macula lutea should always be practiced, for while in the normal eye the halo is often absent and the coloration of this spot vari- able, in diseased states an accurate picture of the macula is often 3 34 THK USE OF THE OPHTHAI.MCSCOPE. of the utmost importance. The location of the yellow spot is about one and one-tialf optic nerve diameters to the outer side of the disc and is usually best seen by the indirect method. The retina, being a transparent membrane, is practically invisi- ble and reveals nothing of its delicate structure excepting the retinal vessels, which are readily seen ramifying within its inner layers. Some, however, have claimed to have seen, especially in the deeply pigmented eye of the negro, with a weak illumination, the presence of the retina as a very faint grayish tinge in the neighborhood of the disc. To the observer, especially when in- experienced, the retinal vessels seem to course over and form a part of the background of the eye. They should, however, always remember that they lie some little distance in front of the under- lying choroid. This can be more easily appreciated in the slightly pigmented eye, especially the albino, where they are readily seen passing over the choroidal vessels. Recognition of the choroid varies with the pigmentation of the eye. The bright red color from the pupil when the eye is illuminated with the opthalmo- scopic mirror arises from the choroid. The choroidal vessels ap- pear as flat curvilinear stripes of a light pink hue interlacing in distinct meshes. The pigment stroma shows as irregular patches within the meshes of the choroidal vessels. The pigmentation is often more dense around the optic nerve and posterior part of the fundus. The visible choroidal vessels are always broader than the retinal trunks, and no distinction can be made between the arteries and veins. NORMAL REFRACTIOX AND ACCOMMODATION, 35 CHAPTER III. Refraction and Accommodation of the Eye. By Chas. H. Hf:lfrich, M. D., Surgeon to the X. Y. Ophthalmic Hospital. Normal Refraction and Accommodation. — The dioptric media of a normal or emmetropic eye f cornea, aqueous humor, lens and vitreous humor) have the requisite refractive power to bring parallel rays of light to a focus on the layer of rods and cones of the retina. These media are centered on the optic axis, a line passing through the centre of the cornea and the posterior pole of the eye. Fig. S. Schematic eye. *J•^ anterior or first principal focus; A, anterior surface of the cornea; H^ and H'^, principal points; K^ and K^^ nodal points; 4'^^, posterior or second principal focus; F.r., fovea centralis; ^^ 4>^^^ optic axis. 36 REFRACTION AND ACCOMMODATION OF THE EYE. Upon the optic axis are situated the cardinal points of the dioptric system. Objects situated at a distance of five metres or more are con- sidered as being at infinity, because those rays from them which enter an eye are so shghtly divergent that for practical purposes they may be considered parallel. As parallel rays are brought to a focus at the second principal focus, the eye is capable of forming distinct inverted images of distant objects upon the retina. The eye, however, can also see near objects distinctly, and as the rays from such sources become more divergent the nearer they ap- proach, it is obvious that it must contain some mechanism to in- crease its refractive power. The power by which it is increased so that divergent rays are also brought to a focus on the retina is the accommodation. Fig. 9. Changes in the eye produced by accommodation, r, cornea; a, anterior chamber; /, lens; v, vitreous humor; /, iris; z, zonula of Zinn; Tn, ciliary muscle. By the term static refraction is meant the power the eye has when at rest (without an effort of accommodation) to bring parallel rays of light to a focus on the retina or to render diver- gent rays less divergent. The dynamic refraction constitutes the increase of refractive power produced by the effort of accommodation. The mechanism of accommodation is as follows: By con- THE FAR AND NEAR POINTS. 37 tracting the ciliary muscle the tension on the zonula of Zinn is relaxed, permitting the lens to become more convex through its own elasticit_y, and thus increasing the refractive power. The changes which take place in accommodation are repre- sented by the dotted lines in (Fig. 9.) The anterior surface of the lens advances and becomes more convex, while the convexit}' of its posterior surface increases but little and does not change its position at all. Associated with this act is a contraction of the pupil. The far and near points. — The name piuidum rcmotiivi, or far jjoint, is given to the point to which the ej'e is adapted when at rest. It represents the most distant point of distinct vision, and is designated by R. By the term pitnclum p7'oximnm or near point, is understood the nearest point of distinct vision. It is found by ascertaining the nearest point at which the smallest test- letters can be read, and is designated b}' P. It is possible for the eye to see all objects distinctly between these two points. The range or amplitude of accommodation is the amount of accommodative effort of which an eye is capable, and is equal to the difference in the refractive power when in a state of rest and when its acommodation is exerted to the utmost. It may be represented b}^ that convex lens, placed in front of an eye, which would give to ra3^s coming from the near point a direction as if they came from the far point. If we consider a equals the number of dioptres represented by the range of accommodation, p the number of dioptres represented b}^ the eye when adapted to its near point, and r the number of dioptres represented by the eye when adapted to its far point, we can calculate the amplitude of accommodation by the following formula: — a = p — r. In the emmetropic e3'e R is at infinity, therefore r = o; hence a =p. To illustrate, when the near p jint is 20 cm. (a focal length of 20 cm. represents a lens of 5. D) from the eye,' we have a =5. D. In myopia R is at a fixed distance, and, for example, if it is situ- ated at 50 cm. (myopia of 2. D) and P at 20 cm. (5. D) we have a=S' D.-2. D.=3. D. The hyperopic eye is adapted for rays which converge to a point behind the retina, therefore r is negative and must be added \.o p. In this case we have a —/>_(—;') and reduced a =p —- r. To illus- 38 REFRACTION AND ACCOMMODATION OF THE EYE. trate, if the hyperopia is lo. D. and P is situated at 20 cm., we have a =5. D.-\^io. D.=r^. D. Convergence. — Ordinarily man looks simultaneously with both eyes, yet appreciates but a single image. This union in one single impression of the retinal images received by both eyes is called binocular vision. In order to obtain this each eye must receive upon its fovea centralis a distinct image of the object, and hence it is necessary that both lines of fixation (a line connecting the object of fixation with the centre of rotation) be directed towards the object looked at. When looking at a distant object the lines of fixation are parallel, but the nearer it approaches the more the lines of fixation must converge and the eyes turn in. If an object is moved along the median line (I M, Fig. 10), a line Fig. 10. The metre angle. perpendicular to the middle of a line uniting the centres of rota- tion, both eyes converge equally to any given situation. The degree of convergence is measured by the angle through which an eye turns when it fixes the object. When it is situated at I, one metre distant from the eye, the angle of convergence E I M ACCOMMODATION AND COXVERGEXCE ASSOCIATED. 39 is one metre angle which is taken as a unit. If the object be situated at ^2 of a metre, it is obvious that the angle of converg- ence is twice as large as in the former instance; that is, it equals 2 metre angles. Accommodation and Convergence Associated. — With ever}' degree of convergence is associated a certain effort of the accommodation. When looking at an object situated at one metre, it is necessary to converge i metre angle, and an effort of the ac- comodation equal to a convex lens of i. D must be employed. That is, the refraction and convergence must increase b}' an equal quantit}^ which is the inverse of the distance of the object. This association between accommodation and convergence, however, is not absolute, for with the lines of fixation fixed on a given point and stationary, the accommodation can be somewhat increased and diminished; and conversely, with a given amount of accommodation, the degree of convergence can be augmented and reduced. If an object is held at one metre and first weak convex and then weak concave glasses be placed before the eyes the distinct- ness of the image is unaltered. The relative amplitude of accom- modation is thus obtained. The part represented b}^ the strongest convex glass which can be placed before the eye without affecting the distinctness of the object is termed the negative, and the part represented b}^ the strongest concave glass the positive. When sustained efforts of the accommodation are necessary at any dis- tance, it is essential that the positive relative amplitude of accom- modation be considerable. That the convergence may be altered while the same effort of accommodation is maintained can be demonstrated by placing a weak prism with its base in before one ej'e. If the convergence remained unaltered, the prism would cause double vision, but the eyes rotate outward and the object looked at is still distinct and the image single. Likewise, it will be found that a weak prism with its base out will be followed by a rotation of the eye inward wnth no effect on the distinctness of the image. The relative amplitude of convergence is thus obtained. The Angle Alpha and Angle Gamma. — The optic axis A A' (Fig. II.) is an imaginary line, which ma}^ be regarded as pass- ing through the centre of the cornea C and the posterior pole of 40 REFRACTION AND ACCOMMODATION OF THE KYK. the eye — a point situated between the fovea and the optic papilla. Upon it are the cardinal points and the centre of rotation M. Fig. II. Schematic figure showing the angles a and }. AA^, optic axis; *^. anterior focus; ^'\ posterior focus; WW^, principal points; K^K^^, nodal points; M, center of rotation; C, centre of cornea; BB, base of the cornea; BL, major axis of the corneal ellipsoid; F, fovea centralis; O, poinf of fixation; K^O, line of vision; MO, line of fixation; O X B, angle a\ O M A, angle } . Ths visual line O F unites the point of fixation O — the object looked at — with the fovea. It does not coincide with the optic axis, but crosses it at the nodal points. THE ANGLE ALPHA AND ANGLE GAMMA. 4I The line of fixation O M joins the centre of rotation with the point of fixation. If the fovea coincided with the posterior pole, the visual line, line of fixation and optic axis would also coincide, but this is not the case. The apex of the corneal ellipsoid E does not coincide with the centre of the cornea, and therefore neither does the major axis of the ellipse E L coincide with the optic axis. The angle O X E formed by the visual line and the major axis of the corneal ellipse is called the angle alpha. When the anterior portion of the corneal axis is situated to the temporal side of the line of vision, the angle a is called positive; when it is situated to the nasal side, negative. The angle O M A formed b}^ the line of fixation with the optic axis is called the angle gamma. It is termed positive when the anterior extremit}^ of the line of fixation passes to the inner side of the optic axis, and negative when it passes to the outer side. In practice, it is usual to consider the line of fixation and the visual line as indentical. In order to measure the angle gamma, the patient is placed be- fore the perimeter as for an examination of the field of vision. A lighted candle is moved along the arc of the perimeter, and by means of the corneal reflection of the flame the centre of the cornea is found. The position of the candle at the perimeter is now read from the arc in degrees and represents the size of the angle. Its average size is five degrees. In emmetropia and hyperopia the visual line cuts the cornea to the inside of its major axis, and the angle gamma is therefore posi- tive. Ownng to the shortness of the eyeball in hyperopia, the effect of which is to increase the distance between the fovea and the optic axis, the angle gamma is very much greater than in emmetropia. This may give to the eyes the appearance of an apparent divergent strabismus, as the axes of the corneae seem to diverge though the fixation is correct. In myopia the length of the eyeball is too great, so the visual line cuts the cornea nearer the major axis, or they may coincide, or it may cut it to the outer side making the angle gamma nega- tive. In the latter case the effect will be to give the eyes the ap- pearance of an apparent convergent strabismus. 42 REFRACTION AND ACCOMMODATION OF THE EYE. Abnormalities of Refraction and Accommodation.— As has been explained in the preceding pages, a normal or emmetropic eye is one whose static refraction is sufficient to bring parallel rays to a focus on the retina; or, one whose retina is situated at the focus of its dioptric system. Its far point is always at in- finity. Any departure from emmetropia is known as ametropia of which three different forms are recognized: i. Hypermetropia, in which the retina is situated in front of the focus of parallel rays. 2. Myopia, in which the retina is situated behind the focus of parallel rays. 3. Astigmatism, in which the refraction of the different meridians is different. Hypermetropia or Hyperopia. — In hyperopia the static re- fraction is not sufficient to bring parallel rays to a focus on the retina. Such rays if not intercepted by the retina would come to a focus behind it. As they are intercepted by the retina they do not form there a distinct image of the object looked at but a circle of diffusion. In order to bring parallel rays to a focus on the retina, it is necessary either to place an appropriate convex lens before the eye which causes them to converge or to call the accommodation into play. Fig. J 2 shows how the parallel rays a b converge toward a point r, behind the retina, after passing through the dioptric system, and how the diffusion circle d e\^ formed upon the retina. Fig. 12. Formation of diffusion circles on the retina in hyperopia. As the retina in hyperopia is nearer the dioptric system than its principal focus, rays passing out from any point upon it such as R (Fig. 13) will leave the eye divergent and will appear to come from a point R situated behind the eye. The point R' , the virtual conjugate focus of R, is the far point HYPERMETROPIA OR HYPEROPIA. Fig. 13. 43 Far point of a hyperopic eye. of the eye, or the point towards which the rays must converge be- fore entering in order to be brought to a focus on the retina. Be- ing behind the eye it is negative. Jn order that parallel rays may be brought to a fccus on the retina, it is necessary that the refrac- tive power of the e3^e be increased by such a lens as will render them convergent towards the point R' . This is shown in Fig. 14 where the lens L renders the parallel rays convergent towards R' , and which the dioptric S5'stem render still more convergent so that they come to a focus at R on the retina. Fig. 14. Correction of hyperopia by a convex lens. The greater the hyperopia the nearer the far point is to the eye, the more convergent the rays must be in order to co i;e to a focus on the retina, and the stronger must be the lens which renders them so. But the power of accommodation is also sufficient to increase the static refraction sufficiently to bring parallel rays to a focus on the retina if the degree of hyperopia is not too great. In fact, it Ordinarilv does so in such cases so that the vision mav 44 REFRACTION AND ACCOMMODATION OF THE EYE. be normal for distant objects, which has given rise to the mislead- ing term of farsightedness. A beginner might fall into the error of considering such an eye emmetropic; but it can be proven to be hyperopic by successively placing stronger and stronger convex glasses before it, which, as the accommodation relaxes, do not "in- terfere with the distinctness of the object until the hyperopia is overcorrected, or an artificial myopia is produced. Hence, it is necessary to find the strongest convex glass through which the hyperopic eye can see distant objects most distinctly in order to find the measure of the error. Generally the ciliary muscle, through force of habit, does not relax to its fullest extent, so that the strongest convex glass simply represents the amount of mayii- fest hyperopia (Hm). The balance of it, the late7it (HI), can only be made manifest by instilling a solution of some cycloplegic like atropine which suspends the accommodation. The sum of the latent and manifest hyperopia gives the total (Ht). Theoreticall}^ that glass placed in contact with the eye whose focal distance is equal to the distance of the far point behind the eye, or which renders parallel rays convergent to- wards the far point, is the measure of the hyperopia. In prac- tice, however, the glass is placed about 15 mm. in front of the eye, and it is regarded as the measure, though in reality it is not as great. Causes. — The eyeball is either abnormally short, constituting axial hyperopia, or its refractive power may be deficient, curva- ture hyperopia. Hyperopia is nearly always congenital. Most children are so at birth, but as they grow older the refraction increases and they become less hyperopic, or emmetropic, or myopic. Senile changes in the lens, flattening, give rise to it; and its removal, as for cataract, produces a high degree. The latter condition, however, is termed aphakia. Symptoms. — The constant effort of the accommodation ne- cessary in order to see distinctly gives rise to many symptoms. As the ciliary muscle tires, vision blurs, and it is necessary to stop work and rub the eyes. The resp.te obtained in this way is only temporary, as the muscle soon tires again and the per- formance must be repeated again and again until finally the work must be discontinued. Such people often seek a good light because the contraction of the pupil renders the vision HYPERMETROPIA OR HYPEROPIA. 45 clearer. Frequently too they hold the object near the face to secure larger retinal images and contract the lids to shut off the more divergent rays. This gives the semblance of myopia, and many children are erroneously given concave glasses which aggravate the trouble. When left uncorrected, hyperopia frequentl}' gives rise to con- junctivitis, blepharitis, nictitation of the lids, and congestion of the retina, choroid and optic nerve. Headaches and various reflex neuroses are very common. Strabismus convergens is frequenth' associated with hyperopia the discussion of which will be found in the chapter upon that subject. Hyperopia is often complicated with spasm of the ciliary muscle, the effect of which is to bring nearly or wholly the entire accommodation into play. This reduces the amount of manifest hyperopia when it is of high degree, and in some instances may even convert the case into one of false myopia. The vision in the latter instance will be improved by concave glasses, though it would be a serious error to prescribe them. Such a mistake is prevented by detecting the real nature of the refractive error by means of the ophthalmoscope, as described in the chapter on dipotometry. When spasm of the accommodation is present, it is imperative that a cycloplegic be instilled to temporarily paralyze the ciliary muscle and so suspend the accommodation. Manifest hyperopia is divided into facultative, relative, and absolute. Facultative hyperopia may be overcome b}^ using the accom- modation without squinting. Relative hyperopia represents a greater degree, and can only be overcome by the accommodation when the patient squints inward. Absolute hyperopia is the highest degree, and cannot be over- come b}^ using the entire accommodation. The determination of hyperopia will be described in the chapter on dioptometry. Correction of Hyperopia. — If the patient has normal acute- ness of vision and no asthenopic s}- mptoms glasses need not be prescribed for him. 46 REFRACTION AND ACCOMMODATION OF THE EYE. When distant vision is imperfect, and asthenopic symptoms are present, it is necessary to prescribe glasses which represent the amount of manifest trouble, either for constant use or for near work. In some instances, it may be necessary to correct the mani- fest and part of the latent if the latter exists. As a rule, if hyperopia is associated with exophoria it is best to prescribe as weak a convex glass as possible, whereas if esophoria is present, the strongest. In spasm of the accommodation it is advisable to put on nearly the entire correction while the eye is under the influence of the cycioplegic, and later glasses which correct all the manifest and as much of the latent as is tolerated Many cases of convergent strabismus in children are cured by prescribing appropriate glasses. The degree of hyperopia can be determined by the direct examination with the ophthalmoscope or skiascopy if the child is too young to know its letters. Myopia. — In this form of ametropia parallel rays of light are brought to a focus in front of the retina, therefore the latter is situated beyond the principal focus. The focus of the rays a b (Fig. 15) is at/ where they cross each other, and on arriving at the retina form the diffusion circle c d. Fig. 15. Formation of diffusion circles on the retina in myopia. As the retina is situated behind the principal focus, rays com- ing from any point upon it such as c (Fig. 16) leave the eye con- vergent and meet at a point r in front of it. The points (f and r are conjugate foci, for if the rays coming from r enter the eye its dioptric system will bring them to a focus at c. For this reason r is the far point of the e3^e, as it is the most distant point of distinct vision. A myopic eye is adapted for MYOPIA. 47 divergent rays of light, therefore if a distant object is brought nearer it can be seen distinctly when it arrives at the far point. In order that a myopic eye may be able to see objects at infinity, it is necessary, that parallel rays be given a divergence as if they came from its far point. This can be accomplished b}' a concave Fig, 1 6. Far point of a myopic eye. lens whose focal distance coincides with the distance of the far point from the e\"e. Such a glass placed in contact with the cornea would represent theoreticalh' the degree of myopia. In practice, however, the glass is placed about ij mm. in front of the cornea, and is somewhat stronger than the theoretical degree. The effect of a concave glass rendering parallel rays divergent as if they came from the far point is shown in (Fig. 17.) Fig. 17. Correction of myopia with a concave lens. The divergence given to parallel rays by a weak concave glass can be overcome by an effort of the accommodation, and this is of 48 REFRACTION AND ACCOMMODATION OF THE EYE. importance in testing for myopia. It makes it essential to select the weakest concave glass that renders distant vision most distinct. Spasm of the accommodation is also frequently present in myopia, rendering the instillation of a cycloplegic necessary. In fact, it is generally the best plan, everything else being equal, to test myopic eyes with the accommodation paralyzed in order to pre- vent the very serious mistake of prescribing too strong concave glasses. Causes. — Myopia is most frequently due to an increased length of the axis of the eyeball, axial myopia; but may be due to an abnormally high refractive power, curvature myopia. It is rarely congenital, but comes on about the eighth year and is very prone to increase. Its progressive increase is encouraged by use of the eyes at near work, such as reading, writing, drawing, sewing, etc., but the essential connection between such work and the lengthening of the eyeball is still problematical. Children, when reading and writing, bend their heads forward to bring them close to the books. In such a position the visual plane is lowered, the ciliary muscle is kept tense, and the eyes are made strongly convergent. On account of the excessive convergence the recti are rendered tense; and, owing to the lowering of the visual field, the obliqui also. The pressure of these muscles, augmented by_ the ciliary, increases the internal tension of the eye. The tension is further augmented by the hypersemia due to the woik itself and the interference with the return of venous blood induced by bending the head forward. It is presumed that the increased tension causes the envelopes of the eye to yield, but it is certain that there must be some predisposing causes as well. While myopia is more apt to come on during school life, and is more prevalent among the upper classes and in artisans whose work demands close inspection, the reverse is frequently true. All school chil- dren working under the same conditions do not become myopic, and many high degrees of myopia are found in people in the lower walks of life who do not use their eyes for close work. In cases of commencing cataract, a weak degree of myopia often sets in as the result of the changes in the lens which cause an increase in its refractive power. Conical cornea gives rise to myopia by the increase of the MYOPIA. 49 curvature of the cornea and the lengthening of the axis of the eyeball. Symptoms. — Subjective symptoms are not as common as in hyperopia. The most common are headaches, aching of the eye- balls, burning of the lids, floating specks and congestion of the conjunctiva. ^Myopes ordinarily half close the lids when viewing distant objects and hold small objects quite close to the eyes. The most pronounced objective symptoms are found when progressive myopia becomes complicated with organic disease. Posterior staphyloma, recognized by the ophthalmoscope as a white crescentic patch at the outer side of the optic papilla, is found in nearly all myopic eyes. It is caused b\' the increased tension which results in atrophy of the choroid at this point, per- mitting the white sclerotic to be seen. In extreme cases it may become annular and extend all around the optic papilla. Often it is possible to distinguish between a stationary and a progressive myopia by the edge of the staphyloma, which if clear cut, usually denotes it to be stationary. Conversely, if it extends towards the macula and is irregular it is more likely to be pro- gressive. More serious and frequent complications of progressive myopia are choroidal degeneration and haemorrhages in the neighborhood of the yellow spot, detachment of the retina and opacities in the vitreous humor. Divergent squint and exophoria are frequently associated with myopia. Treatment. — On account of the ability of myopes to see fine objects so distinctly when held near to the eyes, they are popu- larh' supposed to have strong eyes. From what has been said it is easy to appreciate what a serious mistake this is. Owing to the progressive character of the trouble its manage- ment is a most important ta.sk, especially during the school life of children. ^^lany cases are stationary and need cause no anxiety, but those which are progressive demand special care. In order to prevent the necessity of too great convergence, these patients should occupy themselves with large objects which need not be held so close to the eyes. A proper position at the desk is necessary with the book on a slope and the head upright. The desk should be so placed that 4 50 RKFRACTION AND ACCOMMODATION OF THE EYE. a good light comes over the shoulder, and it should not be too low. It is essential that the number of working hours be restricted and that frequent short rests be taken. Proper exercise in the open air is also advisable. When the more serious complications are present, complete rest of the eyes with suspension of the accom- modation by atropine is to be ordered. During this time smoked glasses should be worn. The correction by suitable glasses is an important part of the treatment of myopia. Very weak degrees of mj^opia in young people with good amplitude of accommodation may be fully cor- rected by glasses to be worn constantly, but if it amounts to more than say 2. D. , weaker glasses for reading are required in addition. In higher degrees, providing the vision is good, nearly the full correction for distance can be worn, but a separate glass for reading should be given. Such cases should be warned not to use their distance glasses for near work. The proper near glass is one that will permit the patient to read at about jo cm., at which distance the convergence is not excessive. Such a glass can always be found by deducting from the distance glass the lens whose focal length is equal to jo cm. This lens is j.^5 D. In like manner proper glasses for the special distance, at which painting and piano playing are carried on can be calculated. Patients whose acuteness of vision is much reduced are prone to hold their work nearer thanjo cm. in order to obtain larger retinal images. If so, the near glasses must be still further reduced or taken away entirely. Since Fukala recommended extraction of the lens for extreme degrees of myopia the operation has been taken up by a number of German surgeons and lately by some in the United States. The operation consists first in making a discission of the lens, and later when it has become swollen and cataractous it is removed through a linear incision. Jackson calculates that a myopia corrected by a lens of from 17 to 18 dioptres will be followed by emmetropia upon extracting the lens of the eye, and a gain in the size of the retinal image of about 55 per cent. As the dangers are comparatively insignificant and the ad- vantages great, the operation is no doubt destined to play an important part in the management of myopia of more than 15. D. Swanzy operates only upon one eye, thereby improving the ASTIGMATISM OR ASTIGMIA. 5 1 vision in it for distant objects, leaving the unoperated eye better adapted for near work. His method is to make repeated discis- sions until the lens is absorbed, and does not extract unless glaucoma supervenes. Astigmatism or Astigmia. — In discussing hyperopia and myopia, the cornea has been considered as an ellipsoid of revolu- tion, so that planes passing through it produce sections having an equal curvature, the effect of which is to bring all raj^s emanating from a luminous point to a single focus. But there is also a form of eye in which all the rays of light are not brought to a focus at a single point, because the refractive power is not the same in all its meridians, or in the various sections of the same meridian. In astigmatism, those rays of light which enter in the direction of the greater curvature form their focus first and at a point nearer the dioptric system than those which enter in the direction of a meridian of less curvature. Homocentric light is there- fore brought to a focus at several points instead of one. Astigmatism is divided into regular and irregular. Fig i8. Refraction of the rays in regular astigmatism. In regular astigmatism the curvature of the cornea is greater in one meridian than in another, whereas in irregular astigmatism the curvature varies in the different sectors of the same meridian. Regular astigmatism is divided into simple hyperopic, compouyid hyperopic, simple myopic, compound myopic and mixed. The meridians of maximum and minimum curvatures are alwa3^s at right angles to each other, and most usually are the vertical and horizontal. They are known as the principal meridians, the vertical being generally that of the greatest curvature. The intermediate meridians between the principal meridians are of regularly intermediate refracting power. The 52 REFRACTION AND ACCOMMODATION OF THE EYE. effect on a pencil of rays passing through an astigmatic eye whose vertical meridian is that of the greatest curvature is shown in Fig. 1 8 by various sections supposed to be thrown on a screen placed at varying distances from the cornea. Remembering that the rays passing through the vertical meridian are most sharply refracted, we have at A, not a round section, but a horizontal oval. At B the rays passing through the. vertical meridian have come to a point, and those from the horizontal meridian form a horizontal line. Beyond this, the vertical rays diverge, having crossed at the focus, while the horizontal diffusion decreases, giving rise to the section at C, and later, when the two are equal, a circle as at D. The figure next becomes a vertical oval, as at E and later, when the horizontal rays come to a focus, a vertical line at F. Finally a vertical oval as at G. The interval between the foci of the two principal meridians is called the focal interval of Sturm. The position of the retina with reference to the two principal foci designates the kind of astigmatism. Thus in simple hyperopic astigmatism one focus is situated upon the retina and the other behind; in compound hyperopic both are behind; in simple myopic one is situated upon and the other in front ; in compound myopic both are in front ; in mixed one in front and the other be- hind. Causes — The seat of astigmatism is usually the cornea but it may also be present in the lens, and when this is the case it may neutralize some of the corneal astigmatism. Sometimes, however, it augments it. Lentil astigmatism is often compensatory and is produced by localized contractions of the ciliary muscle. Astig- matism may also be produced by an oblique position of the lens. Operations upon the cornea frequently produce it by the contrac- tion of the cicatrix formed by the healing of the incision. Symptoms — From what has been said it will be easy to under- stand the difficulties under which an astigmatic individual labors in appreciating horizontal or vertical lines, depending upon the kind of astigmatism present. As letter-press is composed for the most part of horizontal and vertical lines, and as the astigmatic eye is unable to clearly recognize at the same moment both kinds of lines in the same plane, considerable difficulty in reading letters is ASTIGMATISM OR ASTIGMIA. 53 experienced because the circles of diffusion which form in one direction cover the distinct images which are formed in the other. If parallel rays from a point enter an e3-e which is emmetropic in the vertical meridian and hyperopic in the horizontal, those rays which enter the former meridian will focus at a point on the retina, while those which enter the latter will form horizontal diffusion lines at either side. As a line is made up of an infinite number of points such an eye would appreciate horizontal lines much clearer than vertical ones, because the lines of diffusion would not materially affect horizontal lines except to elongate them. These facts are utilized in the diagnosis of astigmatism b}" the use of the ordinary " clock face " test-tj^pe. They also explain why astigmatic persons often partly close their eyelids to shut out the rays from one meridian and incline their heads to one side or the other to bring the other principal meridian to correspond to the slit-like palpebral opening. For like reasons a stenopaic slit improves the vision of astigmatic in- dividuals. Persons with hyperopic astigmatism frequently bring objects at which they ma}^ be looking very near their ej^es to increase the visual angle. Astigmatism is the cause of a very large per- centage of headaches and gives rise to a number of nervous troubles of a reflex nature. Chorea and epileps}' have been cured by correcting it with proper glasses. Frequently the weaker degrees give rise to more of these troubles than the higher, owing to the constant efforts of the ciliary muscle to overcome the error. The presence of astigmatism can often be determined by the ophthalmoscopic appearance. An observer has difficulty in see- ing both vertical and horizontal vessels simultaneously, and must alter his accommodation to see first one and then the other. The optic papilla, instead of being circular, appears oval. In the direct examination the long axis corresponds to the meridian of greatest curvature and in the indirect to the least. Treatment. — As spherical lenses refract light equalh' in all me- ridians, it is evident that they cannot correct the differences in the refractive powers of the two principal meridians in astigmatism. This canonl}' be corrected by cylindrical lenses, which are sections 54 REFRACTION AND ACCOMMODATION OF THE EYE. of cylinders parallel to their axes. Such lenses refract light in one direction only, viz. , that at right angles to their axes. Thus simple hyperopic and myopic astigmatism, where one meridian is emmetropic and the other hyperopic or myopic, are corrected by convex or concave cylinders with their axes corresponding to the emmetropic meridian. Cases of compound hyperopic and compound myopic astigma- tism, where both foci are either behind or in front of the retina, are corrected by convex or concave sphericals which render one me- ridian emmetropic and partially correct the other, combined with convex or concave cylinders which correct the remainder. Mixed astigmatism, where the retina is situated between the two foci, requires a combination of a convex and a concave cylinder placed at right angles to each other which set back one focus and advance the other. A variety of combinations of spherical with cylindrical lenses is possible which are optical equivalents. In testing the compound forms of astigmatism, it is the rule to correct as much as possible with spherical lenses and the balance with cylinders. As in simple myopia and hyperopia, the weakest concave and the strongest convex glasses which render distant vision most dis- tinct represent the degree of the error. In prescribing glasses, it is the general rule to fully correct the astigmatism with cylinders, but the sphericals may be weakened to suit the accommodation. The general rules governing their selection in hyperopia and myopia apply in astigmatism. In simple hyperopic or myopic astigmatism, the strongest convex and weakest concave cylinders which improve distant vision most are selected. In compound hyperopic the spherical may be weakened, and in compound myopic this is frequently necessary, especially for near work. Mixed astigmatism ordinarily receives the full correction. As a general rule, all cases of astigmatism ought to be thoroughly tested with the accommodation paralyzed. Irregular Astigmatism. — A low degree of this defect occurs in the majority of eyes. This is often more manifest when the pupil is dilated, or when the eye is being tested under atropine. It will be found impossible to bring the vision up to what it was before the mydriatic was instilled. PRESBYOPIA. 55 Higher degrees reduce the vision very much. The stenopaic hole increases vision, but such spectacles are impracticable on account of their small field. Sometimes one meridian of regular curvature can be found, and, if so, the vision is benefited, by means of a cylindrical lens, which can be prescribed. Irregular astigmatism is frequentl}" produced by the cicatrices of ulcers of the cornea. The congenital form is due to irregular refracting power in different parts of the lens. Anisometropia. — By this term is meant a difference in the refraction of the two eyes, one being more hyperopic or m3^opic than its fellow, or a different form of ametropia existing in each eye. When the dift'erence is slight, it is usualh- possible to fuU}^ cor- rect each eye. When the difference is considerable, an attempt may be made to do so, but if it is impossible the stronger glass should be weakened. Sometimes the choice of eyes to be cor- rected lies with the vision, the best eye receiving the proper correc- tion. Again, it maybe advisable to correct one for distance and the other for near. Each case is usually a law^ unto itself, and should be dealt w^ith accordingl3\ The difficulties are usually due to the absence of binocular vision and the prismatic effects of the correcting lenses. Presbyopia. — There is a diminution in the amplitude of accommodation, which, commencing at an early age, progresses with advancing years. It is caused chiefly by a progressive loss of elasticity of the lens, and the different layers becoming more homogeneous. Late in life the ciliary muscle becomes less power- ful, and this adds to the difficulty. The effect of this progressive diminution is to cause the near point to recede from the eye. From the tenth year there is a steady decline in the dynamic re- fraction and a relative recession of the near point. This is shown diagramatically in Fig. 19 devised by Bonders. The numbers along the top refer to the ages, and those at the side give the number of dioptres. The line starting at zero and terminating in the curve r r shows the static refraction, w^hich remains unchanged until the fifty-fifth year, when it diminishes. At this age the emmetropic ej^e becomes hyperopic, the hyperopic eye more hyperopic and the myopic eye less myopic. 56 REFRACTION AND ACCOMMODATION OF THE EYE. The curve //> shows the maximum refracting power and how it progressive!}^ diminishes as age advances. Both curves meet at the age of seventy-three, which marks the point when accommodation ceases. The number of dioptres included between the two curves on any given vertical line ex- presses the amplitude of accommodation at the age which the vertical line represents. Fig. 19. Range of accommodation at different ages. The change in the amphtude of accommodation is the same in all eyes, whether emmetropic or ametropic, though it will be seen that the position of the near point wnll vary with the condi- tion of the static refraction. From the diagram we obtain the following table giving the range of accommodation at different ages: YEARS. RANGE OF ACOMMODATION. 14. D 10 15 D PRESBYOPIA. 57 20 10. D 25 8.50 D 30 1- 35 5-50 D 40 4-50 I) 45 3-50 D 50 2.50 D 55 1-75 D 60 I. D 65 . . • 0.75 D 70 0.25 D 75 o The recession of the near point does not give rise to an}' dis- turbance until it passes be\'ond the distance at which the person ordinarily reads, writes or sews. When this occurs such occupa- tions become difficult, on account of the small retinal images ob- tained. This distance differs with different people, therefore 22 cm., the point selected by Bonders as the commencement of presbyopia, is purely arbitrary, though it is customary to state that such is the case. In order to see at 22 cm. a positive re- fracting power of ^.5 D. is necessary, and if the range of accom- modation is less than that presbyopia is present. As the emme- tropic eye at forty has just that amount, presbyopia commences in such an eye at that age. A hyperopic eye, however, would become presbyopic earlier, and a m^^opic eye later, depending upon the degree of the ametropia. Thus a hj^perope of i. D. would become presbyopic at thirty-five, because the amount of his hyperopia deducted from his range of accommodation, ^.^o D. — I. D., leaves him but /.50 D or just sufficient to bring the near point to 22 cm. A myope of i. D. would not become pres- b^^opic until forty-five, because his myopia added to his range would give him a positive refraction of /.50 D. Thus it will be seen that it is always necessary to take a patient's static refraction into account before fitting him for near work. If presbyopia is considered present when the near point recedes beyond 22 cm., it is obvious that it is corrected by that convex glass which brings it back to that point, and the amount is meas- ured by the glass which does so. 58 REFRACTION AND ACCOMMODATION OF THE EYE. Most text-books give a table showing the amount of presbyopia present in an emmetropic eye at various ages to assist the student jl in determining the amount in a patient. As this is only approximate, and as all people do not want to hold their work at ^^ cm., the wisdom of it is very questionable. It is far better to individualize every case. Book-keepers, painters, violinists, carpenters, etc., work at a greater distance than 22 cm., and watch-makers and engravers at a shorter distance. The best course to pursue is to find the distance at which their work must be held, and fit them for that particular distance. The theoretical glass having been determined in this manner, it is necessary, as Dr. Norton first pointed out some years ago in a paper read before the Homoeopathic Medical Society of the County of New York, to test the muscles at the near point with the glasses on, and if exophoria be present their strength reduced and if esophoria be present their strength increased. The method of ascertaining this is described in the chapter on the muscles. \ DIOPTOMETRY. 59 CHAPTER IV. Dioptometry. By Chas. H, HEI.FRICH, M. D., Surgeon to the N. Y. Ophthai^mic HOSPlTAIv. By dioptometry is understood the methods for determining the refraction and accommodation of the eye. These methods are of two kinds — subjective and objective. Subjective Dioptometry embraces the methods which de- pend largely upon the statements of the patients themselves. The method which is almost universally used, and which it is wise always to employ even though other methods are also fol- lowed, is that based upon the acuteness of vision. It has been determined by experiment that the smallest distance separating two objects which permits of their being seen discrete is one that subtends a visual angle of one minute. Nearer than that they appear as one. The visual angle ma}' be conceived to be formed by lines extending from the extremities of an object which meet at the nodal point of the eye, as in Fig. 20. Fig. 20. The visual angle. These lines represent secondary axes, which cross each other at the nodal point without undergoing refraction, and upon reaching the retina determine the size of the retinal image. 6o DIOPTOMETRY. Snellen's test-t3^pes which are in general use are based upon this principle. Each letter as a whole, held at the distance marked above it, subtends an angle of 5^ while the component strokes and the spaces between contiguous strokes subtend angles of i'. It is evident by the figure that the distance of the object is an important matter. The size of the object remaining the same, the angle becomes larger the nearer the object is brought to the e5^e; while conversely, the greater the distance the larger the ob- ject must be to preserve the same angle. Snellen's test-types are so designed that they are seen under a visual angle of five minutes when held at the distance at which they should be seen. The largest type should be seen at 60 metres by the normal eye, and from this they range down to a size visible at five metres. Fig. 22 shows them reduced in size. In testing the acuteness of vision, which is the first step to be taken, the patient should be seated with his back to the light and the test-type for distance placed opposite him at a distance of five metres or more, as space will permit. Such a distance is practically, infinity, and has the advantage that such rays which come from the card and enter the eye are parallel. Testing each eye separately, the patient is asked to read the smallest line of letters he can. His acuteness of vision ( F) is expressed by a fraction, the numerator of which represents the distance of the test-card and the denominator, the distance at which the line of type he read should be distinguished. Thus, if he simply read the largest type at a distance of five metres his acuteness of vivsion would be expressed as follows: It is important not to reduce the fraction, as it represents both the distance and the line read. The abbreviations O. D. and O. S. respectively stand for the right and left eye, and are utilized for designating the eye ex- amined. The abbreviation O. U. stands for both t-yes used simul- taneously. Should the patient's sight be so bad that he is unable to read the largest type, the greatest distance at which he can count the examiner's fingers should be ascertained. If even this is impossible, he should be placed in a dark room, and by altern- ately shading and uncovering a lighted candle his power to dis- tinguish light should be noted. After the acuteness of vision has been ascertained and recorded, DIOPTOMETRY. 6 1 the next step is the determination of the static refraction. In order to do this, it is necessary to possess a case of trial lenses and appurtenances, such as can be found at a first-class optician's, and several trial frames. The numbering of lenses is now almost uni- ■ versally after the metric s5'Stem which takes as the unit a lens having a refractive power of i dioptre, and which has a focal length of I metre, or about 40 inches. A lens of 2. D. is twice as strong and, therefore, has a focal dis- tance of half a metre. Between the w^hole numbers are lenses of .25 Z>., .so B. and .75 /^. The advantage of this system over the old or English system, where a strong lens was taken as the unit and where the number expressed the focal distance and not the refractive power, is that we are dealing with whole numbers in our calculations and not with vulgar fractions. It is a very simple matter both to find the focal distance of a given lens of the dioptric system and its equivalent in the English system. If it be required to find the focal distance of a given lens of the dioptric system, divide 100 centimeters (i metre) by the num- ber of the lens and the answer will be the focal length in centi- metres. For example, the focal length of 5 D. is ^^^=20 cm. If the focal length is known and we desire to ascertain its dioptric number, we divide 100 cm. by the focal length, as for example with a focal length of 20 cm., thus -y/=5. D. In translating from the old inch system to the metric, w^e can consider 40 inches equal to one metre, and to obtain its dioptric equivalent, we divide 40 by the number of the lens in inches. For instance. No. 20 of the old system is equal to 2. D., for 4i=2. To convex lenses is given the plus sign (4-), and to concave lenses the minus (— ) sign. In ascertaining the static refraction, each eye must be tested separately, as in the case of the acuteness of vision. Considerable advantage is obtained by commencing the test with convex spherical lenses, as these cannot be overcome by an effort of the accommodation. If these lenses increase the acuteness of vision, or do not make it worse, the refraction is hyperopic. Should the weakest convex lenses make the vision worse, concave spherical lenses should be employed. In the event of their failure to im- prove, convex cylindrical lenses are next utilized, and lastly con- cave C3dinders. 62 DIOPTOMETRY. Even though the acuteness of vision is normal in the first place, it is still necessary to place convex lenses in front of the eye in order to determine if there is an}^ manifest hyperopia present. Under such circumstances the strongest convex lens through which the said line of type can be read is the measure of the* manifest hyperopia. In some instances the acuteness of vision may not be up to the normal, and no lens or combination of lenses makes it so, though the same line can be read equally well with convex lenses up to a certain strength. In this case the strongest lens also represents the manifest hyperopia. If convex lenses improve the vision to a certain degree, but short of the normal, recourse should next be had to convex cylindrical lenses in ad- dition to the strongest sphericals found, which may bring it up to normal, the case being one of compound hyperopic astigmatism. The cylinder must be rotated in front of the spherical until the axis of the astigmatism is found. The strongest convex cylinder should be ascertained as in the case of convex sphericals. In the event of failure with convex glasses, concave ones should be employed. Unless they actually improve the vision they are not to be considered, because all eyes, no matter what their refraction is, can overcome the weaker concave lenses by an effort of the accommodation. Presuming, however, that they do improve the vision, the weakest concave glass which produces the maximum acuteness obtainable is the measure of the myopia. If the vision is improved somewhat by concave glasses, though not up to normal, concave cylinders should be tried in addition to the weakest spherical obtained in the first place, and the combina- tion may bring the vision up to normal. This would indicate compound myopic astigmatism. Failing with both convex and concave sphericals, convex cylin- ders should be employed to find if simple hyperopic astigmatism exists. The cylinder should be slowly rotated in the frames in order to find at what axis it seems best. This being found, stronger lenses are placed in the frames at this axis until the maxi- mum improvement is obtained. In the case of simple hyperopic astigmatism the strongest con- vex cylinder represents the measure of it. Simple myopic astigmatism is tested in a similar manner, but here the weakest concave cylinder is the measure. METHODS OF DETERMINING ASTIGMATISM. 63 In testing as if for simple h3'peropic astigmatism, a certain im- provement ma}' be obtained, but less than normal. Leaving the strongest convex cylinder so ascertained in position, concave cylinders are added in a position at right angles to the former until the maximum improvement is obtained. Such a combination composed of the strongest convex cylinder and the weakest concave C3'linder is the measure of the mixed astigmatism. This, in brief, is the plan to be followed in the examination of Fig. 21. Wallace's astigmatic chart. any given case, and if closely adhered to will prevent much con- fusion and loss of time. There are other methods of determining the astigmatism which must also be employed either as soon as its presence is determined or as a check upon results obtained after the former methods. Thus the presence of astigmatism is frequently discovered by ask- ing the patient to look at the clock-face test-type, made up of lines, in series of three, radiating from a center in various directions. Wallace's astigmatic chart is one of the most convenient. If 64 DIOPTOMETRY. astigmatism is present, one set of lines will stand out clear and distinct, while the others, but especially those at right angles to the first, will be indistinct. These designate the principal meri- dians of the astigmatism. Or the stenopaic slit may be rotated in front of the eye until a point is found where the vision is most distinct, which will designate one of the principal meridians, and as the emeridians are always at right angles to one another the other meridian is determined at the same time. Convex and concave glasses are now placed in front of the slit and the degree of hy- peropia or myopia, if either exists, ascertained. Next, rotating the slit to a position at right angles to the first the same procedure is again followed out. If convex lenses improve or do not make the vision worse in one meridian, and concave lenses fail to im- prove it in the other, the case is one of simple hyperopic astigma- tism. If concave glasses improve the vision in one position, and convex glasses make it worse in the other, simple myopic astig- matism is present. If convex glasses improve or do not make vision worse in both positions, it is a case of compound hyperopic astigmatism. The difference between the strongest convex glass in each position represents the astigmatism, and the weaker of the two, thus found, the hyperopia. Compound myopic astigmatism is determined in the same manner by the difference between the tw-o weakest con- cave glasses. If the case is mixed astigmatism, convex glasses will improve or will not make the vision worse in one position and concave glasses will improve the vision in the other. Numerous combinations and variations of these methods are made by different surgeons, but the same principles hold good throughout. After the astigmatism is determined by any of these methods, it is usual to place the correcting lenses in the frames and have the patient look at the clock face, when, if the astigmatism is pro- perly corrected, the lines will all appear similar. In all cases of astigmatism, or in any case where spasm of the accommodation is found or suspected, the test should also be made under the influence of a cycloplegic. Cycloplegics. — By cycloplegics are meant those drugs which produce temporary paralysis of the ciliary muscle, and therefore CYCLOPLEGICS. 65 suspension of the accommodation. The importance of this in determining ametropia has been stated in the preceding chapter. In addition, however, complete physiological rest of the eyes is obtained which often removes congestive conditions of the retina and choroid, and later when glasses are prescribed they give more comfort than they would have done without the use of a cycloplegic. The drugs most commonly employed are the sul- phates of atropine, hyoscyamine and duboisine and the hydro- bromates of homatropine and scopolamine. (i) Atropine is usually employed in a strength of four grains to the ounce. Ordinarily it paralyzes the accommodation in about two hours and the effects remain for a w^eek. A drop of the solution should be dropped into the outer canthus three times during one da^^ In cases of marked spasm of the accommoda- tion in young hyperopic subjects it can be continued for several days. (2) Hyoscyamine and Duboisine are employed in the form of solutions made up of two grains to the ounce. Their action is much more rapid than atropine and their cycloplegic effect more transitory. (3) Scopolamine x^2iy either be employed in a one per cent, solu- tion, a single drop being instilled, or in a one-fifth per cent, solution, one drop every fifteen minutes for an hour and a half. Cycloplegia occurs in about fort3'-five minutes and lasts from three to five days. Toxic symptoms sometimes develop, so considerable care should be exercised. (4) Homatropine used in a three per cent, solution, one drop being instilled every fifteen minutes for an hour and a-half pre- ceding the examination, can be employed when a very transitory effect on the ciliary muscle is desired. Its effect is increased by dropping a drop of a four per cent, solution of cocaine in the eye each time before instilling the homatropine. The cycloplegic ef- fects of homatropine pass off in about fifty hours, and are in a degree neutralized by eserine. It is not safe to use strong cycloplegics in elderly people on ac- count of the danger of precipitating an attack of glaucoma. Of course, they must never be employed if glaucoma is suspected or present. It is unnecessar}^ to use them in people whose ad- vanced age denotes that the accommodative power is very w^eak. 5 66 DIOPTOMETRY. Patients soon become familiar with the letters on a test card, and children are apt to memorize them before being tested, so it is advis- able to have several cards with different letters. Thus a new card should al-ways be displayed for each eye, and if at any time there is any suspicion that the patient is drawing upon his memory a different one must be substituted. In order to avoid the neces- sit}^ of walking across the room each time to make such a change, Fig. 22. Helfrich's changeable test-type. and especially in order to be able to make it without the patient's knowledge, I devised a changeable test-type, the plans of which were presented to Messrs. Clairmont & Co., of New York, who made the apparatus and perfected the motor for working it. This instrument was described in a paper read before the Homoeopathic Medical Society of the County of New York in 1893. It is illustrated in Fig:. 22. REFRACTOMETER. 67 The apparatus consists of an ornamented wooden case, upon which are mounted the ordinary Snellen test-tj^pes. The five lower lines only are capable of being changed, the change being produced by the revolution of five quadrangular rollers permitting the exhibition of four series of letters. Motor power is furnished by an accordion-pleated rubber tube, which, when expanded bj^ the column of air communicated to it by the pressure of a bulb, elevates a weight to which is attached an arm. As the arm moves upward it carries a cog which locks with the wheel that revolves the five rollers. This wheel contains four slots, placed at intervals of ninety degrees, for the reception of two catches, an upper and a lower one, which limit the revolution of the wheel to a quarter of a circle. After each quarter revolution the weight carries the arm back to its former position, setting the ap- paratus for the next change. It is operated by a bulb at the side of the patient, which is connected with the motor by tubing. An instrument called the Refractometer has been invented by H. L. De Zeng, whose purpose is the estimation of the total re- fractive error and particularl}- the whole amount of astigmatism present in all the dioptric media without the use of a cycloplegic. This instrument shown in Fig. 23 is manufactured by the Cataract Optical Co., of Buffalo. While disclaiming that any mechanical device can wholly replace the ordinar}^ test under a cycloplegic this instrument is certainly of great value where a cycloplegic is contra-indicated or refused, as well as in general routine work. In brief this instrument consists of a nickel tube, in the head of which is placed a stationery concave lens of 20. D. It also con- tains an inner tube w^hich is movable along its cylindrical axis by means of a rack and pinion adjustment, and which carries at its front end a convex achromatic objective. These lenses in com- bination at different distances give all the spherical foci from + .12 D to + 18. D, and from — .12 D to — 9. D inclusive. The convex spherical effects are recorded upon a revolving dial at the side and the concave effects upon the top of the inner tube, visible to the observer through an oval opening in the top of the outer tube. Owing to the range of the negative scale being limited to — 9. D, two auxilliary caps accompany the instrument, one containing 68 DIOPTOMKTRY. — lo. D and the other — 20. D, which, when placed over the eye piece raises the negative scale to either — 19. D or — 29. D re- spectively. The outer tube is further armed at its front end with a revolving head, composed of two revolving discs, containing blanks, a stenopaic slit, and eleven minus concave cylinders set at right angles with their radii. The resulting combinations possi- ble give a range of cylindrical lenses from — .12 D to — 8.75 D, which can be rotated to any given axis, the latter being indicated by a pointer. Fig. 23. De Zeng's refractometer. By reason of the instrument's optical construction, it has an am- plification of two and one-third diameters, and in consequence of this the test-types furnished with it are reduced^'to three-sevenths of the size of Snellen's letters, so that the visual acuity may be reliably estimated with the instrument. The instrument must be properly adjusted for whatever range is desired, either 3, 4, 5 or 6 metres. The best method employed in testing is what is known as the " fogging system," which consists in over-correcting a hyperopic CONVERGENCE AND ACCOMMODATION. 69 eye with convex lenses or under-correcting a mj'opic one with concave lenses which are too weak. The effect of this is to render the lines and letters deeph^ blurred, which causes relaxation of the ciliary muscle and in consequence latent errors to become mani- fest. With the instrument properly adjusted, and the patient proper!}^ placed, the thumb-screw is turned until the test-letters are distinctly seen and the reading noted. Fogging is next resorted to b}^ producing artificial myopia, which encourages relaxation of the accommodation. The thumb- screw is now turned slowl}^ back and the patient requested to watch the astigmatic fan. If he states that one or more lines ap- pear distinct before the others he is astigmatic, whereas if they appear equally distinct simultaneously the error is simple hyper- opia or myopia. If astigmatism is present it is necessary to utilize the concave cylinders contained in the revolving discs to render the lines equally clear. This procedure should be repeated to verify the result or to make any necessar}' corrections. The power of convergence is tested with an opthalmo-dynamome- ter, that of Landolt's being the simplest and best. It consists of a metallic cylinder blackened on the outside, containing a vertical slit 0.3 mm. wide covered with ground glass. Beneath the cylinder is attached a tape measure graduated on one side in centimetres, and on the other in metre-angles. The vertical line of light, produced when the cylinder is placed over a lighted candle, is the object of fixation. Approaching the patient in the median line until the patient sees the line double the near point of con- vergence is found and the distance in centimetres with its equiva- lent in metre -angles recorded. The minimum of convergence is found by withdrawing the instrument from the patient; but as it is usually negative, it is determined by the strength of the strongest abducting prism which will not cause diplopia with the patient fixing the object at six metres. If the number of this prism is divided by seven, the quotient will approximately give in metre- angles the deviation of each eye when the prism is placed before one. The amplitude of convergence is equivalent to the differ- ence between the maximum and minimum of convergence. Accommodation is tested by means of the reading tj^pes of Snellen or Jaeger. A sample is shown in Fig. 24. It is necessary to test each eye separatel}^ and finally both to- 70 DIOPTOMETRY. gether. The nearest point the type can be read represents the punctum proximum. This subject has already been discussed in the preceding chapter. Presbyopia is to be determined after the static refraction has been tested. With the distance glasses in the frame, the patient is asked to hold the reading type or a newspaper at the distance at which he desires to work or read. Convex glasses are now added to the distance glasses, until the best vision at this distance is ob- tained. The optical equivalent of the glasses before each eye is Fig. 24. O. D. Tlift elouel)eMt adapted for Utho- pniphic purposes U a calcareoua elate found on the banks of tha Danube, in Bavarin, the finest being found near ^funich. A good Btonfl is porous, yet briltla, of a pale yoUowish diiib. and Bomotmjes of a gray nouti'ai tint The stones am foi-med into slaba from one and & half to threa Inches in Uilckneea To prc-paro them for use. two etonea are put £.ce to laoo with eoaie fino sifted Bond betwct^n them, and then are rubbed together wiUi a arcular. .5OM. o. s. Tim stone Ijoit adapted for !itha- pniLihic purposoB is a cttloftreoua e\u.X4s found on the banka of the Danube, In Ba\'aria, the finest being found near MunicK 'A good Btona is porous, yot brittle, of a pale yoUowiah drab, and Bometimea of a gray neutral tint The atones are formed into slaba trom one and a half to three Inches in thlckneaa. To prepare them for use, two stones are put face to fiu30 with some fine sifted 6a nd between them, and then ar» rubbed together with a, circular. O. D. The artist completes a chalk (lra"wir).g -upoii a grained stone ad he ■would make one with pencil or chalk upon paper. If -while in this state a wet sponge is passed over the face of the stone, the draw* ing will xu.h oiE To •75M. O. S. - The ai-tist completes a chaUc drawing upon a grained stone as Jie would make one with pencil or chalk upon paper. If while in this State a wet sponge is passed over the face of the stone, the draw* ing will rub affi To Type for testing accommodation. now computed, and the resultant glass is presumably his prescrip- tion for near. The approximate amount of presbyopia at different ages can be computed from the chart (Fig. 19) given in the previ- ous chapter. This amount must be added to the amount of hyper- opia and deducted from myopia. This should not be considered as final, but used sim.ply as a check on the result obtained by testing and to save unnecessary loss of time. ESTIMATION OF REFRACTIOX BY THE DIRECT METHOD. 7 I Objective Dioptometry. — Objective dioptometry embraces the methods of determining the refraction independent of any statements b}^ the patient. These methods are valuable in conjunction with the test made b}' the trial lenses and test letters, and especially so when the patient is illiterate or too \'oung to read letters. Frequenth^ the}^ are utilized to save time in arriving at an approx- imate estimate of the error, the accurate degree of which is fully determined in the ordinary manner. Not that they are inaccurate in themselves when applied b\' an expert, but because it is a safer plan to check results. Estimation of Refraction by the Direct Method — A qualitative estimation can be made with the ophthalmoscope held at a httle distance from the observed eye. When it is remem- bered that the rays issuing from a hyperopic eye are divergent and those from a myopic eye convergent, it is eas}^ to understand how an observer can see an upright image of the retinal vessels in the former and an inverted serial image in front of the latter. If the observer moves his head from side to side, the vessels seen in a hyperopic eye will mov^e with the mirror, the image being upright, while they will move in the opposite direction if the eye be m3^opic. At this distance no vessels can be seen in an emmetropic eye, because the pencils of rays emanating from any two points upon the retina (each is made up of parallel rays) will diverge from each other so that no rays will enter the observer's eye. Close to the eye, however, an upright image of the fundus can be seen. The quayititative examination is conducted w4th the mirror held close to the observed eye, if possible as near as 13 mm., the anterior focus of the e3^e and the proper situation for the glasses to be worn. If the examination is conducted at a greater distance proper allowance must be made. In following out this method, it is imperative that both the surgeon and the patient thoroughly relax their accommodation. This is easily accomplished for the patient, if no spasm exists, when the examination is made in a dark room, but the examiner can onl}- attain it after much practice. It is rather doubtful if any expert can relax his accommodation absolutely unless he be so old that he practically has none. Still, many can do so thoroughU^ enough to obtain approximately correct tests. 72 DIOPTOMETRY. The most desirable point in the eye-ground upon which to focus is either the edge of the disc or the medium-sized vessels be- tween the disc and the macula, especially two vessels running at right angles to each other. The macula is unsuitable, because of the contraction of the pupil caused by throwing the light upon it and the annoying corneal reflections obtained. If the observer has any error of refraction, it must either be cor- rected with glasses or allowance made for it in computing the final result. All these conditions being fulfilled the examination is commenced. If the patient's eye is emmetropic, the vessels will be seen distinctly, and convex lenses rotated back of the opening in the ophthalmoscope will blur them. If hyperopia is present the divergent rays issuing from the eye are rendered parallel by the rotation of convex lenses, and the strongest convex lens through which the vessels are seen distinctly is the measure of the error. The convergent rays from a myopic eye are rendered parallel by concave glasses, and the weakest concave lens through which the vessels are seen most distinctly is a measure of the myopia. The direct method is used to determine the height of retinal tumors by estimating the refraction at their summit, and the depth of a cupping of the papilla by estimating the refraction at its bottom. If the examinatii n is conducted at a distance not more than 2.5 cm. from an e3^e, a hyperopia of i. D will represent a shortening of the axis equal to 0.3 mm. and a myopia of i. Da lengthening of the axis to that same amount. Astigmatism can also be estimated by this method. It is known to be present when the upper and lower margins of the disc and the horizontal vessels are well defined wdiile the lateral margins and vertical vessels are blurred, or vice versa. Its presence may also be suspected if the disc is elongated either horizontally, or vertically, the long axis corresponding to the meridian of greatest refraction. In estimating the degree it is the best to fix two vessels run- ning at right angles to each other and whose direction conform most nearly to the principal meridians of the astigmatism. If the vessels in one meridian are seen distinctly, while in order to see the vessels in the opposite meridian a convex or concave lens is necessary, the case is respectivel}^ one of simple hyperopic or ESTIMATION OF REFRACTION BY THE INDIRECT METHOD. 73 myopic astigmatism. If, in order to see distinctl}' the vessels in the two principal meridians, two convex or two concave lenses of different strength is required, the case is one of compound astig- matism, either hyperopic or myopic. The difference in strength between the two convex or two concave lenses represents the astigmatism, while the weaker lens represents the simple hyperopia or myopia. The axis of the cylinder to correct the astigmatism is placc'l in the direction of the vessel which was seen through the strongest of the two lenses. It seems unnecessary to again state that in hyperopic astigma- tism the strongest convex lenses represent the measure and in myopic astigmatism the weakest concave. In mixed astigmatism the vessels in one meridian are rendered distinct by convex glasses and the vess Is in the opposite meridian by concave glasses. Hyperopia exists in the meridian at right angles to that in which the vessels were made distinct by the con- vex glasses and myopia exists in the other. The axes of the cylinders to correct this would be th- reverse of this, because they refract only thos.. rays which enter at right angles to their axes. Estimation of the Refraction by the Indirect Method. — This method is not generally resorted to, because of its difficulties. It is sometimes used in estimating very high degrees of m3'0pia, but rareh^ in hyperopia. The rays coming from an emmetropic eye being parallel they are brought to a focus by the object glass at its principal focus, whereas the divergent rays from a hyperopic eye are brought to a focus farther from the object glass than its princii^al focus and the convergent rays from a myopic eye nearer than its principal focus. The degree of the ametropia is deter- mined' by measuring this distance. Schmidt-Rimpier's method is usuall ^ employed. Schweigger uses the indirect method in comparison with the direct method to determine the presence of astigmatism. It has already been explained that thti disc appears elongated in the direction of the meridian of greatest refraction when seen in the upright image, so it is only necessary to state that the reverse ob- tains in the inverted image. Skiascopy (Retinoscopy, or the Shadow Test). — This is a method of determining the refraction by observing the direction in which the light appears to move across the pupil when the 74 DIOPTOMETRY. mirror is rotated in various directions. The test should be made in a dark room at a distance of one metre from the patient. It is convenient to place a tape on the wall extending from the posi- tion of the examined eye to a distance beyond that of the ob- server. This is graduated in centimetres, and at appropriate intervals the corresponding number of dioptres marked. Either a plane or concave mirror can be employed, but the preference is with the former. The light is covered with an opaque asbestos shade having an aperture i cm. in diameter. If the plane mirror is used the light should be near the surgeon, but if the concave mirror is used, behind the patient. The arrangement is shown in Fig. 25. Skiascopy has been elaborated especially by Jackson, whose de- scription is here followed and whose work is the ablest published. By rotating the mirror the area of light it throws on the face is made to move in the direction the mirror is rotated. Those rays which enter the pupil form a small light area on the retina, which also moves when the mirror is rotated. This area moves with the light on the face when the plane mirror is used and in the opposite direction if the concave mirror is employed. For the plane mirror this movement is shown in Fig. 26. Fig. 26. Movement of the light area on the retina with the plane mirror. When the mirror occupies the position A A the rays from L which enter the eye are reflected as if they came from /, and after passing through the eye are condensed at «, on the lower part of the retina. At the same time the light falls on the lower part of ^Skiascopy by Dr. Edward Jackson. Fig. 25. Correct position for retinoscopy SKIASCOPY. 75 the face. If now the mirror is rotated to B B the light which enters the eye is reflected as if it came from /', and is condensed toward d, on the upper part of the retina. Simultaneously the light which falls on the face moves upw^ard also. The same movement of the light with the light on the face occurs in hj^per- opia and myopia as well as in emmetropia. The movement of the light area on the retina caused by a con- cave mirror is shown in Fig. 27. Fig. 27. Movemeiit of the light area on the retina with the concave mirror. When the mirror occupies the position A A the rays which enter the eye come from the focus of the mirror at / and are con- densed towards a, on the upper part of the retina, while the light falls on the lower part of the face. When the mirror is rotated to B B the rays which enter the eye come from /' and are con- densed towards d, on the lower part of the retina, while the light on the face moves upward. The same is true in hyperopia and myopia. The rea/ movement of the light on the retina, as it would ap- pear from behind, is alwa3's with the light on the face with the plane mirror and in the opposite direction with the concave mirror. In our examination, however, we do not see it in that waj^, but we watch the apparent movement as seen through the pupil. When the plane mirror is used the apparent movement in the pupil and the real movement on the retina are the same when the observer sees an erect image, and in the opposite direction when he sees aji in- verted image. 76 DIOPTOMETRY. The reverse of this obtains with the concave mirror. The rays of light coming from a myopic e3^e are convergent and cross each other at its far point, and proceed divergently. The point B (Fig. 28), at which they cross and which" corre- sponds to the far point, is known as ih^ poi7it of reversal. As has been explained under myopia, the distance of the far point from the eye represents the focal length of the glass required to correct it, and, therefore, if the point of reversal is known the amount of myopia is also known. Retinoscopy is an accurate method of determining the point of reversal. Fig. 28. The point of reversal of a myopic eye. In the following description it is assumed that the plane mirror is used, though it will apply equally to the concave mirror if we reverse the movement in the pupil and change the lenses. If the mirror is held closer to the eye than its point of reversal, as at A (Fig. 28), an erect image is seen, and the light in the pupil will seem to move with the light on the face. Be5^ond the point of reversal, as at C, an inverted image is seen, and the light will appear to move in an opposite direction to the light on the face. At the point of reversal it is impossible to see which way the light moves, and the illumination is much more feeble. At a dis- tance of one or two metres from the point of reversal the illumina- tion is very bright, but as the distance increases it becomes more and more feeble. Without altering the rapidity of the movement of the mirror, the apparent movement of the light is more rapid as we approach the point of reversal. While the test depends mainly on the direction of the movement SKIASCOPY. 77 of the light in the pupil, the degree of illumination and the rapidity of movement aid in arriving at a diagnosis. Myopia is estimated by finding the nearest point that an in- verted image is seen (C, Fig. 28) and the most distant point at which an upright image is seen, as at A. Midway between the two is the point of reversal, B, whose distance from the eye should be noted on the tape for that purpose, and the number of dioptres corresponding is the measure of the myopia. Thus if C is at 55 cm. and A at 45 cm. B would be at 50 cm., which corresponds to 2: D. giving a myopia of that amount. When the myopia is of high degree, the point of reversal lies very close to the eye, and in this situation a slight error in marking the distance may mean an error of a dioptre or more in estimating the myopia; whereas if a similar error is made when the point of reversal is situated at a metre or more from the e3^e it is unimportant. Therefore, in high degrees of myopia, in order to check results, it is well to cor- rect all but about one dioptre by placing a suitable concave lens in a frame before the eye and measure the remainder, which is to be added to the lens in the frame. If the m3^opia is less than one dioptre, the point of reversal lies so far away from the eye that when near it one cannot see which way the light moves. In this case put a weak convex glass in the frame to increase the myopia, then determine the point of reversal, and deduct the convex glass from the amount of myopia found. Hyperopia gives an upright image no matter how far we recede from the eye, because the raj'^s leave it divergently. In order to obtain a point of reversal, it is necessary to convert it into an artificial myopia by putting a convex glass in the frame and then finding the point of reversal as in myopia. The amount of myopia is to be deducted from the convex lens, the hyperopia being represented by the remainder. Thus, if a convex 5. D lens is placed in the frame, and the point of reversal is found at 1 metre (i. D), the hyperopia v/ill be 4. D. That is, 4. D out of the five were necessar}- to render the divergent rays parallel and the other dioptre to bring them to a focus at I metre. Emmetropia acts the same as hyperopia, but when a convex 78 DIOPTOMETRY. lens is added the myopia produced equals the strength of the lens, proving that the rays were parallel in the first place. In astigmatism the refraction of the principal meridians is ob- tained in the same way as in myopia or hyperopia. In order to determine the refraction of a certain meridian, it is necessary to rotate the mirror about an axis at right angles to it, which causes the light to traverse the length of the meridian. The direction of the meridian is revealed by the area of light as- suming a band-like shape as its point of reversal is approached. This is most marked in the higher degrees of astigmatism. Near the point of reversal, where the band-like appearance is most dis- tinct, it is easy to cause the apparent movement from side to side, but more difficult in the direction of the length of the band. The latter, however, is to be watched, as it determines the point of reversal. If the astigmatism is of low degree, this band-like appearance may not be perceptible; but when we have determined the point of reversal of one meridian it will be found that there is still distinct movement, either upright or inverted, in the direction at right angles to this. Supposing the case to be one of myopic astigma- tism, either natural or artificial, and the surgeon starts at a point nearer the eye than either point of reversal and gradually with- draws from it, the following phenomena occur: At the start the movement will be with the light on the face in all directions. Withdrawing to the nearest point of reversal there will be no movement in the meridian whose reversal-point it is, but direct movement at right angles to it. Between the two points of re- versal the former meridian gives an inverted movement and the latter direct. At the farthest reversal-point the direct movement for that meridian ceases and the other remains indirect. Beyond both points of reversal the movement is against the mirror in all directions. The degree of the myopia of both principal meridians, either natural or artificial, having been determined, the astigma- tism present is represented by the difference between them. As a final test the cylinder correcting the astigmatism should be put in the frame together with the concave or convex lens which will remove the point of reversal to about i metre, and the movements watched again. When using the concave mirror the position of the observer OPHTHALMOMETRY. 79 does not admit of much change, the distance being generally one metre. The movements of the light are the reverse of those just de- scribed. Skiascopy is the most valuable of all objective methods, and the student should practice it industriously upon an artificial eye made for the purpose before he can depend upon his results in actual practice. Ophthalraometry. — The term indicates mensuration of the eye, but it is usually employed to mean the measurement of the radii of curvature of the cornea and the corneal astigmatism pres- ent in an eye with the ophthalmometer. The ophthalmometer in general use in this countr}^ is that of Javal and Schiotz and is shown in Fig. 29. Fig. 29. Javal and Schiotz ophthalmometer. The principles upon which it is based are as follows: The surface of the cornea acts as a convex reflector, the size of- the image produced by it, of an object of known size at a known distance, depending on its radius of curvature. The size of the image is determined by doubling it with a double refracting prism, and then altering the strength of the prism until the images come into contact. When this has taken place, a displacement equal to the size of the image has been produced. Two objects 8o DIOPTOMETRY. known as mires are situated upon an arc, one a white rectilinear figure, which is stationary, and the other, made up of white enameled blocks, capable of being moved along the arc. These objects are so placed that their images are reflected by the cornea and are viewed through a telescope by the observer. The tele- scope contains a prism (to double the images) placed between two bi-convex lenses, with a third bi-convex lens to shorten the pos- terior foci of the two images. It stands upon a tripod, which can be moved in order to obtain the proper focus. The patient places his chin on the rest and looks in the tube, the eye which is not under observation being covered by a disc. When everything is properly adjusted, the central images are obtained on a spider web, also provided in the tube, and the movable object is moved along the arc until its image comes in contact with the image of the rectilinear object. Its position on the arc is noted upon the index. The arc itself is now turned on its own axis to a position at right angles to its first position, and the relation of the two images noted. If astigmatism is present, they will either overlap or sepa- rate, but if absent, they will occupy the same relative position. The degree of astigmatism is measured by the overlapping, each step of the white enameled block representing one dioptre. If the reflections are separated in the second position they are brought in contact once more and the arc turned back to its primary position, where they will overlap. The overlapping in this case will give the measure of an astigmatism against the rule; that of the previous instance with the rule. The ophthalmometer merely measures the corneal astigmatism and not the refraction of the eye. Corneal astigmatism may be modified by lental astigmatism, consequently the ordinary test with the trial lenses should always be made in addition. Ophthalmometry is servicable in revealing the corneal astig- matism and the principal meridians. General Considerations. — After the test is completed a proper record of it should be made in the surgeon's case-book. As this is the first step in testing any case, the result forms an integral part of the complete record. To it should be added the record of the correcting lens, and finally the acuteness of vision produced by this lens. The following example will illustrate this: GENERAL CONSIDERATIONS. 8 1 O. D. V= I ^ 2.50 D V= f O. S.F ==4 + 0.75 D V=i When the correcting lens is a compound glass, the component lenses are united by the sign Q, which signifies ' ' combined with." Thus a combination composed of a + 3. D spherical with a — 1.50 D cylinder axis vertical is recorded — 3. D* O + 1.50 D^ axis 90°. Notice that the spherical lens is always recorded in advance of the C3dinder, and that the sign — or — is expressed to show that the lenses are either convex or concave. Simple cylinders are ground on one side only, the other side being plane. Compound glasses contain the spherical on one side and the cylinder upon the other. The correcting lenses for mixed astigmatism may either be crossed cylinders, a convex cylinder on one side and a concave cylinder at right angles on the other, or a combination of a spherical with a cylinder. Thus in a case of mixed astigmatism corrected by a convex cylinder of 2. D axis vertical and a concave cylinder of i. D axis horizontal the prescription may either be -^ 2. D^ axis 90 r — I. D^ axis 180, or — 2. D* Q — 3. D*^ axis 180. The two are optical equivalents. Unless specially ordered to do otherwise, the optician will grind the lens according to the latter. The sign f is usually employed when two cylinders are combined, the con- vex cylinder being expressed first. Patients should be instructed to return with their glasses after they have obtained them from the optician, in order that the sur- geon may ascertain if the lenses have been correctly ground and that the frames are properly fitted. The importance of this can- not be overestimated. The correctness of the lens is verified by neutralizing it with the opposite form of lens, that is, convex spherical and cylinders either alone or in combination are neu- tralized by concave sphericals or cylinders of the same number. If one holds a convex glass near one eye, and fixes an object like the edge of a door, the edge will appear to move in an opposite direction to the lens when the latter is moved from side to side. With a concave lens it moves in the same direction. If a convex and concave lens of equal strength, held together, are moved in a similar manner, the object will remain stationary, the effect of the convex being neutrahzed by the concave. Thus the number 82 DIOPTOMKTRY. of any lens can be ascertained by neutralizing it with the lenses from a trial case, which are always numbered. The optical centre of the lens should coincide with its geometric centre, unless it has been ordered decentered. To find the optical centre of a lens we can utilize the reflection of a piece of paper pasted on the window pane with our back turned to the window. A reflection of it appears on the anterior and posterior surfaces of the lens and when the images overlie each other the optic axis of the lens is determined and therefore the optical centre which is situated upon this. The point can be marked upon the lens with ink and its situation as regards the geometric centre noted. It can also be determined by refraction by finding two meridians of the lens at right angles to each other which do not displace a vertical line horizontally when it is viewed through the lens. It is customary to take the edge of a door or a card. When the lens occupies such a position that the vertical line appears as a continuous line, above and below, with that seen through the lens, this meridian is marked by a line with a pen. The glass is rotated at right angles and the same process gone through with again. The point at which these two lines intersect each other is the optical centre. The frames should be so fitted that the pupil is opposite the geometric centre, and the optical centre should coincide with the latter unless it has been purposely decentered. This is the rule when glasses are to be worn for distance or con- stant use. Near glasses are usually decentered in about 4 mm. on account of the convergence of the visual lines. Reading glasses are also tilted forward and placed lower down than dis- tance glasses, to conform with the depression of the visual line. A decentered glass when not required is sufficient to render void the beneficial effects of the most perfect prescription. Lenses are often decentered in a given direction when a prismatic effect is desired. Convex and concave lenses may be considered as being made up of a series of prisms. The effect of decentering a convex glass in, is equivalent to obtaining a prism with its base in, while to decenter a concave glass inwards produces a prism with its base out. The degree of prismatic effect obtainable depends on the distance the lens is decentered and the strength of the lens. The greater the decentration and the greater the strength of the lens the greater the prismatic effect. GKNERAI^ CONSIDERATIONS. 83 Spectacle frames are always preferable to eye-glasses, and in fact their use is imperative in high grades of astigmatism. Still the prejudices of many patients, particularly women, against them must be regarded if we wish them to wear their glasses, so under these circumstances eye-glasses must frequently be prescribed. Nowadaj^s, with the many improved guards in use, eye-glasses can be fitted nearly as perfectly as spectacles, and if the patient is taught to take proper care of them and to have them readjusted frequently they answer the purpose quite as well. When separate glasses for reading and distance are required a ' ' bifocal lens ' ' for constant use may be prescribed to avoid the in- convenience of changing from one to the other. Many peo- ple never become accustomed to them, however, and often meet with accidents caused by looking through the lower part of the glass when going down stairs or stepping out of a con- veyance. 84 HYGIENE OF THE EYE. CHAPTER V. Hygiene of the Eye. Under this heading we shall endeavor to gather together a few very essential and practical points, some of which, while they may be elsewhere considered, are of sufficient importance to merit repetition. Many cases of blindness have undoubtedly re- sulted from the neglect of simple everyday precautions, which are supposed to be so generally understood, by the laity as well as the medical profession, that we are unable to find any author who has devoted the slightest space to the subject. The care of the eye commences at birth, and in order to secure its highest usefulness must be continued throughout the whole life. The eyes of the new-born babe should be at once carefully cleansed with warm water or a saturated solution of boracic acid. In all cases of gonorrhceal or leucorrhoeal discharge in the mother the method recommended by Crede should always be employed. This consists of the instillation between the eyelids of the child immediately after birth of a 2% solution, gr. x. ad ^j.rof nitrate of silver. This method is practiced by many of the best obstet- ricians in all cases, and since its general adoption the percentage of cases of blindness from ophthalmia neonatorum has been won- derfully reduced. In former years the percentage of blindness from this disease alone formed, in different countries, from 20 to 79 per cent, of all the cases of blindness. The examination of the eyes of the babe from day to day should be a part of the physician's routine duty for at least one or two weeks, so that the onset of any trouble may be at once met by active treatment. The eyes of young infants should be protected from all glaring lights, and especially the direct rays of the sun, both indoors and out. The babe should never have its attention attracted by ob- jects held close to the eyes, for repeated convergence at close objects may predispose or even produce strabismus. This obser- vation holds good as the child grows older, for in addition, from SCHOOI. HYGIENE 85 poring over story and picture books, when too fine or held too close to the eyes, myopia threatens. The fine worsted and bead work used in some of the kindergarten teachings is for this reason objectionable. Give the growing child plenty of out-door amuse- ments, vvhere the eyes may have a long range during the develop- ing period of life, and we shall see fewer little ones wearing glasses for myopia and astigmatism. School Hygiene. — We believe that one of the most important fields for the exhibition of the to-day knowledge and interest in hygiene is presented in our educational institutions. When we consider the total number of hours passed in the class rooms during the child's school and college life, the additional hours required lor study and preparation outside of the school-room by the present day system of forcing the child too rapidly and all children alike, to keep up with their classes, then when we compare these hours with the time left for recreation, exercise and sleep, and recall that these years are the years of physiologi- cal growth, is it any wonder that we find so many commencing their active life as physical wrecks? It is, therefore, plainly a duty we owe to posterity to consider carefully the hygienic environ- ments of our children as well as their mental and moral training. The school life of the growing child should be so regulated as to secure the best mental advancement and at the same time the best physical development. Every observing physician has seen many children w^ho commenced school life in apparently good health soon complaining of headaches, nervousness, loss of appetite and other symptoms indicative of impaired general vigor. It is, however, not our function to consider the subject of school hygiene in its relation to the general health, but simph^ as to its bearing upon the eyes of our children. In the early part of the present century we find attention first called to the relations existing between the myopic eye and the demands of civilized life. W^ithin a comparatively few years more complete and S3^stematic examinations of the eyes of school- children have been made, so that to-day we have as a basis for our statistics the examinations of the eyes of over two hundred thousand pupils of all grades. An analysis of these examina- tions show that in the primary schools nearly all the children enter with normal eyes. In the higher grades 25 per cent, have 86 HYGIKNK OF THE KYK. become myopic, while in university life the percentage of myopia has increased to from 60 to 70 per cent., which shows that the number of near-sighted pupils increase from the lowest to the highest schools and that the increase is in direct propor- tion to the length of time devoted to the strain of school life. In the face of these facts, it seems the imperative duty of the hour to carefully investigate the cause of this deterioration in the eyes of our children during school life. The evident relationship of this increasing near-sightedness with school work seems to indi- cate some fault in our educational methods. Owing to the fact that myopia is often hereditary, it is impossible to wholly eradicate the condition for generations to come. We believe, however, that acquired myopia can be prevented, or very greatly decreased, by careful and frequent examinations of the eyes, together with thorough hygienic preventive methods, during the years of physi- cal growth and mental training of the child. First, as to the importance of frequent examinations of the eyes of children. Statistics prove that a very large proportion of the eyes of young children are hypermetropic. So great is this pre- ponderance that many authorities claim the normal eye to be a hypermetropic one. Careful observations have shown that in almost every instance the change from far to near-sight is through the turnstile of astigmatism. That this change does take place has been proven by the progressive increase in the percentage of myopia during school life. By repeated examinations, from year to year, the first change can be detected and suitable treatment taken to check its progress. We believe that the eyes of every child should be carefully examined at the commencement of school life, and that the examination be repeated every year at least until the time of full development of both body and mind. The care of the teeth commences even earlier than this and is continued through the whole life. We have become educated to the importance and necessity of sending our children to the den- tist every six months or year for examination, whether disease is suspected or not. The far more precious and delicate organ, the eye, on the contrary, is almost universally left to do its work un- aided and uncared for, until often serious and irreparable damage has been done and the innocent victims of our ignorance and neglect are deprived of the full realization of God's greatest SCHOOL HYGIENE. 87 gift, that of sight. It is not the vision alone that pays the penalty of this criminal neglect, but a long train of physical wrecks brought about through reflex action, from eye-strain. It is not our purpose at this time to go into the details as to how or what general conditions may result from defective eyes, but merely to sound a warning as to the danger from neglect of the eyes in early life. To continue the comparison with the teeth, we can get very acceptable false teeth, when lost from neglect, but artificial eyes have not proven of much practical service. There is great need of popular education as to the importance of such examinations of the eyes. Parents who follow out the greatest precautions for the welfare of their children in other re- spects are unmindful in this, through lack of knowledge of its importance. Rxaminatio7i of the Eyes Upon Entrance of School. — Every school should possess a series of test letters, and each scholar at the commencement of each term should have the eyes examined by the teacher. This examination is so simple that any teacher can be instructed in a few moments so that they can determine if any defect exists. All that is essential is a set of Snellen's test- types placed in a good light; the smallest letters should then be read with each eye separatel}^ at twenty feet. The child should then be examined with the astigmatic card at the same distance, and the lines running in all directions should appear with each eye alone equally clear and distinct. Then a small card clearly printed in 4}^ point (diamond) type should be read by the child, while the teacher measures with a rule the nearest point at which it can be clearly read. This distance should correspond with the normal near-point of an emmetropic eye, which should be recorded on the back of the card for the different ages from six to twenty years. If these tests show no defect the child may then be admitted to the school, but, on the contrar}^, if a defect be found in any of the tests, particularly the first, the parents of the child should be at once informed of the existing defect of vision and the consequent need of professional advice. Further than this, during the school year, if the child complains frequently of headaches while studying, or seems to be getting nervous, anaemic, etc., the teacher's duty is to again suggest to the parents the wisdom of seeking a physician's advice. b« HYGIENE OF THE EYE. The examination as suggested would at once detect imperfect vision, from any cause; if due to refractive errors it could then be corrected, if to intra-ocular disease treatment might save the sight which otherwise might possibly be lost In all cases of children with inflamed eyes they should be re- quired to present a physician's certificate of the non-infectious nature of the disease before being permitted to enter the schools. Our orphan asylums, piblic homes and institutions of all kinds require a physician's certificate before admitting children with any redness or inflammation of the eyes. Should we be any less strict before permitting these children to associate with the healthy ones in our schools ? Let us now consider other faulty conditions of school life which bear more or less directly upon the eye as well as the general health of the child. T.ie curriculum of study in the majority of public schools is a hard and fast one, which all students are ex- pected to follow. We believe a more elastic curriculum should be adopted, whereby children with defective eyes, or in more or less feeble health, should only be required to take as many and such studies as they may master in safety Such a modified course, while it would lengthen the student life by one or more j^ears, would do much toward preserving the eyes and general health, A decided reform should also be made in the system of requir- ing study at home. The average school sessions of five or six hours a day should be sufficient to prepare for college by the time they are sixteen or eighteen without requiring nearly as many ad- ditional hours of stud}^ at home, which robs the student of the recreation and sleep he should have. The work at home is usually accomplished when the body is tired, and the brain slug- gish, generally by artificial light (which is too often an improper one) and frequently with a faulty position of the body. We be- lieve that with a proper regulation of recitation and study during school-hours alone, the brain, made more active by sufficient re- creat'on, exercise and sleep outside, will accomplish far more than by the present system. The paper and type used in school-books have in recent years been vastly improved, yet there is room for still further improve- ment. In selecting books for children, the type should always be large, bold and clear. Cohn and Weber claim that type at least THE COXSTRUCTIOX OF SCHOOL BriLDIXGS. 89 one and a half millimetres in height (equal to long primer) is the smallest that should be used in school-books, and the distance be- tween the lines, or leading as it is called, should be two and a half millimetres. The paper should be of a dull finish, instead of the highly glazed finish of many books, and of a dead white or a cream color. In many of the books used by children the print is too small and of a poor impression, which is ver}' injurious to the eyes. This perhaps applies more particularly to the interesting books and periodicals prepared for the young, and especiall}^ to newspapers. The character and the amount of reading is too often not properly regulated at home. The reading of sensational papers and novels at hours when the child should be at sleep is a habit too freel}^ indulged at the expense of both mental and physical development. There should also be frequent breaks in the application of the eyes at close work. This frequent interval of rest for both the brain and the eyes can easily be secured in the school-room by a change from the books to the blackboard, to oral instruction, lectures, etc. The school session should be broken b}' short re- cesses in the open air, gymnastic exercises, etc. The system of examination, usually followed in schools, we be- lieve, can be modified with benefit to the eyes and health of the pupil. The present method of frequent set examinations for promotions results in an unusual amount of study, or cramming, for a given time previous to the examination. This additional amount of study is always secured, at the expense of the eyes and health by taking the time from the already- too limited hours given up to recreation and rest. All educators recognize that "cramming" is not the best method of learning, and yet the prevalent system of examinations leads to this. We would sug- gest that a better method to determine the true standing of the pupil would be by unexpected examinations, or by allowing the standing and fitness for promotion to rest upon the marks for daily recitations and the teacher's estimate of the pupil. The ConstrudioJi of School Buildings. — A consideration of the eyes and health of our school-children must necessarily involve the location of the building, as to surroundings, light, etc., and the school furniture. The location in cities should avoid narrow streets, and hio:h sur- 90 HYGIENK OF THK KYK- rounding buildings, which interfere both with light and air; and away from noises, exhalations, smoke and dust of factories, stables, markets, etc. Play-grounds in the open air, either in ample grounds or on the roof of the building, should be provided for in- termission of the sessions. The building should be so constructed as to avoid dampness and should furnish ample ventilation with- out draughts. In the country, especially, care should be taken that the location be well drained and away from malarial and other injurious environments. Sufficient light is of the utmost importance, and should be first considered in the architectural plan of all school-houses. The quantity of light, Cohn says, cannot be too much, while Javal says that every portion of the room should be so flooded with light that the darkest place will have sufficient illumination on a dark day. To secure this, Javal says that the distance of surrounding structures should be twice their height. The necessity of suffi- cient light is shown by an attempt to read in the twilight or in a dimly-lighted room. A test as to the amount of light is the ability of a normal eye to read diamond type readily at twelve inches. According to Risley the window surface should never fall below one square foot of glass for every five square feet of floor space, and that this should be exceeded in many localities, on the north side of buildings and on the ground" floors. The quantity of the light is, of course, modified by the color of the walls in the school-rooms. The light shades of yellow, green, blue or gray should be used in the coloring of the walls and also of the furniture and wood- work. The loss of light caused by large sur- faces of blackboards can be saved by roller shades, of the same color as the walls, to be lowered when not in use. Next in importance to the quantity of the light is its direction. The ideal light of the school-room is that from the left side, or the left and the rear, of the pupils. Lighting of the room from two opposite sides should be avoided if possible, yet when neces- sary to secure the requisite amount of light that from the right side should be high up in the room. In this way we secure a dif- fused light in the room from the illumination of the ceiling and avoid the objectionable cross-lights. This arrangement at the same time affords better means of ventilation. SCHOOL FURNITURE. 9 1 School Furniture. — In the most excellent and thorough article upon School Hygiene, by Dr. S. D. Risley,* to which we are greatly indebted in the preparation of this chapter, much space has been devoted to the consideration of the school furniture. While the faulty construction of the school desk and seat is a very im- portant factor, according to orthopaedic surgeons, in the causa- tion of spinal curvature, it has, and undoubtedly still is no small factor in the increasing myopia of school life. Vast improvements have been made in the average school-rooms of to-day in this re- spect, still a visit to almost any school will show more or less of the pupils in an improper position. The grave danger to the eyes lies in the pupil bending over his desk and thus bringing the eyes too close to the work. This abnormal near point adds greatly to the strain upon the accommodation and convergence, and at the same time causes an increased congestion of the coats of the eye, all of which serves to increase the tendency to near-sightedness. The proper arrangement of the seat and desk is such that the child will find it easier to sit upright at his work than in any other position he can assume. The directions and measurements for securing such a position by means of a correct seat and desk are fully given in the article referred to. The blackboard forms an important adjunct to school life, and its more general and extended use should be encouraged. The strain upon the eyes is much less when looking at a relatively distant object like the blackboard than it is at the near point, as in reading and writing. Hence instruction by board exercises is much less fatiguing than work done with the pencil or pen. The surface of the board should be kept black and clean by frequent washing, and the crayons used should be either white or yellow. Wall maps and charts are also useful, for the same reason as the blackboard, in that they permit of instruction at a greater dis- tance. The character of the type, paper, etc., in school-books has already been referred to. In all children who have alread}^ developed near-sight, to avoid the increasing tendency to draw the work nearer and nearer to the eyes, some of the many forms of head rest, which hold the head erect and at the proper distance from the work, should be used. In considering the subject of hygiene of the eye we have dwelt ^System of Diseases of the Eye. Norris and Oliver. Vol. II. 1897. 92 HYGIKNE OF THE EYE. at length upon the care of the eyes in children, because it is at this time of life that the greatest danger to vision exists. Further- more, when the proper care has been given to the eyes in early life we enter adult life with better eyes and a better understand- ing of their requirements. In all classes, men, women and chil- dren, there is an inherent prejudice to the use of glasses, but to those suffering from refractive errors the use of the correct glass is one of the greatest boons to humanity. We acknowledge that the prevalent error of all oculists is the too early and frequent prescribing of glasses. In many instances the use of glasses can be avoided by the correction of some deficiency in the balance of the extrinsic muscles of the eyes which is the cause of the asthen- opic or reflex symptoms. In all cases of decided refractive errors, however, the use of correcting lenses is a necessity. When glasses are required they should be given proper care by the wearer. We have often seen patients wearing glasses so scratched and dirty that a great effort must necessarily be made to see through them. In using eye-glasses, the}^ should never be folded, as they soon be- come misshappen or scratched. For the same reason glasses should not be thrown carelessly upon tables, stands, etc., and when out of shape, nicked and scratched they should be repaired or new ones purchased. After the correct lens has been selected care should be taken that the frames are correctly adjusted by a com- petent optician, as oftentimes improperly fitted frames destroy all the benefit that would have resulted from the glasses. The too common custom of allowing incompetent opticians, jewellers, peddlers, etc., to examine the eyes and fit glasses cannot be too strongly reprimanded. The prevalent habit of going without glasses for reading as long as possible is also a bad one. The public should be taught that all normal eyes require glasses for near vision about the age of forty or forty-five. That postponing their use later than this age causes an effort of the accommodation which does harm. The prejudice to the use of glasses seems to be dying out, and the laity are realizing more and more the necessity of attention to the eyes. One of the most important questions relating to the general care of the eyes is that as to the best light. This should always be answered, the diffuse natural light of day, and the next best, HYGIENE OF THE EYE. 93 that which most nearly approaches dayHght. Artificial light should be profuse, white and steady and that which most nearly meets these requirements is that known as the Welsbach light. The incandescent light, w^hen protected by translucent globes, is also an excellent light. Gas and kerosene are also good, but -should be shaded with globes colored w^hite on the inside and tinted green on the outside. What has been said in regard to children in school applies as well to the adult, that the use of the eyes should only be when the body is in the erect position, and that the light should fall upon the book or paper from the left side. It hardly seems necessary to caution against the use of the eyes in reading after twilight, when the illumination has become poor, when riding on the cars, while lying down, etc , but as all these things are being done daily we cannot cry don't too often. In conclusion let us remind the reader that the health of the eye depends to a great measure upon the condition of the general -system. The eye is not a separate and distinct organ, to be treated wholly independent of the general bodily health. While the eye can undoubtedly cause abnormal conditions of other organs, it can at the same time suffer from other diseased condi- tions. Therefore, by obeying the general laws of hygiene the usefulness of the eYes wuU be best maintained. 94 GENBRAI, DISEASES WITH EYE SYMPTOMS. CHAPTER VI. A Tabulated Statement of Diseases With More or Less Characteristic Eye Symptoms. From The Eye as an Aid in General Diagnosis by B. H. Linnell. M. D. Abdommal growths. — More or less pigmentation of the skin of the eyehds. Addison'' s disease of the supra-renal capsules. — Pigmentation of the skin of the hds and of the sclera. Albuminuria. — Retinitis and neuro-retinitis. Alcoholism. — Paretic mydriasis. Paralysis of accommodation, or spastic myosis in the early excitable stage. Paralysis of the external ocular muscles. Ptosis. Ancemia {Cerebral). — Paretic mydriasis. Ancsmia (^ConstitutionaV) . — Paralysis of accommodation, chorodi- itis, retinitis and retinal haemorrhages. Aneurism of orbital artery, or internal carotid. — Exophthalmus. Aneurism of aorta and arteria innominata. — Reflex spastic my- driasis on the side of the lesion. Retinal pulsation. Apoplexy. — Dilation or contraction of the pupils distinguishes it from embolism, in which the pupils are unaffected. Spastic myosis in premonitory stage. When, during a seizure, my- driasis occurs after a previous myosis, it is an unfavorable symptom, signifying increasing pressure. Nystagmus. Homonymous hemianopsia. Apoplexy of cortex or cor 07ia radiata. — Byes and extremities para- lyzed on the same side. Eyes deviate toward the side of the lesion. Apoplexy of the crus or pons varolii. — Eyes and extremities para- lyzed on opposite sides. Eyes deviate away from the side on which the lesion exists. Apoplexy of the pons. — Spastic myosis. Apoplexy of ventricles. — Spastic myosis. GENERAL DISEASES WITH EYE SYMPTOMS. 95 Atheroma. — Conjunctival hsemorrhage. Intra-ocular hoemorr- hages. Atrophy , progressive ^ muscular. — Ocular paralyses. Basedow' s disease or exophthalmic goitre. — Diminished frequency of winking. Spasm of the levator of the upper lid. (Abadie's sign.) Widening of the palpebral fissure, owing to contrac- tion of Mueller's muscle. (Stellwag's or Dalrymple's sign.) Loss of associated movement of the upper lid and the eye- ball. (Von Graefe's sign.) Exophthalmus. Brairi, abscess of . — Neuritis. Brain, basilar affectiojis of. — Loss of pupillary reflexes. Homony- mous hemianopsia. Paralyses of ocular muscles. Brain, cerebral cortical affectio7is . — Conjugate ocular paralyses (or ophthalmoplegias), loss of voluntary movements of the eyes, with preservation of involuntary or reflex movements of pupil and eye-ball. Eyes paralyzed on side opposite the cerebral lesion. Ej^es deviate towards side of lesion. Psychic visual disorder. Brai?i, cerebral affections, with increased i7itra-cranial pressure. — Paretic mydriasis ordinarily. Sometimes reflex spastic my- driasis. Brain, cerebellum, affections of. — Nystagmus. Brain, concussion of. — Sluggish action of pupils without marked dilatation or contraction. Brain, hypercEmia of. — Spastic myosis. Brain, tumor of. — Nystagmus. Paretic mydriasis. Choked disc. Choked neitritis. Atrophy of optic nerve. Homonymous hem- ianopsia, when pressure is extended upon fibres of one tract. Cholera. — Conjunctival hsemorrhage. Anaesthesia of cornea. Neuro-paralytic keratitis. Loss of the light reflex indicates a fatal termination even in apparently mild cases. Preserva- tion of the light reflex warrants a favorable prognosis, even in severe cases. Black patches appear in the sclerotic below the cornea in severe cases. They are of irregular form and size and tend to coalesce. Their presence is of very un- favorable significance. Coma, alcoholic or urcemic. — Mydriasis. 96 GENERAL DISEASES WITH EYE SYMPTOMS. Coma, syphilitic. — Myosis and reflex iridoplegia. Death, signs of. — Opacity and insensibility of the cornea. Dessic- cation of the sclera. Abolition of pupillary reflexes. Ab- sence of the red reflex from the fundus. Dejital affectio7is. — Various forms of inflammation of the cornea. Nictitation. Diabetes. — Eczema of the eyelids. Conjunctival haemorrhage. Ulceration of the cornea. Paralysis of the external ocular muscles and of the accommodation. Cortical cataract. Retin- itis and neuro- retinitis. Atrophy of the optic nerve. De- generation of the retinal vessels and haemorrhages. La- grange found, in 52 cases of diabetes, 13 of intra-ocular haemorrhage and the same number of cases of cataract. (See "Arch, d' Ophth.," Jan., 1887.) Galezowski found, in 144 cases of diabetes, 5 of paresis of accommodation, 4 of kera- titis, 7 of iritis, 4 of glaucoma, 46 of cataract, 27 of retinitis, 31 of amblyopia, 3 of amotio retinae, and 3 of atrophy of the optic nerve. (See " Jahr. f. Aug.," 1883, p. 297.) Digestion, disorders of. — Styes. Nictitation. Diphtheria. — Diphtheritic conjunctivitis. Paralyses of the ex- ternal e5^e muscles rare; of accommodation more frequent. Embolism, cerebral. No pupillary symptoms; in contradistinction from apoplexy. Epilepsy. — Paretic mydriasis during the seizure or spastic myosis. Hippus as consciousness returns and frequently during the in- tervals. Spasms of the ocular muscles. Fever, puerperal a?id typhoid. — Metastatic suppurative choroiditis. Fever, relapsi7ig. — Iritis. Fifth nerve, affections of. — Reflex spastic myosis. Fourth ventricle, lesions in. — Nuclear ocular paralyses 'affecting separate nuclei of the third nerve, or successive implication of its various branches. Also total paralysis of all the muscles of both eyes. Friedreich' s disease (hereditary ataxia). — Nystagmus. Gout. — Retinitis. Heart, aortic ijisufficieyicy . — Alternate reddening and pallor of the optic disc. GENERAI. DISEASES WITH EYE SYMPTOMS. 97 Hearty endocarditis. — Embolism of the arteria centralis retinae. Heart, organic affections of . — CEdema of lids. Venous hyperaemia of retina and pulsation retinal arteries. Seen with valvular affections, fatty heart and aortic insufficiency. Heart, hyp ei^trophy of left ventrical — Retinal haemorrhages. Heart, valvula? lesions of. — Retinal haemorrhages. Helminthiasis . — Reflex spastic mydriasis. Hepatic affections. — Pigmentation of the skin of the lids. Color- ation of sclera. Hydrcemia. — GBdema of lids. Hydrocephalics. — Paretic mydriasis. Neuritis and atrophy of optic nerve. Hysteria. — Chromidrosis. Epiphora. Ptosis. Spastic myosis (during a hysterical convulsion). Hippus. Hyperaesthesia of the retina. Spasm of accommodation. Ambh^opia. Contrac- tion of the visual field. Sudden onset, erratic course, sudden disappearance. Insanity. — Monocular mydriasis and paralysis of accommodation are suspicious premonitory signs, as is also transient recur- rent mydriasis. Kidney , diseases of . — Degeneration of the retinal vessels with or without haemorrhages. Retinitis and neuro-retinitis. Am- blyopia. CEdema of lids. Leprosy. — Leprous nodules in eyelids, conjunctiva, cornea and iris. Anaesthetic spots and white patches in the lids. According to Lopez (" Archiv. f. Aug.," xxii, 2 and 3) " the eye is affected in half the cases, the e}^ with its appendages in all cases." Knies. Liing, diseases of apex. — Reflex spastic mydriasis. Malaria. — Chronic superficial non-suppurative keratitis. Sensi- tiveness of supra-orbital nerves. Retinal haemorrhages. Choroiditis. Mania. — Reflex spastic mydriasis. Masturbation. — Paralysis of accommodation. Hyperaesthesia of retina. Melancholia. — Reflex spastic mydriasis. 7 98 GKNKRAI. DIvSEASKS WITH BYK SYMPTOMS. Meningitis, cerebral, acute. — Mydriasis or myosis, photophobia. Injection of conjunctiva. Meningitis, cerebral, chronic. — Interstitial and peri-neuritis. Atrophy of the optic nerve. Mejiingitis , of the co?ivexity. — Cortical blindness or hemianopsia with preserved pupillary light reflex. Hypersesthesia of the retina. Photophobia, phosphenes, etc. Meningitis, cere bro- spinal. — Eye symptoms frequent. Conjunc- tivitis in early stages. I^ater oedema of conjunctiva, denoting exudation in cranial cavity. Strabismus. Nystagmus. Spastic myosis in early stages. Reflex spastic mydriasis from pinching the skin at the back of the neck. (Parrot's sign.) Hippus. Choroiditis. Photophobia. Neuritis. • Meningitis, spinal. — Spastic mydriasis in the early stage. Menijigitis, tubercular. — Strabismus. Nystagmus. Ocular paraly- ses. Spastic myosis in early stage. Rapid alternation of myosis and mydriasis. Paretic mydriasis in later stages in contra-dis- tinction from cerebro-spinal meningitis, in which it is rare. Tuberculosis of the choroid. Homonymous hemianopsia. Meningeal hcsmorrhage. — Nystagmus. Hemianopsia. Menstruation, disorders of . — Styes. Myelitis, acute and chronic. — Neuritis or simple atrophy of the. optic nerve. Myxcedema. — Thickening and swelling of the Uds. Nephritis. — See diseases of the kidney. Neuralgia of the fifth nerve. — Paralysis of accommodation. Neuritis, multiple or pseudo-tabes. — Axial neuritis with central scotoma. Absence of pupillary symptoms, in contra-distinc- tion from true tabes. Nicotine poisoni7ig . — Spastic myosis. Retro-bulbar neuritis with central scotoma. Paralysis agitans. — Tremor of the lids. Ptosis. Paralysis, general (^paralysis of i?isane, paresis). — Monocular mydriasis and paralysis of the accommodation and transient recurrent mydriasis are suspicious premonitory symptoms. Paretic mydriasis is an early symptom. The ' ' Argyll- GENERAL DISEASES WITH EYE SYMPTOMS. 99 Robertson pupil," is found in fifty per cent, of the cases. Anisocorea. Paretic myosis. Optic-neuritis. Atroph}^ of optic nerve. Soul blindness. Sudden development and transient duration of ocular symptoms, similar to multiple sclerosis and tabes. Polio e7icephalitis superior {iyiflarnination of the floor of the fourth ventricle^. — Progressive paralyses of the ocular muscles is the essential feature. Pons varolii, lesions of. — Nystagmus. Associate ocular paralyses in horizontal lines. Spastic myosis. An isolated lesion for one side produces paralysis of the external rectus on the same side. PycBtnia. — Metastatic suppurative choroiditis. Retinal haemor- rhages. Rachitis. — Cortical or laminated cataract. Rheumatism. — Paralysis of external ocular muscles, usually of one eye, and affecting one or more contiguous branches of the nerve such as the superior rectus and levator palpebrae superioris. Iritis with gelatinous exudation. Sclerosis, 77iultiple. — Nystagmus, a frequent and valuable diag- nostic sign. Ocular paralyses characterized by sudden de- velopment, transient duration and variable course, similar to syphilis and tabes. Hippus. Paralysis of accommodation. Impairment of vision, but rarely complete blindnesss. Cen- tral scotoma. Irregular or concentric contraction of the visual field. Neuritis. Scrofula. — Eczema of lids. Styes. Ciliary blepharitis. Con- junctivitis. Pustules and abscesses of the cornea. Phlyc- tenular conjunctivitis and keratitis. Choroiditis. Snake poisoning. — Retinal haemorrhages. Skin, exte7isive burns of, — Reflex spastic mydriasis (skin reflex). Spinal cord, infla77i77iation a7id congestio7i of, spi7ial irritatio7i. — Spastic mydriasis occurs in the early stages. Spinal cord, degenerative disease of . — Nystagmus. Syphilis. — Every tissue of the eye, except the lens, is affected. Inflammation of the lids, orbit and lachrymal passages. Ar- rest of development, such as microphthalmus, etc., in the lOO GENERAL DISEASES WITH EYE SYMPTOMS. congenital form. Periostitis and caries of the orbit. Para- lytic affections of the lids and external ocular muscles. Various muscles are suddenly, successively and transiently involved. Parenchymatous keratitis. Inflammation of the sclera with gummata. Mydriasis with loss of accommoda- tion. Gummous iritis. Choroiditis. Degeneration of the retinal vessels with or without haemorrhages. Retinitis and neuro-retinitis. Atrophy of the optic nerve. Heteronymous and homonymous hemianopsia. Zimmerman, of Milwaukee^ says, in '' Knapp's Archives," January, 1895, that only about 15 per cent, of the cases of brain syphilis are without ocular symptoms. Tabes. — x^naesthesia of the skin of the lids, of the conjunctiva and cornea, with false localization of sensation. Paresis of orbi- cularis palpebrarum. Narrowing of the palpebral fissure. Ptosis. Paralysis of the ocular muscles, sudden in develop- ment and transient in duration, similar to syphilitic paralyses and to those which occur in multiple sclerosis. Spastic my- driasis may be a premonitory symptom. Paretic myosis oc- curs in 23 percent, of the cases. The "Argyll-Robertson pupil " is a very characteristic symptom, and occurs in 70 per cent, of the cases. In 25 per cent, it is an early symptom. Reflex iridoplegia, or failure of all the pupillary reflexes. The reaction to light fails flrst, followed by loss of reaction with accommodation and convergence, and lastly the skin reflex is lost. Anisocorea occurs in 34 per cent, of the cases. Reflex iridoplegia is a valuable diagnostic point between true and false tabes, or multiple neuritis. In the latter, myosis and reflex iridoplegia are wanting. Atrophy of the optic nerve. Ocular symptoms may appear very early, even many years before the ataxic symptoms. Gowers relates 'a case where twenty years elapsed between blindness, optic nerve atrophy, etc., and the onset of ataxia. When spinal symp- toms are well marked, ocular symptoms are often latent or ab- sent, and the reverse is also true, viz. , when ocular symptoms are m-arked the spinal symptoms are slight or absent and may be lo7ig delayed. Trichinosis. — CEdema of the lids and paralysis of accommodation. GENERAL DISEASES WITH EYE SYMPTOMS. lOI Tuberculosis. — Periostitis and caries of the orbit. Tubercular nodules in eyelids, conjunctiva, iris and choroid. Iritis with grayish-red nodules. Typhoid J ever. — Anaesthesia of the cornea, neuro-paralytic keratitis. Hippus in stage of cerebral manifestations. Me- tastatic suppurative choroiditis. Intra-ocular haemorrhages. UrcBniia, — Mydriasis is a premonitory sign. Sudden failure of vision. Uterine affections. — Pigmentation of the skin of the lids. Para- lysis of accommodation. Urticaria. — Reflex spastic mydriasis. I02 DISEASES OF THE EYELIDS. CHAPTER VII. Diseases of the Eyelids. Anatomy. — The e3^ehds form the external covering of the eyeballs, and serve to protect the eye from injury, both from ex- cessive light and foreign substances; they also serve at the same time to distribute to the eyes the moisture secreted by the various glands. The eyelids, or palpebrse, are two thin movable folds, the upper being the larger and more movable of the two; their movement is both voluntary and involuntary, the latter action being due to the orbicularis muscle. The opening of the lids is chiefly by the action of the levator palpebrae superioris lifting the upper lid; when opened an elliptical space is left between the margins of the lids; this opening varies greatly, being larger in prominent eyes than in sunken ones, and greater when looking upward. The angles of junction of the upper and lower lids are called canthi; the outer caiithus is more acute than the inner; near the extremity of the inner canthus is found on both the upper and lower lid a slight elevation, the apex of which is pierced by a small orifice, t\i^ punctum lachrymale, the commencement of the small channel or canaliculus leading to the tear sac. The eyelids are composed of four layers, arranged from without inward in the following order, the integument, a layer of mus- cular fibres, the tarsus, or as often erroneously called the tarsal cartilage, and the conjunctiva. The iiitegument , which is ex- tremely thin but similar in every other respect to the integument elsewhere, becomes, at the margin of the lids, continuous with the conjunctiva. Beneath the skin the connective tissue is loose and contains no fat. The muscular fibres consist of the orbicularis palpebrarum, a large flat, voluntary muscle extending over the orbital margins above and below and terminating by tendinous attachments at the angles of the lids, the tendons, together with some flbres of the muscle, being inserted in the adjacent bony wall. The fibres of ANATOMY OF THE EYELIDS. 103 the orbicularis which lie upon the tarsi are paler than the others, and certain bundles of these which give to the lid its involuntary action, are known as the ciliary muscles of Riolani. The orbic- ularis is somewhat adherent to the skin, but glides loosely over the tarsus. It receives its nerve supply from the facial. Its fibres being more or less circular in arrangement, and, acting as a sphincter, serve to close the eyes. Fig. Section through upper eyelid. A, the ciliary muscle of Riolanus: B, follicle of the eye-lashes; C, opening of the Meibomian follicles. The levator palp ebrcE supe?ioris arises at the apex of the orbit, and passing along its upper wall becomes intermingled in front of the tarsus with the orbicularis; other fibres become attached to the upper edge of the tarsus, and still others go to the con- junctiva. This muscle is supplied by a branch from the third nerve, and its action is, as its name implies, to raise the upper lid. The lower lid is supplied with a prolongation from the inferior rectus, whose insertion and action is analogous to that of the levator palpebrse. The tarsi are two thin, elongated plates composed of condensed fibrous tissue, and serve to form the framework of the lids; they are united to each other and to the adjacent bone through the medium of the internal and external lateral ligaments. The conjunctiva is a delicate mucous membrane which com- mences at the free border of the lid, where it is continuous with I04 DISEASES OF THE EYELIDS. the skin; it lines the inner surface of the lids and is then reflected upon the globe, over which it passes and becomes continuous with the cornea. The palpebral portion is thicker and more vascular than that covering the globe, and is firmly attached to the tarsus. Where it passes from the lids to the globe it is thin and loose, and forms what are called the fornix conjunctivae. The plica semilu?iaris is a verticle fold of conjunctiva at the inner canthus, and the reddish elevation at the inner angle is called the caruncula lachrymalis . The cilia are short, thick, curved hairs, arranged in double or triple rows at the margins of the lids; their follicles are sur- rounded by sebaceous glands and the glands of Moll. Within the tarsus are embedded the Meibomian glands, which in struct- ure resemble the sebaceous glands. These various glands by their secretions serve to lubricate the eye, and discharge their secretion through excretory ducts, opening by minute orifices upon the free border of the lids between the rows of cilia. Blepharitis. — {Blepharitis Simplex, Blepha?o- Adenitis, Bleph- aritis Ciliaris, Blepharitis Margiyialis , Seborrhoea; Blepha- ritis Ulcerosa, Blepharitis Hypert7'ophica, or Squamosa.^ Under this general heading, inflammation of the lids, we shall group the various clinical sub-divisions. The numerous names (of which the above are but few) that have been given to an inflam- mation involving the border of the eyelids may be all grouped under two headings — non-ulcerative and ulcerative blepharitis. Symptoms. — The non-ulcerative form commences as a simple hypersemia of the lid border, which gives to the lids a red, swollen appearance. This is accompanied by a slight burning and smarting in the eyelids, which is aggravated by cold winds, smoke, dust, exposure to bright light, or use of the eyes at close work. • There is agglutination of the eyelids in the morning, with dry scales or scabs adhering to the margins of the lids, and more or less photo- phobia and lachrymation are present. This variety depends upon an abnormal secretion of the sebaceous glands The ulcerative variety may be considered as an extension of the preceding form. If we remove with the forceps the yellow crusts surrounding and embedding the cilia, w^hich have formed through neglect in the previous stage, we find a red, bleeding ulcerative surface. This surface continues to secrete pus that forms other BLEPHARITIS. 105 crusts, and by extension of the ulceration the entire edge of the lid may become involved. At this stage the disease is known as blepharitis ulcerosa, and as it advances the edge of the lid not only becomes red and covered with scales, but considerably thickened, and it is then termed blephaj^itis hypertrophica. If the disease still continues unchecked, it involves the hair follicles and causes the lashes to become stunted and misplaced (^trichiasis') , or to fall out, and when entirely wanting we have the condition known as {?nadarosis) . The final stage of the disease is when the lid itself becomes rounded, red, thickened, everted and de- prived of lashes {lippitiido) . Course. — The course of the disease is usually ver}^ chronic, and yet should be cured by thorough and prolonged treatment. Causes — The disease is especially the result of refractive errors in young, delicate persons of a strumous diathesis. As the causes are so closely associated with the treatment, they will be considered further under that heading. Treatment. — First, we should examine the refraction, and, if any error is found, correct the same with the proper glass, as in many cases this alone will cure the entire trouble. In rare cases the presence of lice on the e3'elashes may be the exciting cause {^phthiriasis ciliariiiji) , when we should be careful to remove them and apply either cosmoline or some mercurial ointment, which will destroy them and prevent their recurrence. Fungous growths in the hair follicles are also said to cause this disease, in which case the hairs should be extirpated, and either external or internal medication employed. Another cause is frequently found in affections of the lachry- mal canal, particularly catarrh of the lachrymal sac and stricture of the duct; in these cases the tears, being hindered from flowing through their natural passage into the nose, collect in the eye, flow over the lids and down the cheek; thus the retention of the tears will cause an inflammation of the margins and even- tually of the whole structure of the lids. Any other affection which will have the same result (flowing of the tears over the lids) will, of course, produce the same trouble, and this is often found in slight degrees of eversion of the lower lids {ectropiu7}i) , which displaces the puncta lachrymalis and thus prevents the tears from passing into the sac. In all such cases the first thing I06 DISEASES OF THE EYELIDS. to be done is to open the canaliculus into the sac, and, if neces- sary, the nasal duct into the nose, so as to give a free passage for the tears into that organ, after which the treatment is the same as in uncomplicated cases. But the most common causes of ciliary blepharitis are exposure to wind, dust, smoke, etc., especially when complicated with want of cleanliness ; it is for this reason we see this trouble so fre- quently among the poorer classes. As it is upon this point — cleanliness — that the success of our treatment depends to a great extent, we should impress upon the patient's mind the necessity of it in terms as forcible as possible. They should be directed to remove the scales or crusts from the margins of the lids as soon as formed, not allowing them to re- main even a few minutes. This should not be done by rubbing, as the patient is inclined to do on account of the itching sensation, for by so doing excoriations are made, lymph is thrown out and new scabs form, which only aggravate the inflammation. But they should be directed to moisten the crusts in warm water and then carefully remove them with a piece of fine linen, or by draw- ing the cilia between the thumb and fingers; at the same time gentle traction may be made on the lashes, so as to remove all that are loose, as the}^ act only as foreign bodies. Sometimes the scabs are so thick and firm that moistening in warm water is not sufficient to remove them; in such cases, hot compresses or poul- tices should be applied for ten or twenty minutes at a time, until they can be easily taken away. In the treatment of chroyiic inflammation of the margins of the lids, external applicatio7is are of great value and without their use a cure is often impossible. It is true that a careful attention to cleanliness, together with the internal administration of the indi- cated remedy, will cure a large proportion of the cases, but the duration of treatment will be usually much longer than if we em- ploy local means at the same time we give internal remedies. Oosmoline or Vaseline. — This unguent has been of great service in the treatment of blepharitis. It may be used alone or to form a base for the administration of other remedies. It pre- vents the formation of new scales and the agglutination of the lids, besides seeming to exert a beneficial influence over the prog- ress of the disease. This, like all other ointments, should be BLEPHARITIS. IO7 used once or twice a daj^ or even oftener, if the case is very severe. All scales or crusts should be carefully removed; after which a very little of the ointment may be applied to the edge of the lids with the finger or a camel's hair brush. The smallest amount possible, to oil the ciliary margins of the lids, should be applied, as an aggravation of the inflammation may result from its too free use. Mercury. — For years this has been a favorite local application in blepharitis. It seems to be better adapted to the severe forms of inflammation of the lids than Graphites, for there is more red- ness, more swelling, more secretion and more tendency toward ulceration. The two following prescriptions have been employed with the most favorable results, especially the yellow oxide: ^. Hydrarg. ox3'd. flav., gr. ij. Vaselin, 5^- Misce. 9^. Liq. Hydrarg. nitr., gtt. iij. Vaselin, . 5ij- Misce. In some cases more of the mercury is used, in others less, ac- cording to the severity of the symptoms. Grrapho- vaseline. — Graphites, as will be seen in the sympto- matology, is more commonly indicated in blepharitis than any other one remedy. Many cures have resulted from its internal administration alone, when indicated, but more brilliant results may be obtained by employing at the same time locally the follow- ing unguentum: ^. Graphites, gr, ij, Vasehn, 3ij- Misce. Various other ointments and washes have been used with vari- able success. The use of milk, cream, lard and simple cerate, to prevent the lids from sticking together, have also been of aid, with internal medication. Graphites. — This is one of the most important remedies we possess for the chronic form of this disease, though it may be in- dicated in acute attacks, especially if complicated with ulcers or pustules on the cornea. Particularly useful if the inflammation occurs in scrofulous subjects covered with eczematous ej^uptiojis io8 disp:ases of the eyelids. chiefly on the head and behind the ears; which are moist, fissured a7id bleed easily. The edges of the lids are slightly swollen, of a pale red color and covered with d7y scales or sciirfs, or the mar- gins may be ulcerated. The inflammation may be confined to the canthi, especially the outer, which have a great tendency to crack and bleed, upon a?iy attempt to open the lids. Burning and dryness of the lids are often present, also biting, and itching, causing a constant desire to rub them. It is important in eczema of the lids, if the eruption is moist, with tendency to crack, while the margins are covered with scales or crusts. Mercurius sol. — Very favorable results have been gained by this remedy in blepharitis, especially if dependent upon or found in a syphilitic subject, or if caused from working over fires or forges. The lids are thick, red, swollen and ulcerated (particularly the upper) a7id sensitive to heat or cold and to touch. Profuse acrid lachrymation is usually present, which makes the lids sore, red and painful, especially worse in the open air or by the constant application of cold water. All the symptoms are worse in the evening after going to bed and from warmth in general, also from the glare of a fire or any artificial light. The concomitant symp- toms should receive special attention, as excoriaton of the nose from the acrid coryza, flabby condition of the tongue, nocturnal pains, etc., etc. Hepar sulph. — This is the remedy most frequently employed in acute phlegmonous inflammation, especially after the first stage has passed and suppui'atiofi is about to, or has already, taken place. The lids are inflamed, as if erysipelas had invaded them, with throbbing, aching, stinging pains, and very sensitive to touch; the pains are aggravated by cold and from contact, but ameliorated by warmth. It may also be useful in certain forms of blepharitis in which the lids are inflamed, sore and corroded, as if eaten out, or if small red swellings are found along the margins of the lids, which are painful in the evening and upon touch. There \'$> gen- eral amelioration from warmth. Often called for when the Mei- bomian glands are affected. For eczema palpebrarum, in which the scabs are thick and honeycombed in character on and around the lids, it is very valuable. Pulsatilla. — Blepharitis, both acute and chronic, especially if the glands of the lids are affected (blepharo-adenitis) or when BLEPHARITIS. 109 there is a great tendenc}- to the formation of styes or abscesses on the margin of the palpebrae. Blepharitis resulting from high living or fat food and when accompanied by acne of the face; also in cases in which the lachrymal passages are involved. The swelling, redness and discharges vary, though the latter are more often profuse and bland, causing agglutination of the lids in the morning. Itching and burning are the chief sensations experi- enced. The S3^mptoms are usually aggravated in the evening, in a warm room or in a cold draught of air, but ameliorated iji the cool open air. Oalcarea carb. — Blepharitis occurring in persons inclined to grow fat, or in imhealthy, '^pot-bellied''' children of a scrofulous diathesis who sweat much about the head. The lids are red, swollen and indurated. Inflammation of the margins of the lids, causing loss of the eyelashes, with thick, purulent, excoriating discharge and burning, sticking pains. Great itching and burn- ing of the margins of the lids, particularl}^ at the canthi; throb- bing pain in the lids. Most of the eye symptoms are worse in the morning, on moving the eyes, and in damp weather. Great reliance should be placed on the general cachexia of the patient. Oalcarea iod. — Seems to act better than the carbonate in ble- pharitis found in those unhealthy children afflicted with enlarge- ment of the glands and especially of the tonsils. Rhus tox. — Its chief use is in acute phlegmonous inflamma- tion of the lids and erj^sipelas; lids cedematously swollen (espe- cialh' the upper) and accompanied by pi'ofuse lachrymatio7i ; there ma}^ be erysipelatous swelliiig of the lids, with vesicles on the skin; chemosis \l oi\.^\i present. The pains are worse at night, and in cold, damp weather, but relieved by warm applications. It may be of service in acute aggravations of chronic inflammation from exposure in w^et weather or when worse at that time, with much swelling of the lids 2,w^ prof use lachrymation . Mezereum. — Blepharitis accompanied b}^ tinea capitis ; or eczema of the lids and head, characterized by thick hard scabs, from under which pus exudes on pressure. Antimoniuin crud. — Obstinate cases in which the lids are red, swollen and moist, with pustules on the face. Especially in cross children. Pustules on the ciliary margins. Arsenicum. — Inflammation of the margins of the lids, which no DISEASES OF THE EYELIDS. SiXQ. thick, red and excoriated by the bunmig, acrid lachrymatio7i. The cheek may also be excoriated. The lids are sometimes oedematoUvSly swollen and spasmodically closed, especially when the cornea is at the same time affected. The characteristic burning pains are important and usually present. The general condition of the patient decides us in the selection, as the great prostration, restlessness, aggravation after midnight and thirst are commonly seen in scofulous children. Often useful in the early stages of abscess of the lids. Sulphur. — A remedy called for, especially in the chronic form of this disease and when found in children of a strumous diathesis who are irritable and cross by day and restless and feverish by night; also for blepharitis appearing after the suppression of an eruption or when the patient is covered with eczema. The lids are red, swollen and agglutinated in the morning, or there may be numerous small, itching pustules on the margins. The pains are itsually of a sticking character, though we may have itching, biting, burning and a variety of other sensations in the lids. There is generally great aversion to water so that they cannot bear to have the eyes washed. Eczematous affections of the lids, like eczema in other portions of the body, which indicate Sulphur, are often controlled. Psorinum. — Old chronic cases of inflammation of the lids, es- pecially when subject. to occasional exacerbations. It has also been of service in the acute variety when the internal surface of the lids was chiefly affected, wnth considerable photophobia. Par- ticularly indicated in a strumous diathesis, with unhealthy, offen- sive discharges from the eyes. Aconite. — Chiefly called for in the acute variety of this trouble, especially when caused from exposure to cold dry winds and in the very first stage '$>^^ dacryocystitis phleg-inonosa, page 139. Hypertrophy of the Lachrymal Gland is very rare. It is a circumscribed, nodular tumor of gradual growth and has been known to occur in children and infants. If it increases suf- ficiently to cause interference with the movements of the eyeball it should be removed. Tumors of the Lachrymal Gland, such as fibroids, sarco- matas, adenomas, hydatid cysts and cancers have all been recorded. They require extirpation of the gland. AnomaUes of the Puncta and Canaliculi. — Eversion of the puncta is frequently found in blepharitis and conjunctivitis, causing epiphora, or watering of the eye, and will often result in ectropium from the irritation of the tears flowing over the lid. The same result will occur from a narrowing or stoppage of the canaliculus, from wounds of the lid involving the canaliculus, or foreign bodies in the canaliculi blocking the passage of the tears. Obstruction of the canaliculus can be relieved by slit- ting up the canal with the canaliculus knife (Fig. 43), a narrow-bladed, probe-pointed knife, which is to be entered into Fig. 43. Agnew's canalicula knife. the puncta vertically, the handle then brought to a horizontal position, when the knife is pushed directly inward until it reaches the inner wall (the lid being kept taut with the thumb of the other hand), the knife is then brought to the vertical position, cutting through the whole length of the canaliculus. The edge of the knife should be kept toward the conjunctiva during its passage, so as to divide the canaliculus close to the muco-cutane- ous junction. It is better, where possible, to preserve the physio- logical suction action of the canaliculus by onl}^ slitting it up for two or three mm. from the punctum and dilating the remainder of the canal with probes. STRICrURA DUCTUS LACHRYMALIS. 1 35 Strictura Ductus Lachrymalis. — Stricture of the nasal duct is the most common affection of the lachrymal apparatus. Symptoms. — The chief characteristic symptom of stricture is the overflow of tears, which is increased on exposure to cold wind or bright light. There is also often noticed a dryness of the nos- tril on the same side as the stricture. Usually on making pressure with the finger over the sac we can press out from the puncta a few drops of clear viscid secretion. We may also find a slight conjunctivitis present. Causes. — It is usually due to the extension of a nasal catarrh. Injury or periostitis of the nasal bones, carious teeth, or pressure from tumors in that vicinity may cause it. Its treatment will be found under dacryocystitis. Dacryocystitis Oatarrhalis. — Catarrhal inflammation of the lachrymal sac is generally the result of a stricture or associated with it. The catarrhal inflammation, on the other hand, may be the cause of the stricture, as the swelling of the mucous membrane will in itself cause a damming up of the secretions. The reten- tion of the tears, from obstruction, causes a gradual distension of the sac — a swelling at the inner angle of the ej^e. By making firm pressure on this swelling the mucus can be pressed either out of the canaliculus, or if no stricture remaining, down through the nasal duct into the nose. The contents of the swelling may be either clear and transparent or mixed with pus. This disease usuall}^ develops ver}^ slowly, with simply the history of having had a watery eye for a long while previous to noticing any swell- ing of the sac, and oftentimes they will notice a dryness of the corresponding nostril. The swelling is usually free from pain or sensitiveness to touch. Treatment. — Since lachr3mial diseases are frequently depend- ent upon nasal catarrh, treatment must be directed to this affec- tion. As in nearl}^ all cases of blennorrhoea of the sac, a more or less firm stricture of the lachrymal duct is present, this will require our special attention. If the stricture is due to inflammatory swelling of the mucous membrane, the knife is rarel}^ necessary. Bony strictures are to be regarded as incurable. The cutting of the stricture is only necessar}^ in those rare cases that will not yield to probing and electrolysis. 136 AFFECTIONS OF THE IvACHRYMAL APPARATUS. If the Stricture in the nasal duct is so firm as to not yield to the probe, the best operation to divide the stricture is that of Stil- lings, who, after slitting the canaliculus (as already described), introduces into the lachrymal sac a triangular shaped knife (Fig. 44) in the same way as a probe, and then forces it down tw^o or three times in succession, the blade being turned in a different direction at each passage. Fig. 44. Norton's modification of StilUnge's knife for stricture of the lachrymal passage. Blood issuing from the nostrils is proof that the passage has been opened. Care should be taken for a day or two after the operation to see that the canaliculus does not close, and, commenc- ing on the second day after the operation, the duct should be probed every two or three days until it remains permanently opened. A passage sufficient to admit of a Bowman probe, from No. 5 to 8 (varying in different cases) , should be secured (Fig. 45). The use of larger probes has been recommended, but in my ex- perience they have not proved as satisfactory. If there is very Httle catarrhal inflammation, especially in children, it is not always necessary to probe after Stillings's operation. A far better method than operating, when it can be carried out, is that of gradual dilatation of the strictures by using larger and larger Fig. 45- Bowman's set of probes, Nos. i, 2, 3, 4, 5, 6, 7, 8. probes. Commencing with No. o or 00, the canaliculus and duct can be gradually distended so as to admit of a No. 4 or 5 Bowman DACRYOCYSTITIS CATARRHALIS. 1 37 probe without even slitting the canaliculus. In many cases the dilatation to simply a No. i probe has been sufficient to result in a cure, and in some cases it seems to be better than to dilate to a larger size. Rarely, where the punctum is occluded, it will be necessary to slightly nick it with the point of the knife so as to admit of the smallest-sized probe. The advantages of this method seems to lay in the fact that we do not destroy the function of the parts and that the normal suction action of the canal is retained. This plan, of course, is not practical in very firm or bon}^ strict- ures. Marked benefit has also been observed from electrolysis, and there is no doubt it should be more extensivei}^ employed. My plan has been to insert a probe the usual w^ay until it comes in contact with the stricture, then attaching the probe to the negative pole of a battery, apply the positive to the temple, and make gentle pressure as the stricture yields. Usually four or five treatments will be sufficient to keep the passage permanently opened. In the treatment of the blenorrhoea, a free vent for the secre- tions through the opened or unopened canaliculus being present, the patient should be instructed to press out the matter several ti?nes a day. Mild astringent injections of boracic acid, sulphate of zinc of a two to four per cent, solution or some similar preparation may sometimes prove very serviceable. Fig 46. Agnew's lachrymal s^^ringe. Recently I have been using with good results an injection of the blue pyoktanin, i to i,ooo. Pulsatilla. — One of the most important remedies for dacryo- cystitis, which may sometimes be cut short at its very beginning with it, and may be useful at any stage of the inflammation. It 138 AFFECTIONS OF THF l^ACHRYMAI, APPARATUS. is also important in blenorrhoea of the sac, if the discharge is profuse and bland. Profuse thick and bland discharge from the nose; especially beneficial in children. Stannum. — Very favorable results have frequently been ob- tained in controlling the yellow-white discharge from the lachry- mal sac, itching or sharp pain in the inner canthus, especially at night. Hepar sulph. — Inflammation of the lachrymal sac after pus has formed, or in blennorrhoea, with great sensitiveness to touch and cold, with profuse discharge. Throbbing pains. Euphrasia. — Much thick, yellow, acrid discharge, making the lids sore and excoriated. Blurring of the vision relieved by wink- ing. Thin, watery, blayid discharge from the nose. Argentum nit. — Discharge very profuse, caruncula lachry- malis swollen, looking like a lump of red flesh; conjunctiva usually congested. Aconite. — In the first stage, when the lids are much swollen, with great heat, dryness, tenderness, sharp pains and general fever. Apis. — Before the formation of pus. lyids oedematously swol- len, with stinging, shooting pains. Patient drowsy, without thirst. Arum triph. — Catarrh of the lachrymal sac, with desire to bore into that side of the nose; nose obstructed, compelling to breathe through the mouth; nostrils sore, the left discharges continually. Mercurius. — In the later stages after the pus has become thin and excoriating ; acrid coryza ; nocturnal aggravation. Petroleum. — Discharge from the lachrymal sac, with rough- ness of the cheek, occipital headache, and other marked concom- itant symptoms. In the early stages, when there is considerable swelling of the lids, with burning pains. Silicea. — Occasionally indicated in dacryocystitis characterized by the usual symptoms of pain, swelling, tenderness and lachry- mation ; even cases that have far advanced toward suppuration have been checked. Blennorrhoea of the lachrymal sac often calls for it. The patient is particularly sensitive to cold air and wishes to keep warmly covered. Other remedies which have been recommended and proved use- DACRYOCYSTITIS PHLKGMONOSA. 1 39 ful are Bell., Calc, Cinnab., Hydrast., Kali iod., Merc, prot.^ Nat. mur., Nux, Sulph, and Zinc suli>h. Dacryocystitis Phlegmonosa. — Phlegmonous inflammation of the lachrymal sac may be considered as merely a higher stage or extension of the preceding disease. It consists in a purulent inflammation of the connective tissue surrounding the lachrymal sac. and results in an abscess that breaks externally. Symptoms. — In this the swelling is greatly increased and ex- tremel}^ sensitive to touch. The integument becomes very tense and assumes a dusky-red hue. There is usually an oedematous in- filtration of the surrounding parts, viz.: eyelids, side of the nose and cheek. There is intense pain and heat, with sometimes gen- eral symptoms of chills, fever and vomiting. The conjunctiva may be inflamed and even chemosed. Differential Diagnosis. Tlie appearance at this time resembles an abscess of the cellular tissue overlying the lachrymal sac and must be carefully differentiated, but in the dacryocN-stitis phleg- monosa firm pressure over the swelling will usually empty the tumor either through the puncta or downward through the nose, while in abscess it will not. In dacryocystitis we also have the previous history of a long-continued lachrymation, which is, of course, absent in abscess. An abscess over the lachrymal sac is rare, and we may therefore generally assume the abscess to have originated within the sac. Course. — If left to itself the swelling usually increases steadily, the skin over the sac becomes thinner and thinner, until it finally gives way, the abscess discharges leaving a fistula of the lachrymal sac, which is extremely difficult to heal. Cause. — A catarrhal inflammation precedes a phlegmon. The decomposed secretions in the sac penetrate the mucous membrane and set up a purulent inflammation. The exciting cause is fre- quently a simple cold in the head. Treatment. — At the commencement, before the formation of pus, cold compresses (even ice) are advisable, w^hich, together with the indicated remedy, may cause the inflammation to abort before an abscess has formed. As soon, however, as pus has begun to collect in the lachrymal sac, our treatment must undergo a decided change. The t?/'^/ and 140 AFFECTIONS OF THE LACHRYMAL APPARATUS. most important step to be taken to prevent its breaking externally, with the possible formation of a fistula, is the opening of the canaliculus into the sac and the evacuation of its contents, through the natural channel. But if the disease has so far advanced that perforation is inevitable, a free incision into the sac should be made externally, after which, and also in case the abscess has opened spontaneously, warm compresses may be employed for twenty-four or forty-eight hours, but must not be continued too long. The opening should be kept open by the insertion of a strip of iodoform gauze every day until the subsidence of the in- flammation, when the opening will usually close without trouble, though it may be necessary to open the nasal duct and establish a free passage for the tears before it does so. Probing of the nasal duct should be avoided until the severity of the inflammation has subsided. Warm and moist applications should be substituted for the cold as soon as suppuration has commenced. Among the best of those in use is a solution of calendula. Internal medica- tion during the whole course of the disease will form an important feature in the treatment. For indications see dacryocystitis catarrhalis, page 137. Fistula Lachrymalis. — An opening externally of the lachry- mal sac, when the result of an abscess breaking,- is often very obstinate and difficult to heal; hence, when evidently about to break, it should be opened with a bistoury. Treatment. — The first point to be attended to is to see that the passage is free into the nose. We must therefore slit up the canaliculus and divide any stricture found in the nasal duct, pro- viding it is sufficient to interfere with the flow of tears; after which the canal should be kept open. The fistula must now be healed, and, if recent, this is best done by touching the edges with a stick of nitrate of silver, or the gentle application of the galvano-cautery. If the edges of the fistula are healed and covered with smooth skin, it will be neces- sary to pare the edges and unite with a suture. The following remedies have been advised and may have been of service in recent cases, though we doubt if any effect can be ob- tained in old chronic fistulse: Brom., Calc, Fluoric ac. , Lach., Merc, Nat. mur., Petrol., Sil. and Sulph. \ ANATOMY OF THE ORBIT. I4I CHAPTER IX. Diseases of the Orbit. Anatomy. — The shape of the orbit is that of a quadrangular pyramid, the base or facial opening, the four walls and the apex. The axes of the orbits converge posteriorly at an angle varying in different individuals. The bones entering into the formation of the orbital walls are the frontal, sphenoid, superior maxillary, malar, palate, ethmoid and lachr3^mal. The optic foramen, sit- uated at the apex of the orbit, transmits the optic nerve and the ophthalmic artery. The superior orbital fissure transmits the third, fourth and sixth nerves, ophthalmic branch of the trige- minus, the superior and inferior ophthalmic veins, few sympa- thetic filaments from the cavernous plexus, the recurrent lach- rymal artery and sometimes orbital branches of the middle menin- geal artery. The inferior orbital fissure gives passage to the malar and infra- orbital nerves, infra-orbital vessels, a facial branch of the ophthalmic vein, and the ascending branches of the spheno- palatine ganglion. The supra-orbital notch, at the upper and inner margin of the orbit, contains the supra-orbital nerve, arterj^ and vein as they pass to the forehead. The orbit, in addition to the eyeball, vessels, muscles, etc., contains considerable adipose tissue. TenoiV s Capsule is the limiting membrane between the cellulo- fatty tissue and the globe and conjunctiva. It ensheaths to some extent the muscles, vessels, nerves, etc., that pass through it, ana is continuous with the periosteum of the orbit as well as with the conjunctiva. It is somewhat analogous to the pleura, and serves as a cup in which the globe revolves. It constitutes a second- ary attachment for the ocular muscles, and by this attachment it renders it possible to sever the tendon of a muscle without losing its entire action upon the eye, for it still remains in connection with the eye through Tenon's capsule, unless too extensive lateral cuts have been made, separating the tendon from the capsule. The dura mater is firmly attached at the sphenoidal fissure and 142 DISEASES OF THE ORBIT. optic foramen and is continuous with the outer sheath of the optic nerve and with the periosteum of the orbit. Cellulitis Orbitae i^Abscess or Phlegmon of the Orbit). — In- flammation of the cellular tissue of the orbit may occur as a simple oedematous cellulitis or in a far more active form as a phlegmojious cellulitis. Symptoms. — In oedematous cellulitis the eye will be slightl}'' bulged forward, its movements limited and sometimes diplopia is complained of. There is usually in these mild cases little or no swelling or redness of the lids or conjunctiva, and but little dull pain, except on pressure upon the globe. This form of cellulitis generally occurs in young and delicate children, and usually sub- sides within a few days. In the severer form, ox phlegmonous cellulitis, the onset is apt to be accompanied with a chill and rise in temperature. There will be swelling and dusky discoloration of the lids, especially the upper, and a more or less intense pain, greatly increased by pressure upon the globe. The eyeball is protruded directly forward, and its movements limited in all directions; in some severe cases it will have absolutely no motion. (In periostitis, which it closely re- sembles, there is greater swelling and redness and the protrusion of the eye and the limitation in its movement is in but one direc- tion.) The conjunctiva is chemosed and the cornea completely or partiall}" anaesthetic. Diplopia is usually present and the vision may be greatly impaired from optic neuritis and atrophy. Digital examination will find the tissues firm, tense and very painful to the touch. In extreme cases the eyeball may become involved and end in panophthalmitis. Causes. — Various and frequently obscure. May be metastatic from phlebitis, septicaemia, puerperal fever, etc. It is often co- incident with facial erysipelas. May result from cold, from in- juries, periostitis and inflammation of the lachrymal gland. Prognosis. — Is always serious as vision may be lost from neur itis, slough of the cornea, or panophthalmitis. It may terminate fatally through meningitis and abscess of the brain, though the large majority recover. Treatment. — When due to a foreign body, \\. should be re- moved, and the ice bag employed to subdue if possible the inflam- CELLULITIS ORBITS. 1 43 matory symptoms. But if suppuration has already set in, poultices should be applied to promote the discharge of pus, which should be evacuated at an early period, by a free incision through the conjunctiva if practicable, if not, through the lid itself. Care should be taken that the pus has free vent at all times. Noyes {loc. cit.) advises an early incision, even before pus forms, claim- ing its value " as a means of arresting the phlegmonous inflam- mation and the formation of pus." as by the incision " the oculo- orbital fascia is relieved, the vessels are unloaded, serum finds vent and the tissues are relaxed." Diet and rest should be pre- scribed according to the general tone of the patient and severity of the attack. Rhus tox. — This is a remedy of the very first importance in this form of inflammation. The lids are cedematously swollen, as well as the conjunctiva, and, upon opening them, a profuse gush of tears takes place. The pains are especially severe at night, vary in character and may be greatly influenced by any change in the weather. Panophthalmitis is liable to complicate the trouble. Hepar sulph. — Especially after pus has formed. Lids swollen and very sensitive to both touch and cold. The pains are usually of a throbbing character. Phytolacca. — Inflammation of the cellular tissue of the orbit without much pain, slow in its course and with little tendency to suppuration. The eye will be protruded and the infiltration into the orbit and lids will be hard and imyielding to touch. Aconite. — In the first stage, when the lids are much swollen, with a tight feeling in them; chemosis, with much heat and sensi- iivejiess in and around the eye, and a sensation as if the eyeball were protruding, making the lids tense, associated with the gen- eral Aconite fever. Apis mel. — Before the formation of pus. Lids cedematously swollen, with stinging, shooting pains. Patient drowsy, without thirst. Lachesis. — Orbital cellulitis following squint operation, point of tenotomy sloughing, with a black spot in the centre; chemosis, and much discharge, with general Lachesis condition. Mercurius. — In the later stages after pus has formed, and even after it has discharged for some time and has become tJiiji in 144 DISKASKS OF THE ORBIT. character, especially if occurring in a syphilitic subject. There is often much pain in and around the eye, always worse at night. Other remedies may be thoug^ht of, as Ars., Bell., Bry., Kali iod. , Sil., Sulphur. Tenonitis. — Inflammation of the capsule of Tenon is a com- paratively rare disease which may follow operations for strabis- mus and less frequently occurs idiopathically, especially in those of a rheumatic diathesis. Symptoms. —There may be slight swelling of the lids, chemosis of the conjunctiva, exophthalmos and diminished mobility of the eye. Pain more or less severe, especially on pressure or movement of the eye, is apt to be present. , Treatment. — Internal medication is all sufficient in this disease and the most serviceable remedies 2.x^ Kalmia lat., Kali iod. , Rhus and Puis. Periostitis Orbitae. — Inflammation of the orbital periosteum may result from injuries or occur idiopathically in rheumatic, syphilitic or scrofulous subjects. The disease is most commonly found in early life and its usual location is the margin of the orbit. Symptoms. — There is present pain, especially from pressure on the bone, oedema of the lids, chemosis and a tense, .swollen, sensi- tive spot in which fluctuation may be detected later. In the acute form there may also be fever, vomiting, delirium, etc. Periostitis in its acute form resembles very closely a phlegmonous cellulitis, and must be differentiated by the acute pain on pressure upon the orbital margin ; by less swelling and redness of the lids ; the in- flammation is more circumscribed, so that the displacement of the eyeball is in one direction and its mobility is more restricted in one direction. In the chro7iic form of periostitis there is simply slight swelling of the upper lid and supra- orbital pain, together with localized swelling at the seat of the inflammation. This is the more fre- quent form, and especially found in young scrofulous subjects. Course. — When chronic, it is very tedious, lasting months or years, and is apt to result in caries of the bone, fistulae, deformity of the lids, etc. In the acute form, if the abscess is near the sur- face and promptly opened, it may heal in a short time ; but if deep CARIES AND NKCROSIS. I45 and neglected, or if occurring in one of a syphilitic or scrofulous constitution, will usually be much more serious. Prognosis. — When near the orbital margin it is favorable, but if deep in the orbit it is much less so, as it may result in atrophy of the optic nerve, paralysis of the orbital muscles, or meningitis. Treatment. — See Caries. Caries and Necrosis of the orbital walls is almost universally a result of periostitis or an injury, although it may occur in the bone itself without a previous inflammation of the periosteum, especially in syphilitic or scrofulous subjects. After the abscess has opened, a fistula is formed which leads to the roughened and denuded bone. The discharge of pus through the fistula has the peculiarly fetid odor of osseus caries. The general symptoms of periostitis are present in caries, and, in addition, the diseased bone can be detected by the probe. Caries is most commonly found in children and necrosis in adults. Treatment. — The general plan of treatment is very similar to that recommended for cellulitis, as we should at first endeavor to prevent destruction of tissue, but, if that does occur, give the pus free vent. If the bone should be diseased the opening must be kept open and an injection of a solution of carbolic acid i to 100, or of the sulphate of zinc gr. x to 5J may be used with advantage. If any of the loose pieces of the bone are discovered they should be removed. The remedies described under cellulitis are also applicable to this disease ; in addition to which we note the fol- lowing : Kali iod. — This form of potash is one of the most important remedies we possess for periostitis. It is especially adapted to the syphilitic variety, though useful when dependent upon other causes. The pain is usually marked, though may be absent en- tirely. The lids will often be oedematous. The crude salt in large doses has seemed to act more rapidly than the attenuations. Aurum. — For both periostitis and caries, when depejideni upon or complicated with a mercurio-syphlitic dyscrasia; also useful in strumous subjects. The pains are tense, and seem to be in the bones, are worse at night, bones sensitive to touch and the patient is excessively sensitive to pain. Mercurius. — As described under cellulitis, will be found very 10 146 DISEASES OF THE ORBIT. useful in both periostitis and caries, particularly when dependent upon S3^philis, as the nocturnal aggravation is very marked under both the drug and disease. The different forms are employed according to general indications. Silicea. — Its action upon diseased bones renders it especially valuable in caries of the orbit. The roughened bone and moder- ately profuse yellow-white discharge are the principal indications, though the weakened general condition, relief from warmth and other concomitant symptoms will be present. Calc. hypophos. — In appreciable doses, has been used as a "tissue remedy" in scrofulous subjects, apparently with good results. The following remedies ma}^ be required: Asaf., Calc. carb.. Fluoric acid, Hecla lava, Lyco., Mezer., Nitr. ac. Petrol., Phos- phor, and Sulphur. Empyema of the Frontal Sinus is extremely rare. The cause is uncertain. It may occur at any time of life, except in young children. The early swelling and distension are unnoticed, but it finally perforates the bony wall and a swelling appears at the upper and inner angle of the orbit, causing epiphora, dis- placement of the eye downward, foreward and outward, with diplopia. The patient may have had headache for a long time, or it may have caused but little discomfort. Treatment. — Similar to that given for cellulitis and perios- titis. Tumores Orbitae. — In the orbit may be found both benign and malignant tumors, which may have developed primarily in the orbit, in some of the neighboring sinuses such as the antrum or ethmoidal, or have spread from the eyeball or face. They usually cause more or less exophthalmos and restriction in the mobility of the eye; the displacement of the eye depends upon the location of the growth. The eye may suffer from inflamma- tion, the optic nerve may become inflamed or atrophic, the retina detached, etc. The examination should be directed to the degree and direction of the exophthalmos; to the impairment in motion, whether in one direction or all; to the feel of the growth, its smoothness, mobility, solidity, pulsation, fluctuation, etc. TUMORES ORBITS. I47 We note the effect of pressure upon the eyeball, if it causes pain on being pushed backward, or if the position of the tumor is altered. We inspect the nostrils, the pharj'nx, the frontal and maxillary sinuses. The tumor may be explored with the hypo- dermic syringe. The history of the case should be elicited for hereditary tendency, the progress of the growth whether slow or rapid, whether associated with pain or not. All these points and many more should be considered, as an aid to diagnosis, prog- nosis and treatment. Nearly all varieties of tumors may be found in the orbit, viz.: Osteoma, naevi, angioma, lipoma, fibroma, cysts (dermoid or hydatid), neuro-fibroma, l^^mphoma, sarcoma, scirrhus, encephalocele, epithelioma, etc. Treatment. — The most approved method of treatment of all tumors of the orbit is to remove them as early as possible, en- deavoring to save the eye whenever sight is present, unless it be a malignant growth and there is danger of not removing the whole of the tumor without sacrificing the globe; in which case it is usually better to remove all the contents of the orbit. A careful diagnosis must be made before operating, in order to aid in the operation and prevent the opening of a vascular tumor. Electricity is of great value in removing vascular tumors of the orbit. When the growth is small the negative pole may be ap- plied by a sponge to the temple, but if large both poles should be attached to platinum needles, two or three inches in length, which are then to be inserted into the tumor. The positive needle should remain in one position while the negative may be inserted at different points for a few moments at a time. Care should be taken to make the first sitting brief, from fear of a too severe in- flammator}" reaction. Our remedies are the same as for tumors in other portions of the body, though we would especially mention Thuja and Kali iodata, which have been of service in some cases. Wounds and Injuries of the Orbit may prove serious from inflammation of the orbital tissue, or periostitis, which they ma3" cause. Penetrating injuries from knives, shot, pitchforks, etc., cause laceration of the soft parts. Injury causing fracture of the orbital walls may prove more or less serious according to the location and extent of the fracture; a slio^ht lesion of the orbital 148 DISEASKS OF THK ORBIT. margin may heal without trouble; in fracture of the frontal or ethmoidal cells we will usually have emphysema of the orbit and lids, due to an entrance of air into the cellular tissue. If the in- jury has occurred in the vault of the orbit, we may have a serious inflammation of the brain- or its. membranes. Frac- ture of the roof of the orbit has frequently been found with a fracture of the base of the skull. Out of 86 cases of fracture of the base of the skull, fracture of the orbital roof was found in 79.* Haemmorrhage into the cellular tissue is very apt to occur in all injuries or wounds of the orbit, hence exophthalmos is usually present. Foreign bodies of large size have frequently remained imbedded in the orbital tissues for a long while without creating any material disturbance. Treatment. — When a foreign body has penetrated the orbit it should be removed as soon as possible, after which cold compresses of calendula in solution, or the ice bag should be applied. Injuries with an effusion of blood into the orbit, causing the eye to protrude, will be benefited by a cold compress and a firm bandage. In emphysema of the orbit and lids a compress ban- dage will be required. Morbus Basedowii (^Exophthalmic Goitre, Graves' Disease'). Symptoms. — The main symptoms of this disease are : rapidity of the, heart's action, enlargement of the thyroid and protrusion of the eyes, although any one of these symptoms may be absent, The acceleration of the heart's action is the earliest, most constant and essential symptom, and this may reach from 100 to 200 beats per minute and may be weak and irregular. Linnell \ in an excellent paper on this disease calls attention to one case in which there was no change in the pulse beat, whether sit- ting or standing, the usual variation returning as the case im- proved. The heart symptoms are usually first developed, followed later by the enlargement of the thyroid and the exophthalmos either simultaneously or in succession. The goitre may develop suddenly, has a soft, elastic feel, a visible pulsation, and a systolic murmur on auscultation. The enlargement of the thyroid and the *BerUn: Graefe and Saetnisch, Handbuch der Augenheilkunde, 1880. t Trans. Amer. Inst. Homoe., 1892. MORBUS BASEDOWII. 1 49 exophthalmos are originally due to vascular engorgement. The exophthalmos is almost universally bilateral, though it may be confined to one side. The degree of protrusion varies. It may be so excessive that the lids are unable to cover the eyes, and ulcera- tion of the cornea may result from the exposure. The protrusion is straight forward, causes no interference with the movements of the eyes, and the eyes may be pressed back into their normal posi- tion, but will become prominent again on relief of the pressure. The exophthalmos gives the patient a frightened, staring appear- ance. On turning the eyes downward the upper lid does not fol- low it at all, or moves along for a certain distance and then re- mains stationary. This peculiarity, called Graefe's sign, because first noticed by him, is of much diagnostic value, because highly characteristic of this disease, and is rarely found in exophthalmos from any other cause. Other symptoms of this disease are dyspnoea and excessive nervousness. There is usually excessive nervous excitability and tremulousness of the hands. The dispo- sition is often changed. The patient is easily frightened and flushes readily. Epistaxis or haemorrhage from other parts may occur. Dilatation and pulsation of the retinal arteries has been ob- served. Anaemia is often present, and in women may be asso- ciated with menstrual disturbances ; rapid emaciation may occur in some cases. Course. — The disease as a rule is very chronic, lasting for sev- eral years with frequent temporary improvements and relapses ; the symptoms may then gradually subside, though often some en- largement of the thyroid or exophthalmos will remain perma- nently. Rarely death occurs in this disease, especially in men in advanced life, from organic disease of the heart or exhaustion. The majority of these cases, however, practically recover. Causes. —Basedow's disease is much more often found in women than in men, some authorities claiming that over 85 per cent, of all cases are found in women. The majority of cases occur between the age of puberty and thirty in women, while the average age in men for the appearance of this disease is from thirty to fifty. This disease has at various times been attributed to a disease of the sympathetic, to rheumatism, etc., and, while its cause has not yet been definitely demonstrated, it will probably be found in I50 DISKASES OF THE ORBIT. some central lesion located in the gray matter of the third and fourth ventricles, the vaso-motor centre and the origin of the pneumogastric. It is generally brought on by some mental shock, by exhaustion from disease, excessive haemorrhages, or severe labor. Treatment. — To promote a permanent cure, rest, especially in the country ; freedom from all excitement, especially emo- tional ; exercise in open air ; a generous diet, and abstinence from all stimulants, are particularly required and should be insisted upon whenever practicable. Galvanization of the sympathetic in the neck has been followed by very good success in many instances, especially when combined with internal medication. Amyl nit. — Cases have been entirely cured by olfaction of this drug alone. The eyes are protruding, staring, and the conjunc- tival vessels injected, as well as those of the fundus. Especially indicated when there are frequent flushes of the face and head, oppressed respiration, etc. BadiagO. — Exophthalmic goitre, with aching pain in the poste- rior portion of the eyeballs, aggravated on moving them, accom- panied by tremulous palpitation of the heart and glandular swell- ings. The pulse is rapid and irregular. Cactus grand. — Cases of exophthalmic goitre have been im- proved, when prescribed on the heart symptoms. Ferrum. — Both the iodide and acetate have been followed by favorable results, especially when the disease comes on after the suppression of the menses ; protruding eyes, enlargement of the thyroid, palpitation of the heart and excessive nervousness. Linnell found good results from the simultaneous use of Iron and Digitalis in one case, after both had been tried separately with no benefit. Lycopus virg. — ^Judging from its provings, in which" we find a rapid, irregular, intermittent and very compressible pulse, together with a bellows murmur over the heart and large vessels, it should be a valuable remedy in this disorder. Linnell (yloc. cit. ) rep )rts very gratifying results from the use of this remedy. Spongia. — Exophthalmos, enlargement of the thyroid and palpitation of the heart, great uneasiness and easily frightened, especially at night ; stitches in the ball and burning around the eyes, with lachrymation in the light ; the eye feels twisted around ; MORBUS BASEDOWII. I5I chromopsies, especially deep red, and photopsies, even when the e3^e is closed at night^ — all indicate this drug, which has proved serviceable. Mr. Hulke"^^ recommends Aconite, and Dr. Samuel Wilks Belladonna. Nat. viur. and Baryta carb. are reported to have cured well- marked cases. Other remedies which have been recommended are Ars., Bell., Brom., Calc, lod., Phos., Sil., Sulph. and Veratrum alb. and viride. * Trans. Ophthal, Soc, Vol. VI. 152 AFFECTIONS OF THE OCUI.AR MUSCIvKS. CHAPTER X. Affections of the Ocular Muscles. Anatomy. — The movements of the eyeball are carried on through the action of six voluntary muscles; four of these passing directly from their origin, around the optic foramen, to their in- sertion in the sclerotic, are called the recti muscles. These muscles are inserted at varying distances, from 5.5 to 8 mm. from the corneal margin, and are distinguished by their relations to the eyeball, as internal, external, superior and inferior rectus. The insertion of the internal rectus is the nearest to the corneal margin, and that of the superior rectus is the most posterior. The remaining muscles, from their taking a curved direction around the eyeball, are known as the superior and inferior oblique muscles. The superior oblique arises at the optic fora- men, passes forward along the upper part of the inner orbital wall to a pulley attached at the superior-internal angle at the front of the orbit; from here it is reflected backward and outward be- tween the superior rectus and the eyeball, and is inserted into the sclerotic, 16 to 18 mm. from the corneal margin on the posterior and outer part of the globe, between the superior and external recti. The inferior oblique arises from the inner and anterior part of the floor of the orbit and passes outward and backward be- tween the inferior and external recti and the globe, and is inserted near the superior oblique, between the superior and external rectus, 17 to 19 mm. from the corneal margin. The internal, superior and inferior recti and the inferior oblique are supplied by the third 7ierve (oculomotorius), the superior oblique by they^2^r/'^ (patheticus) and the external rectus by the sixth (abducens). The action of all these muscles is to turn the eye around a point, called the centre of rotation , situated on the antero-posterior axis of the globe, about 14 mm. behind the anterior surface of the cornea and about 10 mm. in front of the posterior surface of the ANATOMY 153 sclera. These six muscles form three pairs of antagonistic muscles. The axis of rotation of the internal and external recti is vertical, as these muscles turn the globe directly inward and outward The axis of rotation of the superior and inferior recti is horizontal, although not exactly straight across; it forms an angle of 67° with the visual axis, the nasal end of the line being in front of the temporal and is the axis of elevation and depression. The axis of the superior and inferior oblique is also horizontal, forming an angle of 38° with the visual axis, with the temporal extremity in front of the nasal, and the movements about it are those of rotation. (Fig. 47. ) Fig. 47- Axes of ocular muscles. Taken singly, the muscles act as follows: The internal rectus draws the cornea directly inward (adduction), the external rectus turns the cornea directly outward (abduction), the superior rectus turns the cornea upward and slightly inward, the inferior rectus turns the -cornea downward and slightly inward, the superior 154 AFFECTIONS OF THE OCUI.AR MUSCLES. oblique, taking its point of action from the pulley through which it passes, turns the cornea downward and outward and rotates from above downward; the inferior oblique turns the cornea up- ward and outward and rotates it from below upward. Each movement of the eye results from the combined action of certain muscles, and there is never a period at which one or the other is entirely inactive, as by its living and elastic tension it aids in guiding a definite movement, even though it docs not take part in it. In looking directly upward both the superior rectus and inferior oblique are brought into action, the inclination inward of the former being counteracted by the outward tendency of the latter, and so in all other movements of the eye the action of all the muscles must be considered. Paralysis of any one muscle will cause all movements of the eye to be less sure. The function of the ocular muscles is to secure single vision with the two eyes by directing both eyes to the point of fixation in such a manner that the image of the object fixed shall fall simultaneously on the macula luteaof each eye. When this is done, all objects lying in the same horopter will form images upon the respective retinae which will be equidistant from the fovea centralis and will, therefore, be appreciated as single, giving what is called binocular vision. The horopter, as described by Miieller, is represented by a circle which passes through the centres of rotation of each eye and through the apex of the point of fixation of the visual lines. All objects beyond or inside the horopter will cast images on parts of the retinae not equidistant from the fovea and will create the im- pression of two objects or double vision; for example, holding two pins in the same line, one eight inches and the other twenty from the eyes, on looking at the nearest pin the other is seen double, and vice versa. This double vision of objects not lying in the horopter causes no annoyance, because the mind ignores the im- pression of objects with which it does not concern itself. The symmetrical position of the physiological centres of the retina is the anatomical ground for binocular vision. If a distant object be fixed with parallel lines of vision, to fix an object at one side which throws its image in both eyes at an equal distance from the macula lutea, both eyes must move through an equal angle; con- sequently, equal innervation on both sides is necessary for the PARALYSIS OF OCULAR MUSCLES. 1 55 sj^mmetrical movements of the e3"es. All objects are seen single only when retinal images fall on corresponding points of the two retinae. Homonymous Diplopia. If the visual line of the left eye be directed on an object and there is convergence of the right eye, the image, which would in the left eye be formed on the fovea in the right would fall upon the retina to the inner side of the fovea and would be projected outward to the right of the object fixed, or homonymous diplopia. Heteronymous Diplopia. If there is divergence of the right eye at the time the visual line of the left eye is directed upon an object, the impression from the object fixed would in the right eye fall upon the retina to the outer side of the fovea and when projected outward would appear to the left of the object fixed, causing crossed or heteronymous diplopia. The displacement of the false image is always in the direction which is opposite to that of the deviation of the eye. When the eye deviates inward, the diplopia is homonymous; when outward, heteronymous; when upward, the false image is below, and, when downward, it is above. The false image is the image of the deviating e5^e. Binocular Diplopia is present when the visual axis of one ej^e deviates from the object of fixation. Monocular Diplopia is due to the formation of two images of the same object upon one retina and exists when the other eye is closed. As in binocular diplopia there is one image cast upon each one of the two retinae the diplopia disappears on closing either eye, while if the diplopia persists on closing one eye, it is then monocular. The cause of monocular diplopia is either an anomalous refraction or a double pupil. Paralysis of Ocular Muscles. — We may have one or more muscles paralyzed, and the cause ma3^ be either orbital or intra- cranial; if the latter, it may be along the course of the nerves or in the brain. Lesions of the spinal cord may cause paralysis through fibres which proceed to the brain. Symptoms. — The characteristic indications of paralysis are false position of the eye, limitation and irregularity in motion, and double images. x\s secondary effects, we find dizziness, nausea, headache, incorrect projection of the field of vision and inability 156 AFFKCTIONS OF THE OCUI.AR MUSCLES. to guide the hands or feet aright. Indistinct vision may occur in cases of slight paralysis, where actual diplopia is absent due to an overlapping of images. If only one eye is involved the inclina- tion is to close it. Another peculiar effect is the attitude which the head assumes to obviate the double images. It is turned toward the paralyzed muscle to diminish the diplopia. Causes. — The effective causes are localized periostitis, inflam- mation of the sheath of the nerves, basilar meningitis, haemor- rhages, tumors, degeneration of nerve structure or of the cerebral nerve centres, injuries, diphtheria, rheumatism, draught of air, etc. The majorit}^ of cases of ocular paralysis occur in syphilitic subjects and are most frequently of orbital origin. Paralysis may also be the first premonition of sclerosis of the spinal cord. Both eyes may be affected, and the cause then is intra-cranial and gener- ally basilar. Paralysis may occur at any age and may be tempor- ary or permanent. Diagnosis. — In paralysis the secondary deviation is always greater than the primary, while in concomitant strabismus the primary and secondary deviations are equal. The primary devia- tion is the deviation of the affected eye when the healthy eye fixes, while the secondary deviation is the deviation of the good eye when the affected eye fixes. If recovery does not occur, there follows secondary contraction of the opposing or associated muscle. For example, in paralysis of the right external rectus, from diminished resistance, the right internal rectus will turn the eye unduly inward, and the left internal rectus will also undergo contraction, and, if the right eye looks directly forward, the left will consequently squint inward. This fact in old cases often makes the diagnosis as to which muscle was first affected very difficult. Theoretically the examination of the double images should render the diagnosis easy and accurate, but in practice the inabil- ity of many patients to appreciate and describe the relations of the images, together with secondary contractions and involuntary compensations, makes it oftentimes extremely difficult to attain an accurate chart of the double images. In many recent cases we can tell what muscle is affected without an analysis of the double images. The movement of the eye in the direction of action of the paralyzed muscle is less than normal, and is increased PARALYSIS OF OCULAR MUSCLES. 1 57 in the opposite direction; its movements are irregular and jerky. The image of the affected eye is projected — i. e., seems to the patient to lie — in the direction of the paralyzed member. The in- clination of the head, when present, will be such as to favor the lamed muscle and will be in its line of action. When, however, there is any uncertainity as to the muscle affected, the examination of the double images should always be made. The double images are best detected by having one eye covered with a red glass, and the patient to describe the position and inclination of the two lights (one red and the other white) seen when looking at the flame of a candle eight to ten feet away. The images are to be noted in the different parts of the field as fol- lows: First on the level with the patient's eyes directly in front, then to the right and left, and also at about three feet above and below this level at the centre, right and left. The use of the red glass aids the patient in detecting the two images and at the same time informs the physician to which eye each belongs. Paralysis affecting but one single muscle usually attacks either the external rectus or the superior oblique, because each of these muscles is supplied by an independent nerve. Paralysis of several muscles is usually due to the oculomotor nerve. Ophthalmoplegia totalis is a paralysis of all the eye-muscles. In this the lids droop, the eye is directed forward and immovable, pupil dilated and no power of accommodation. Ophthalmoplegia externa, all but the pupil and accommodation affected. Is more frequent than the former and is always of central origin. Ophthalmoplegia interna, only the pupil and accommodation affected. Conjugate paralysis affects associated movements, as to the right or left, etc., eyes will onl}- follow to the median line. As for ex- ample to the right, and appears as paralysis right externus and left internns. But left internus will converge in median line show- ing only affected in associated movements. The cause is a lesion in the association centres of the nerves. Paralysis may result from a lesion anywhere in the course of the nerve tract, intra-cranial, it may affect the centres in the cortex of the brain (cortical paralysis), the association centers, or the nerve nuclei upon the floor of the fourth ventricle (nuclear par- 158 AFFECTIONS OF THE OCULAR MUSCLES. alysis), or the nerve trunks along the base of the skull (basal paralysis). Orbital paralyses occur from a lesion of the nerve trunk or its branches after its entrance into the orbit. Paralysis, External Rectus. — Paralysis of the external rectus muscle causes a limitation in the outward movement of the eye. In complete paralysis the eye can only be turned but little beyond the median line, while in incomplete it may often go to nearly the normal limit, but with an irregular, jerking motion. The head is turned toward the paralyzed side. The deviation of the affected eye is inward; the diplopia is homonymous; the double images are on the same level and parallel, and the distance between the images increases on looking toward the affected side. The line which separates that part of the field in which there is single vision from that in which it is double is not exactly vertical, but is inclined obliquely, the diplopia extending further toward the healthy side below than above. Paralysis, Superior Oblique. — The restriction in motion is downward and outward, and in complete paralysis of this muscle the motion downward is diminished. The deviation of the affected eye is upward and inward, and the image of the affected eye is in- clined inward at the top, owing to the torsion action of this muscle on the eyeball. The obliquity of the false image is in- creased on looking toward the affected side. The diplopia is homonymous and present only in the lower part of the field. The image of the affected eye is lower than that of the healthy eye, and the difference in height between the two images is increased on looking downward and toward the healthy side. The image of the affected eye generally appears nearer to the patient than that of the healthy eye. The direction of the healthy eye, when the diseased eye fixes, is downward and inward. The line of de- marcation between the true and false images is slightly oblique to the horizontal, the end corresponding to the affected side being lower. The face is inclined downward and to the healthy side. Paralysis, Internal Rectus. — In this, the restricted move- ment is inward, the affected eye is outward, the diplopia is heter- onymous, the double images are parallel and of the same height, the distance between them increases on looking toward the healthy PARALYSIS, SUPERIOR RECTUS. 1 59 side and on looking upward. The line of demarcation between the true and false images is oblique to the vertical, the diplopia extending further toward the healthy side above than below. The face is turned in the direction of the affected eye. Paralysis, Superior Rectus. — The restricted motion is up- ward and slightly inward, the deviation of the affected eye is downward and on looking up is downward and outward; diplopia is slightly crossed and in the upper part of the field the false image is higher than the true, its upper end is inclined to the healthy side; the difference in height between the two images increases on looking upward and the obliquity increases on looking to the healthy side. The line of demarcation is inclined to the hori- zontal, the diplopia extending lower toward the affected side. The face is directed slightly upward. Paralysis, Inferior Rectus. — In this we find the restricted movement is downward, the deviation of the affected eye is up- ward and outward, the diplopia is slightly crossed, especialh^ in the lower part of the field; the false images are lower and inclined toward the affected side; the difference in height increases on looking downward and to the affected side, and the obliquity in- creases on looking toward the healthy side. The line of demarca- tion is inclined to the horizontal, the diplopia extending higher toward the affected side. The face is inclined downward and slightly toward the affected side. Paralysis Inferior Oblique. — The resticted movement is up- ward and outward, the deviation of the affected eye is downward and inward, the diplopia is slightly homonymous and especially in the upper part of the field, the image of the affected e^'e is higher and inclined outward, the difference in height increases on looking upward and inward and the obliquity increases on look- ing to the affected side. The line of demarcation is inclined to the horizontal, the diplopia extending lower toward the affected side. The face is directed upward and slightly toward the sound side. Complete Paralysis of the Third Nerve. — In this there is ptosis, slight exophthalmos, pupil moderately dilated, accommo- l6o AFFECTIONS OF THE OCULAR MUSCI.ES. dation paralyzed; movements are restricted in all directions ex- cepting directly outward; the deviation of the affected eye is out- ward; there is heteronymous diplopia, the false image is oblique and inclined toward the healthy side; it also appears higher than the true image and nearer to the patient. The distance between the images increases on looking toward the sound side, and the difference in height increases on looking upward. The face is inclined toward the sound side and slightly upward. Course. — Paralysis may occur suddenly or develop insidiously. Relapses may occur, and the course is always chronic. Many cases, especially old ones, are absolutely incurable, and in even the most favorable ones six weeks or more are required for a cure. The prognosis depends mainl}^ upon the cause. Syphilitic and rheumatic cases are the most favorable. Treatment. — The treatment varies according to the nature of the cause, which should always receive due consideration in the selection of a drug. Our chief reliance must be on internal medi- cation. Prismatic glasses, to which we frequently resort, may be used for two purposes: i. To relieve the annoying diplopia by giving that prism which neutralizes the double vision. 2. For the pur- pose of exercising the paralyzed muscle by using a weak prism, which nearly fuses the double images, when by the exercise of the will they may be brought together; by daily using weaker and weaker prisms much improvement can be made in restoring the muscle power. Electricity is the most valuable agent for the cure of paralysis, and we should employ the constant current, of from two to three milliamperes. The applications should be made daily for from three to five minutes at each sitting, with the negative pole over the insertion of the muscle and the positive at the occiput. Forcible movements of the eye made by seizing the conjunc- tiva over the insertion of the paralyzed muscle with the fixation forceps, and strongly turning the eye in the direction of action of the weakened muscle and then in the directly opposite direction, has proved of very great value in my hands. Under Cocaine this catises no pain. As a last resort, after the condition has existed sufficiently long to render all hopes of improvement by other means impossible. COMPLETE PARALYSIS OF THE THIRD NERVE. l6l careful tenotomy of the opposing muscle may be performed, with or without advancement of the paralyzed muscle, according to the degree of deviation. To overcome the annoying diplopia in hopeless cases, specta- cles with a ground glass before the paralyzed eye may be em- ployed. Oausticum. — Paralysis of the muscles resulting from exposure to cold. It has been especially successful in paralysis of the sphincter pupillse (mydriasis), of the ciliary muscle, levator pal- pebrae superioris (ptosis), orbicularis, and external rectus. Gelseraium. — A valuable remedy in all forms of paralysis of the ocular muscles, especially of the external rectus. Paresis from diphtheria, or associated with paralysis of the muscles of the throat. Rhus tox. — A remedy often indicated in paralysis of the ocu- lar muscles resulting from rheumatism or exposure to cold, wet weather and getting the feet wet. Causticum is very similar in its action, though it is more especially adapted to those cases result- ing from exposure to cold, dry weather. Aconite. — Paresis from exposure to a draught of cold air. Kali iodata. — The iodide of potassium is more commonly in- dicated than any other drug in paralysis of the muscles of syphilitic origin. Appreciable doses are usually employed. Euphrasia. — Paralysis of the muscles, particularly of the third pair of nerves, caused from exposure to cold and wet; especially if catarrhal symptoms of the conjunctiva, blurring of the eyes, re- lieved by winking, etc., are present. Senega. — Want of power of the superior rectus or superior ob- lique, in which the diplopia is relieved by bending the head back- ward. The other muscles may be complicated in the trouble. Arnica. — Paralysis of the muscles resulting from a blow or injury. Ohehdonium. — Paresis of the right external rectus. Distant objects are blurred, and on looking steadily two are seen. Pain in the eye on looking up. Cuprum acet. — Insufficiency or paralysis of the external rec- tus muscle. Merc. iod. flav. — Paralysis of the third pair, especially if syphilitic in origin. II 1 62 AFFLICTIONS OF THE OCUI.AR MUSCI.KS. Nux vom. — Paresis or paralysis of the ocular muscles, partic- ularly if caused or made worse by the use of stimulants or tobacco. Paris quad. — Paralysis of the iris and ciliary muscle, ivith pain drawing from the eye to the back of the head; or pain as if the eyes were pulled into the head. Eyes sensitive to touch. Phosphorus. — Paralysis of the muscles caused or accom- panied by spermatorrhoea or sexual abuse. Spigelia. — When associated with sharp, stabbing pain through the eye and head. Alumina, Aurum, Conium, Hyoscyamus and Sulphur have also been used with advantage. The Localizing Value of Paralyses of Orbital Muscles in Cerebral Disease. Parai^ysis of the Third Nerve. — Ptosis may be present in cortical lesions without any other branch of the third nerve being paralyzed. Ptosis on the same side as the lesion indicates a disease of the pons, if on the opposite side a lesion in the crus cerebri. Paralysis of the third nerve as a whole is usually present in lesions of the cerebral peduncle. Paralysis of the whole or part of the third nerve on the same side as the lesion, coming on at the same time as crossed hemiplegia, indicates a disease of the crus cerebri. The most frequent causes of oculomotor paralyses are basal lesions and usually affects all of its branches. Complete paralysis of all the branches of this nerve with no other paralysis present is always basal. Lesions in the interpeduncular space may also cause total or partial paralysis of the third nerve. Throm- bosis of the cavernous sinus invariably produces paralysis of the third nerve, but all the orbital nerves and the fifth may also be affected. Paralysis of the Fourth Nerve alone is extremely rare, one case on record where due to tumor of the pineal gland, but is more apt to be of basal origin, and is frequently double. May occur in meningitis, from exudation between corpora quadrigemina and the splenium of the corpus callosum according to Pfungen.* *Wieu. Med. Blatt, Nos. S-ii, 1883. STRABISMUS OR SQUINT. 163 It has been found with paralysis of the third in lesion of the cerebral peduncle. PARAI.YSIS OF THE Sixth Nervk when the only focal sign usually results from basal disease. It is also especially liable to occur from distant pressure, and Wernicke says, particularly from a tumor of the cerebellum. Paralysis of the sixth with hemi- plegia of the opposite side indicates a lesion in the pons. The facial is frequently involved with the sixth in the lesion of the pons. Paralysis of the Fifth Nerve with hemiplegia of the oppo- site side points to disease in the pons. Strabismus or Squint is inability to bring the visual axes of both eyes to meet at a certain point, or when the point fixed casts its image only on the macula lutea of one eye, while in the other it falls on some eccentric part of the retina. If the squinting eye deviates inward, it is called strabismus convergens; if outward, divergens; if upward, sursum vergens, and if downward, deor- sum vergens. The squint in concomitant strabismus differs from that of paralysis in the following points: The primary and sec- ondar}^ deviation are equal in strabismus, while in paralytic squint the secondary deviation is greater than the primary. In strabis- mus the extent of the movement in the two eyes is normal and equal, while in paralysis the mobility of the eye decreases in the direction of action of the paralyzed muscle. Diplopia is gener- ally absent in strabismus, except at the commencement of the squint; but, when present, is found in all parts of the field, and in strabismus there is no particular inclination of the head. Strabismus is usually viono-lateral , that is a faulty position of one e5^e; or it may be alternatijig , when the patient will be able to fixate objects with either eye separately, and when doing so the other eye becomes the squinting one. In alternating squint one eye usually is used to fixate distant objects and the other for near objects. The strabismus may also be inte7inittant or con- stant. Strabismus is not observed after death, during deep sleep or in deep narcosis. Concomitant squint is very seldom accompanied by diplopia. This is believed to be due to a suppression of the retinal image in the squinting eye, for, being that of some object with which the 164 AFFECTIONS OF THF OCUIvAR MUSCIvES. mind is not interested, it is simply ignored at will. Hansell* concludes that, " Amblyopia is congenital and not acquired; is not improved by tenotomy when high or of long duration; is al- ways present in monocular squint; is not a factor in alternating squint; can be replaced by full acuity of vision after the hitherto good eye has been rendered by accident or disease inferior to the squinting eye." Binocular visi07t, according to von Graefe, is absent in about 90 per cent, of the cases of strabismus, that it can be produced by prisms in about 25 per cent., and exists after operation in about 50 per cent. Its presence is proved at once by the existence of binocular diplopia, and when not present it is determined by hav- ing the patient look at the flame of a candle at the distance of six or eight feet through a prism placed before one eye, when either diplopia or a corrective squint will occur, if the prism is not too strong, for the patient will endeavor to overcome the prism by squinting and fusing the images, or if neither of these effects occur, absence of binocular vision is proven. Binocular vision is frequently only lost over certain portions of the retina. The visual acuity of the squinting eye is diminished. This may exist before the development of the squint and may be one of the reasons for squinting. Apparent Strabis?nus is the condition where there is a deviation of the optic axes, and yet both eyes fixate and neither moves when the other is closed. This is due to the relation between the optic axis and the visual line. If the optic axis lies to the outer side of the visual line, we have an apparent divergent squint and, if to the inner side, may have the reverse — an ap- parent convergent squint. Strabismus Oonvergens is the most common form of squint met with, and usually develops between the second and seventh years of life. Diplopia is generally present in all cases which de- velop later than childhood. Causes. — In a great majority of cases it is found to exist in connection with hypermetropia. Bonders first called attention to the relation of hypermetropia to convergent strabismus, and showed it to be present in about 75 per cent, of the cases; other *Journ. Amer. Med. Assoc, Feby. 16, 1895. STRABISMUS CONVERGENS. 1 65 authorities since then have placed it as high as 85 per cent. It has also been estimated that about 16 per cent, of all hyper- metropes squint. It is usualh^ the median or slight degrees of hypermetropia that most often induces strabismus. Hyperme- tropia causes strabismus on account of the normal or physiologi- cal relation between convergence and accommodation; that is, with an increase of convergence the relative range of accommo- dation approaches the eye. All hypermetropic eyes require a strong tension of the accommodation for distinct vision, and hence to aid the accommodation they are inclined to converge too much. As a result of too strong continued convergence the hy- permetrope soon learns to give up binocular vision because he finds he can secure a more distinct image, with less strain on the accommodation, by monocular fixation. In the high degrees of hypermetropia there will be but slight cause for sacrificing binocular vision when, in spite of too strong convergence, distinct retinal images cannot be obtained. In the medium and lower grades of h3^per- metropia there does exist the inclination to exchange binocu- lar vision for monocular fixation when any cause makes binocular fixation less valuable, as in differences in refrac- tion, astigmatism, corneal opacities, etc., affecting only one eye. It has also been found by Schweigger and others that the non- squinting eye does not possess full acuity of vision, and this in- duces squint by an effort to secure by convergence as large an image as possible. Another contributing factor in the causation of convergent squint is an insufi&ciency of the external recti muscles, which arises from the fact that in hyperopia there is a deviation inward of the visual lines, and the constant effort necessary on the part of the external recti to maintain parallelism of the visual lines finally results in insufficiency , which favors strabism us convergens. As other predisposing causes we find constantly working in poor light, excessive use of the eyes for near work, weakened ciliary muscle and constant looking to one side. Con- vergent squint may also be found in myopic eyes, due to a pre- ponderance of the internal recti. Macula of the cornea also cause squint from confusion of the retinal images, which cannot be sup- pressed while falling upon identical points of the two retinae; 1 66 AFFECTIONS OF THE OCULAR MUSCLES. hence the eye turns, in order to throw the image upon some eccen- tric part of the retina where it may be suppressed, and the eye is more apt to turn in on account of the greater strength of the in- ternal rectus. In convergent strabismus amblyopia is usually present in the squinting eye. The amblyopia is considered by some to be a con- sequence of the squint and by others as the cause. It is probable that both views are correct, and that in some cases it is the cause of the squint, while in others the amblyopia results from the squint. It is easy to understand that the squinting eye will become amblyopic from long disuse, and in these cases, where it is a consequence of the squint, it is called amblyopia ex anopsia ; in other cases, where there may be a difference in the degree of the Fig. 48. Lawrence's strabismometer. hypermetropia in the two eyes, the child would naturally use the best eye for vision and allow the poorer eye to turn, in order to more readily suppress the indistinct image. Hence we must con- clude that a slight pre-existing amblyopia in one eye, associated with hypermetropia, will have a tendency to cause convergence, and after the squint has become established the amblyopia may increase from disuse. Strabismus convergens is by far the most common form of squint met with, and is, in the majority of cases, a stationary monolateral squint. The degree of the strabismus can be obtained sufficiently accurate for all practical purposes by means of the strabismometer — an ivory scale shaped to fit the lower lid and graduated in millimetres on its free edge (Fig. 48). It is used by covering the good eye and fixing with the squinting eye, the O on the scale is then placed directly under the centre of the pupil, the good eye is then uncovered and the squinting eye allowed to resume its ordinary position ; the number then exactly under the STRABISMUS DIVERGENS. 1 67 centre of the pupil gives the linear measure of the deviating eye in millimetres. Strabismus Divergens is much less frequently seen than con- vergent squint and generally develops later, after childhood has passed. It is frequently in the beginning periodic, but usually becomes permanent later; it may also be alternating; generally, however, it is monolateral and concomitant, in that the deviation of the affected eye, or primary deviation, will be equal to the devia- tion of the good eye, or secondary deviation. Diplopia is usually present at the commencement of the affection, especially when periodic, but gradually disappears as the condition advances. A spontaneous cure never takes place in divergent squint. Causes. — While convergent strabismus is usually associated with hypermetropia, divergence is, on the other hand, most often associated with myopia. About 65 per cent, of all cases of di- vergent squint are myopic. The myope requires little or no accommodation for near vision, hence impulse for convergence is too weak. With this functional insufficiency of the interni, the increased dimensions of the myopic eye adds a mechanical impedi- ment to convergence. Myopes therefore are predisposed to di- vergence and particularly when one eye has less visual power than the other. As myopia increases the demand for convergence in- creases owing to the approximation of the near point, but the strain upon the accommodation and the impulse to convergence decreases. The convergence finally is no longer able to answer the demand upon it and the eye turns out. This occurs first when, fixating near objects and in some cases never exists except at the near point, but usually later on the eye deviates out at all times. In some cases where there is myopia of one eye and emmetropia or hypermetropia of the other a similar process ensues: the myopic eye will then usually be used for near vision, because it is impos- sible to secure binocular vision for reading, and as the myopic eye can be used without any exertion of the accommodation, it is almost invariably used, while the other e>e is used for distant vision. Macula of the cornea may also cause divergence as well as convergence, if in such a location that suppression of the in- distinct image can be more readily obtained by turning the eye outward instead of inward. 1 68 AFFECTIONS OF THE OCULAR MUSCLES. Strabismus Sursum and Deorsum Vergens are usually seen as a complication of lateral deviation and disappear when the lateral deviation is relieved. A concomitant vertical deviation, however, may occur alone, and, when it does, is increased, if an upward deviation, on looking inward, and if downward the squint is the greatest on looking outward. Diplopia is usually present in cases of vertical deviation. Treatment of Strabismus. — This should first be directed toward preventing the development of the squint. Whenever a tendenc}^ to squint is noticed, the child should be prevented from reading, writing and all near use of the eyes as much as possible. As soon as the child is old enough to wear glasses the refractive error should be corrected. My rule is to wait until they are about five years old, and then to prescribe a glass of about a .25 to a .50 D less than the total refractive error as shown by the ophthalmo- scope, to be worn constantly. The use of atropine to paralyze the accommodation, and thus preventing near vision, if continued for several weeks, will often greatly benefit an inclination to conver- gent squint. If the case is one of permanent strabismus, and an early operation is not desired, the good eye should be covered for a short period daily and the child compelled to use the affected eye. In this way the vision of the squinting eye will be retained. The fact must also be borne in mind in the treatment of conver- gent squint that there is a tendency in some cases to a gradual dis- appearance of the squint as the child grows older, and, when this does occur, it is usually not earlier than the tenth year and often much later. The use of remedies has in the early stages of many cases re- lieved the tendency to permanent strabismus. Oicuta vir. — Indicated in strabismus convergens occurring in children, particularly if spasmodic in nature, or caused- from con- vulsions, to which the child is subject. Jaborandi. — Strabismus convergens, periodic and resulting from spasm of the internal recti; also for the return of squint after operation. If helminthiasis has been the cause, Cina, Cyclamen or Spigelia may be required. If due to spasms, convulsions, or any intra- cranial disorders, Agar., Bell., Eserine, Gels., Hyos., Nux or Stram. would be first suggested to our minds. OPERATIVE TREATMENT FOR STRABISMUS. 1 69 Operative Treatment for strabismus ma}^ be by either tenotomy of the contracted muscle, advancement of the weak or opposing muscle, or b}^ both combined. The operation for the relief of squint was first suggested b}^ Taylor in the seventeenth century; his method, however, was unsuccessful, and, consequently, abandoned. In 1839, DiefFenbach made the first successful operation for squint; the method practiced by him was to divide the belly of the muscle instead of its tendon, thereby greatly impairing the action of the muscle and often causing the eye to turn in the opposite direction. At a later period von Graefe placed the operation upon a scientific basis by suggesting the division of the tendon instead of the body of the muscle, and his operation, with some slight modifications, is the one in more common use at present. As to the time when the operation should be made, my preference is to wait until the child is ten years of age, unless it is a very pronounced permanent squint, when a tenotom}^, aiming to correct only a portion of the squint, may be made at a much earlier age. A simple tenotomy corrects a convergent squint of three or four millimetres, but in divergent squint not more than two milli- metres. As the effect of the operation in divergent squint de- creases afterwards, the attempt should be made to get an over- correction. To correct a divergence it is usually necessary to make the tenotomy in both ej^es and often an advancement is also needed. As to the advisability of operating on one or both eyes at the same sitting, authorities seem to be about equally divided. It is, however, always m}" rule to operate upon but one eye at a time, taking at first the eye with the greatest deviation and making a free division of the muscle, and a few weeks later making a second operation upon the other eye, if needed. Previous to operating we should determine the cause of the squint, the vision, the rela- tive power of the muscles, and the degree of the deviation in each eye. The technique of the operation is the same, irrespective of the muscle operated upon. The result to be obtained from the operation is merely cosmetic, as the vision in the squinting eye is not improv^ed and binocular vision is only restored in a few instances. Tenotomy of the Internal Rectus. — As this operation is quite painful, an anaesthetic should be used. Four to six instillations of lyo AFFECTIONS OF THE OCUI.AR MUSCLES. a 4 per cent, solution of cocaine at intervals of about five minutes renders the operation painless, and is to be preferred to a general anaesthetic because we are better able to judge of the effect accom- plished. In young or excessively nervous subjects, ether or chloroform may have to be used. The instruments required are a speculum, fixation forceps, curved scissors and strabismus hook (Figs. 49 to 53). The lids should be widely separated by the Fig. 49. Fig. 50. Fig. 51. Fig. 52. Fig. 53. Mittendorf 's speculum. Fixation forceps. Steven's hook. Blunt-pointed, curved strab- ismus scissors Strabismus hook. Speculum; the conjunctiva and subconjunctival tissue directly over the insertion of the muscle to be divided is seized with the fixation forceps, and with a pair of curved, blunt-pointed scissors, make a vertical cut down to the muscle, which is then separated from the subconjunctival tissue by dissecting backward with the TENOTOMY OF INTERNAL RECTUS. 171 scissors as far as it is desired to have the muscle slide for its re- attachment. The strabismus hook is now to be introduced behind the muscle at its lower edge, and, with the point pressed against the eyeball, turned upward beneath the tendon, which is then to be divided close to its insertion by cutting from the point to the base of the hook. The hook should then be inserted again to see if all the lateral expansions of the tendon have been divided; but too frequent and extensive excursions of the hook should be avoided, as it tends to increase the inflammatory action. Care must be exercised that too extensive dissections of Tenon's cap- sule, both above and below the muscle, are not made, as the cap- sule of Tenon serves as a secondary attachment for the ocular muscles, and, if too freely separated from the sclerotic, the effect of the operation may be too greatly increased and the power of the muscle so much affected that it will have little or no action upon the movements of the eye. The sinking of the caruncle is also the result of a too free dissection of Tenon's capsule. The use of the suture to limit the effect of the operation, if too extensive, may be necessary; it is introduced through the con- junctiva at the margin of the cornea and then through the con- junctiva over the muscle. In convergent strabismus, with good vision in both eyes, the patient should be able after the operation to fixate and hold the eyes on an object at a distance of about six inches, but if the operated eye ceases to converge, or begins to diverge at eight inches, ultimate divergence may be expected. If the vision is poor, or the muscles weak, a convergence at eight or ten inches is sufficient. Diplopia, with the images near together for two or three da3^s after the operation, is not unfavorable, as it is usually due to the inflammatory action and disappears as the inflammation subsides. The effect of an operation for convergent squint may be in- creased, if desired, by a strong suture passed through a fold of the conjunctiva at the outer side near to the cornea, and then carried through the skin at the external canthus, one end above and the other below, about one-eighth of an inch apart, and then tied; or they may be fastened to the skin by strapping. The eye is thus held in the proper position for two days, when the muscle should have become reattached and the suture removed. Subco7ijunctival Tenotomy is preferred by some to the operation 172 AFFECTIONS OF THK OCUI^AR MUSCI.ES. just described. This is made by snipping the conjunctiva along the lower edge of the insertion of the muscle with blunt straight scissors (Fig. 54). The subconjunctival tissues are then separated over the muscle and the strabismus hook inserted, catching up the muscle on the hook. The scissors are now introduced, one blade in front and the other behind the muscle, which is held on the stretch by the hook, and it is di- vided subconjunctivally. Advancement of the Muscle is designed to increase the power of a muscle by shortening it. This operation is useful in cases of Fig. 54. Blunt-pointed straight scissors. extreme divergence and especially in those cases where the oper- ation for convergent strabismus has resulted in a deviation in the opposite direction, and hence the internal rectus is the muscle most frequently advanced. A tenotomy of the opposing muscle is usually necessary and is generally made at the same time. In advancement of the internal rectus the conjunctiva over the tendon is divided as for tenotomy. The conjunctiva between the cornea and the opening is separated from the sclerotic with the scissors. The tendon is then caught upon the hook and held by an assistant. A suture is next introduced from the upper margin between the tendon and the sclerotic, and passed through the ten- don at the median line some distance back of its insertion. Another suture is passed through the tendon from below in the same way. Each suture is then firmly tied on the tendon, a long end being left to each. (See Fig. 55.) The tendon is now to be divided at its insertion, and the sutures passed forward under the conjuncti- val flap, the upper to the upper margin of the cornea and the lower to the lower margin. The sutures are then tied separately; the tighter they are drawn the further is the tendon advanced. The operation for advancement devised by Stevens and described on page 184 under heterophoria is a particularly neat and simple NYSTAGMUS. 1 73 Operation where but little effect is desired, but where great efifects are required we have found the single suture is apt to cut through from the excessive tension. The After-Treatment. — Simple tenotomy creates no serious re- action, and the patients are allowed to return to their homes and to use their eyes as much as is desired. The use of the ice bag, bathing the eyes in cold water or a solution of calendula gives some relief of the soreness experienced for the first day or two. No bandage should be allowed (except while returning home from the operation), for with protection of the eyes there is not that incentive to parallelism of the visual axes which occurs when the eyes are being used. The advancement of a muscle is accom- panied by considerable pain and swelling, which is usually con- trolled by keeping the patient in bed wnth both eyes bandaged, the ice bag applied locally and Aconite given internally. Fig. 55- Operation of advancement. Nystagmus {Oscillation of the Eyeballs). — These movements are involuntary, exceedingly rapid, almost rhythmical and affect both eyes at the same time. The mobility of the eye is not other- wise impaired. The oscillation is generally in the horizontal direction, but may be rotatory, vertical, or in the direction of a sin- gle muscle. It is usually permanent, but may be periodic and in some positions of the eye may have a point of rest. Nystagmus 174 AFFECTIONS OF THE OCUI.AR MUSCI.ES. is increased in near vision and from excitement; in some cases it is complicated by similar movements of the head, but in an oppo- site direction. The sight is always impaired, but objects are seen as they are by the patient. Nystagmus is not infrequentlj^ asso- ciated with squint. Causes. — Generally occurs in early childhood and is princi- pally the result of amblyopia, as in congenital opacities of the cornea, congenital cataract, or total blindness. Nystagmus may be a symptom of cerebral disease, especially disseminated sclerosis. The nystagmus of miners is a peculiar form of this affection, which first comes on while working in the darkness of the mines, and, as it progresses, lasts through the day, but increases as twi- light comes on and has often associated with it night-blindness. These patients are often made dizzy and greatly annoyed by the apparent movement of objects. This form of nystagmus is due to the work done in an insufficient light and with the eyes turned in an unnatural position and often disappears on giving up their work in the mines. Prognosis. — When once developed, it generally remains, al- though it may diminish somewhat in advanced life. Treatment. — If strabismus coexists with nystagmus, tenot- omy of the contracted muscle should be made. If there is any anomaly of refraction, it must be corrected with glasses. Agaricus. — Very useful in all spasmodic affections of the mus- cles of the eye, especially if associated with spasm of the lids, or general chorea. Twitchijigs of the lids varying from frequent winking to spasmodic closure of them. Twitchings of the eyeballs with various sensations in and around them, chiefly pressing and aching. Eyeball sensitive to touch. The spasmodic movemerits are absent during sleeps but return on waking and may be tran- siently relieved by washing in cold water. Belladonna. — -If accompanied by headache and hyperaesthesia of the senses. Hyoscyamus. — Spasmodic action of the eyeballs. Ignatia. — Morbid nictitation and spasmodic affections occur- ring in nervous, hysterical women. Jaborandi, Physostig., Nux, Puis, and Sulph. have also been used with benefit, as may any of that class of remedies denomi- nated our antispasmodics. MUSCULAR ASTHENOPIA. 1 75 Muscular Asthenopia. — This term is applied in a general way to various tired and strained sensations about the eyes and head resulting from insufl&ciency of some of the extrinsic mus- cles of the eye. Special attention was first directed to this sub- ject by von Graefe, which until within a few years had received but meagre attention and had been applied especially to an insuf- ficiency of the internal recti muscles. Within the last five or ten years, however, hardly a number of our current ophthalmological literature has appeared without containing more or less reference to some of the muscular anomalies. To Dr. George T. Stevens is due the credit of having been the one to first turn the present attention of ophthalmologists in this direction, and, while we can- not accept in full his methods of treatment, must acknowledge that by his efforts researches in this line have been greatly ad- vanced and stimulated. An exhaustive consideration of the in- sufficiencies of the ocular muscles is of course impossible within the limits of an ordinary text-book, and it is for this reason, pre- sumably, that none of the more recent works upon the eye give this subject the attention that it should receive. It is a well recognized fact that defects of the ocular muscles can and do cause various reflex disorders, such as vertigo, gen- eral nervous excitements, gastric derangements, neuralgic pains of the back, head, etc. On the other hand, mau}^ asthenopic symptoms of the eye may be the effect of some remote disorder such as uterine disturbances, etc. In treating of muscular asthenopia we shall adopt the terms suggested by Dr. Stevens as more accurately describing the various forms of insufficiency, viz.: Orthophoria: Normal adjustment of the eye muscles. Heterophoria: Abnormal adjustment of the eye muscles. Esophoria: A tendenc}^ of one or both eyes to deviate toward the nose. Exophojda: A tendency of one or both eyes to deviate toward the temple. Hyperphoria: A tendency of one eye to rise above the level of its fellow. Hyperesophoria: A tendency up- ward and inward. Hyperexophoria: A tendency upward and out- ward The designation ' ' right "or " left ' ' must be applied to these two terms. The examination for heterophoria may be practiced by a num- ber of methods. Stevens' Phorometer (Fig. 56). In this test the patient, while 176 AFFECTIONS OF THE OCUI^AR MUSCLKS. holding the head erect, looks at a lighted candle at the distance of twenty feet, which should be upon a level with the eyes. Then with the refractive error, if any, corrected, prisms of sufficient power to produce diplopia are placed with the base inward before Fig. 56. Stevens' phorometer. each eye. The images thus produced are homonymous, and, if seen exactly on the same horizontal plane, there is no tendency to a vertical deviation. If, however, one image is higher than STEVENS PHOROMETER. 1 77 that of the other, there is absence of the vertical equihbrium, or hyperphoria. If the left image is higher than the right, it indi- cates that the visual line of the right eye has a tendenc}- to rise above that of the left; this is right hyperphoria. If the right image is seen above that of the left, it is known as left hyper- phoria. The degree of the deviation is shown by the prism, which, when placed with the base up or down before one e3'e, brings the two images exactly on the same horizontal plane. Diplopia is again induced by placing a prism with the base up or down before one eye, and, if the two images are now exactl}^ ver- tical, no deviation in the horizontal plane is shown. A prism of 7° is usually sufficient to cause vertical diplopia when placed with the base up or down before one ej^e. Say, with the base down before the right eye, if now, the upper image appears more at the Tight than the lower, it indicates esophoria; but, if the upper image is to the left of the lower, exophoria is shown. The degree of the horizontal deviation is shown by the degree of the prism which, when placed with the base in or out bef .re either eye, brings and holds the images in a vertical line. In the Stevens instrument the degree of the deviation is found b}' rotating the test prisms. The amount being indicated on the scale on the face of the prisms. Examination should then be made in the same way at the dis- tance of eighteen inches to determine the condition of the mus- cles in accommodation, and for this purpose a small white cross on a black background is used in the Stevens' phorometer. Man}' oculists claim the examination as to the muscular bal- ance in accommodation is of no consequence. This the writer believes to be a grave error, as in the very large majority of cases the troubles complained of are only present, or at least markedly worse, when using the eyes at near vision. There is no question but that the muscular balance in the majority of instances is de- cidedly different in accommodation than it is in distant vision, and as the eyes are used for a large percentage of the time at near vision the condition of the muscles in accommodation is, there- fore, of the utmo-t importance. The Maddox Test is made by a small glass rod, which may be mounted or held in the hand, and, for hyperphoria, is held exactly vertical before one eye. A red glass may be placed before 12 178 AFFECTIONS OF THE OCUI.AR MUSCLES. either eye to more clearly show the two different objects, the line of light and the flame. When looking at the lighted candle, a long horizontal line of light is seen by the eye in front of which the rod is held, while the other eye sees the natural light. Now, if the line of light passes exactly through the centre of the flame, as seen by the other eye, there is no hyperphoria present; but if above or below, then hyperphoria is shown, and the degree is rep- resented by the prism which causes the line of light to pass directly through the centre of the flame. The rod is now turned horizontally in front of one eye, causing a vertical line of light which, if passing directly through the flame, shows orthophoria of the lateral muscles; if the line is to the same side as the eye before which the rod is held, it indicates esophoria; if to the op- posite side, exophoria, and the prism which brings the vertical line of light directly through the flame indicates the degree of esophoria or exophoria. This we believe to be the most reliable test for muscular insufficiency at present devised. The Savage Test for Insufficiency of the Oblique Muscles. — Occa- sionally cases of undoubted eye-strain are met with which are not relieved even after the most careful correction of the refractive error or of any of the already named forms of heterophoria. These cases may be due to an insufficiency of one of the oblique mus cles, a condition easily detected by Savage's test; but if found, there has been at present no satisfactory suggestion offered as to treatment. In testing, a double prism of six degrees each, base to base, is held with its axis vertical before one eye and the patient re- quested to look at a horizontal line on a card eighteen inches away. With the other eye covered, the line appears to be two, each parallel with the other; on uncovering the other eye, a third line is seen between the other two, with which it should be ex- actly parallel. If there is any loss of balance between the oblique muscles, this test will show a lack of parallelism of the middle line with the other two, the right end of the middle line will point to the low^er line and the left end to the upper line, or vice versa. With the double prism before the right eye, if the middle line is seen nearer the bottom, there is left hyperphoria; if it extends farther to the right than the other two, and not so far to the left, I HYPERPHORIA. 179 exophoria is present; or, if reversed, extending farther to the left and not so far to the right, esophoria is shown. If the right ends of the middle and lower lines converge, insufficiency of the superier oblique of the left eye is shown; if they diverge there is insufficiency of the left inferior oblique. By changing the double prism to the left eye, the right eye may be similarly tested. The Harold Wilson Pho7V?neter. — Of the many different kinds of phorometers now upon the market, the Wilson, in the author's opinion, is far better than any other, because in the one instru- ment are combined the Stevens, the Maddox and the Savage tests. Its accuracy, ease and rapidity of working make it the in- strument /<2r^;^;r/^j- of the ball, twitching of the lids, etc. . Calcarea. — Pale, flabby subjects, inclined to grow fat; with coldness of the extremities and perspiration about the head. Eyes pain after using, and are generalh* worse in damp weather and from warmth. Burning and cutting pains in the lids, and stick- ing pains in the ej^es on reading. Dim vision after fine work. Objects run together. Oonium. — Letters run together on reading. Burning pain deep in the eye. Great dread of light. Kalmia. — Stiff draw^ing sensation in the muscles upon moving the eyes (Nat. mur.). IQO AFFECTIONS OF THE OCUIyAR MUSCLES. Lachesis. — Asthenopic symptoms, especially in the left eye, with a variety of pains and sensations, worse upon thinking of them, using the eyes and on waking in the morning. Lilium tig. — Burning, smarting, and heat in the eyes after reading, relieved in the open air (Pulsat.). Photophobia. Mercurialis peren. — Asthenopia, with a sensation of dryness of the eyes and heaviness of the lids. Mist before the eyes in the morning. Burning pain in the eyes in evening, and upon read- ing. Phosphorus. — Mistiness and vanishing of vision, with pain and stiffness in the eyeball. Light aggravates, so the patient is better in the twilight. Muscse volitantes. Photopsies. Rhododendron. — Insufficiency of the internal recti muscles, with darting pains through the e5^es and head, always worse before a storm. Spigeha. — If accompanied by sharp, stabbing pains through the eye and around it, extending back into the head. In addition to the above, many other remedies have been em- ployed with success. Attention is particularly directed to the fol- lowing: Ammon. carb.. Apis, Arn., Asarum, Carbo veg., Caust., Crocus, Euph., Ignat., Kali carb., Ledum, Lith carb., Macrotin, Nux vom., Paris quad., Phos. ac, Pulsat., Santon, and Sulphur. i ANATOMY OF THE CONJUNCTIVA. I9I CHAPTER XI. Diseases of the Conjunctiva. Anatomy. — The conjunctiva is the dehcate mucous mem- brane Hning the inner surface of the eyehds; from the Hds it is re- flected upon the globe and covers the sclerotic as far as the cornea, with which it becomes continuous. The conjunctiva is divided into three portions: the palpebral, covering the inner surface of the lids; the bulbar, covering the sclerotic; and \}li^ fornix, or loose folded portion connecting these two. At the cornea the conjunctiva overlaps the cornea slightly, and at this point is called the limbus conjunctivae or cornese. The bulbous portion of the conjunctiva is formed of three layers — the external epithelial layer, the fibrous tissue and the subconjunctival tissue. The epithelial layer is formed of cylindrical cells externalh' and a deeper laj^er of smaller cells. The fibrous tissue is a fine retic- ulated structure, containing nucleated cells, together with a few elastic elements. The subconjunctival tissue is loose and elastic, with fibres uniting it to the sclerotic. The conjunctiva, especially the portion covering the lid and forming the cul-de-sac, contains numerous lymphatic follicles and acinous glands. The nerve supply of the conjunctiva is very free and is derived from the fifth pair. The blood supply is also extremely abundant, especially in the region of the limbus and around the caruncle. The function of the conjunctiva is to act as a lubricating surface. Hyperaemia of the Conjunctiva. — In the strict sense of the word, hyperaemia is but the prehminary stage of different diseases, yet in the conjunctiva it is often the only symptom, and is, there- fore, considered here as an independent condition. Symptoms. — The vessels have the appearance of a coarse net- work. The transparency and smoothness of the conjunctiva is 192 DISEASES OF THE CONJUNCTIVA. lost and the papillae of the lids are more marked. The eyes are red, feel hot and heavy, and as though there was sand m them; there is a smarting, itching and a tired feeling on using them, or from exposure to a bright light. Causes. — The most frequent cause is a prolonged effort of the accommodation in those who have some uncorrected error of re- fraction, exposure to severe cold or heat, or from foreign bodies. Often seen in those living or working in a vitiated atmosphere. It is also frequently associated with nasal catarrh, hay fever, etc. Course. — It may be either acute or chronic, and when chronic it may cause a blepharitis, or become a catarrhal conjunctivitis. Treatment. — See conju7ictivitis catarrhalis. Conjunctivitis Catarrhalis is a hypersemia of the conjunc- tiva plus a discharge from the membrane — a simple hypersecre- tion. The healthy conjunctiva secretes mucus mixed with effete epithelial cells, and, when abundant, it becomes tenacious, string}^ and with it small masses of pus. The difference between catarrhal and purulent ophthalmia is simply one of degree; in catarrh the secretion contains elements of pus, but still is never really puru- lent, and is much less likely to destroy the corneal epithelium by maceration than does the purulent. Symptoms. — These are the same as found in hypersemia, but of a higher degree; the itching, smarting and burning sensations, the photophobia, lachrymation and redness of the eye are all present, and, from the greater inflammation and infiltration, we have chemosis. The discharge from the eye may be more or less excessive, but of a bland or muco-purulent character. The amount of secretion varies, and at night it is apt to accumulate and cause crusts on the cilia. The patient often complains of a temporary blurring of vision and black spots before the eyes, due to small flakes of secretion passing in front of the pupil. Course. — An acute attack does not usually last more than from one to three weeks, although it may run into the chronic form, especially in cachectic persons, or from unfavorable surroundings. In the chronic form the discharge is less contagious, and the disease is often associated with an inflammation of the lachrymal sac, especially if one eye only is affected. Cause. — In the acute form, where there is a muco-purulent dis- CONJUNCTIVITIS CATARRHALIS. 193 charge, it is certainly contagious. It may appear as an extension of a nasal catarrh, from an affection of the eyelids, or from an in- flammation of the lachrymal sac. Frequently occurs from an ex- posure to cold, from dust or smoke, from confinement in a close or vitiated atmosphere; often due to refractive errors, and is apt to occur with the exanthemata. Diagnosis. — As other diseases of the eye may very closely re- semble a catarrhal conjunctivitis, the differential diagnostic points should be considered. The principal diseases usually mistaken for conjunctivitis are iritis, episcleritis and keratitis. Differential Diagnosis. Conjunctivitis. Episcleritis. The redness of the j conjunctiva i s general, and on pressure through the lower Hd the in- jected vessels are seen to move with the membrane over the sclerotic. There is always redness of the fornix conjunc- tivae, and usu- ally of the pal- pebral conjunc- tiva. There is a m u co-purulent discharge, more or less profuse. The iris is clear and bright, the pupil reacts readily to light and the cornea is clear. The redness is de e p- s eated, surrounds the cornea as a rosy zone, and is not accompanied by redness of the fornix or palpe- bral conjuncti- va. The inject- ed vessels are beneath the con ju n c ti va, and do not move with it. The iris is dis- colored, pupil sluggish and in- active and the vision is impair- ed. There is usually very se- vere pain in the eye and head, which is gener- ally worse at night. The redness is of a dusky- red color, is subcon- junctival and localized; it is most often sit- uated over the external rectus muscle, or over the internal. There is usu- ally little or nOj pain, and the duration of the disease is much longer. The redness i s dee p-se a t ed, and u s u a lly most marked around the cor- nea. The trans- parency of the corneals always more or less di- minished. The photophobia is more intense and the lachry- mation more profuse. The vision may be greatly impair- ed. Treatment. — The first point in the treatment should be the removal of any exciting cause. To accomplish this the lids should first be everted and examined for the presence of a foreign body, which, if detected, should be removed. If the conjuncti- vitis depends upon any anomaly of refraction, this should be cor- 13 194 DISEASES OF THE CONJUNCTIVA. rected. If due to straining of the e3^es in reading, writing, etc. (especially in the evening) , or exposure to wind, dust or any bright light, as working over a fire, directions to abstain from over-use, or to protect the eyes from the injurious causes, should be given. Should the case be very severe, the patient may be confined to his room, though this is rarely required in pleasant weather. As a local remedy in acute inflammation of the conjunctiva, the use of ice is especially recommended. It may be used in rubber bags made for that purpose or by wrapping it in a towel. If prescribed it should be used consta?itly for twenty-four or forty-eight hours or longer, according to the benefit derived. Cleanliness especially should be required. To prevent the formation of crusts on the lids, the edges may be smeared at night with a little vaseline, simple cerate, cream or the like. In conjunctivitis, after the acute symptoms have subsided, we sometimes find the inflammation will come to a standstill, notwith- standing our most careful selection of remedies. In these cases a mild astringent will be found advisable, and the two following prescriptions have proven of much value: V^. Sodse biboratis, Qj Aquae camphoratse, ....... giij Misce. 9^. Zincisulph., T . gr. ij Sodii chlorid., . gr. iv Aquae dest., . . 5i Misce. Instil a few drops in the eye four times a day. Atropine should not be used unless there is iritic complication. The attendants should be warned that the discharge is con- tagious, and that the sponges, towels, etc., used upon the patient should not be employed for any other purpose. The administration of the internal remedy is, as a rule, all that is necessary in this disease. In the following list of remedies will be found those most frequently indicated. For special indica- tions see Remedies in Conjunctivitis, page 214. Aeon., Pulsat., Euphras., Apis, Rhus, Sulph., Arsen., Merc, sol., Hepar, Graph., Bell., Sepia, Allium cepa. Alumina, Argent, nit., Calcarea Caust., Cham., Cinnabar., Ignat., Nux vom.. Sang., Zincum. co^7UxcTIVITIS purulenta or blexxorrhoica. 195 Conjunctivitis Purulenta or Blennorrhoica.— ( Ophthalmia Neonatorum, Conjimdivitis Gonorrhoica) . An acute inflammation of the conjunctiva with a purulent discharge ma}' occur at any time of life, and bears essentiall}' the same features, whether occuring in the infant soon after birth, or in the adult as a result of infection from a gonorrhoea! or other discharge. It is, how- ever, more commonly spoken of under the heading of its two principal causes as ophthalmia neonatorum and conjunctivitis gonorrhoica; but, as the patholog}', symptoms, course and treat- ment are practical!}^ the same, they will be generally described under the one heading, reserving for each a brief mention of its characteristic peculiarities. Pathology. — No great changes take place in the conjunctiva. It simpl}^ becomes infiltrated with serum, together with a prolifera- tion of cells and lymphoid elements; the blood-vessels become di- lated, the capillaries increased in number and there is also some thickening of the epithelium. The contagiousness of this disease is due to micro-organisms, the gonococci of Xeisser, which are found in the pus secreted by the conjunctiva and also in the super- ficial la3'ers of the conjunctiva itself. Symptoms. — All those of catarrhal conjunctivitis are present in a much higher degree. The most prominent symptom is chemosis, which ma\^ be sufiicient to overlap the cornea. This is due to in- filtration of the conjunctiva wuth exudation, which also extends to the lids, causing a violet colored puffiness. The oedema of the lids is so great as to cause ptosis. The papillae of the conjunctiva are elevated and form villi, which bleed easily and give a thick, swollen appearance to the conjunctiva of the lids. Another most prominent symptom is the discharge, which at first is thin, muco- purulent, but soon becomes distinctly purulent, a thick yellow secretion, and is so excessive that the eye and cheek become literally bathed in pus. At first there is a feeling of heat, smarting and burning pains in the eye, then ciliary pains and shooting pains in the head set in. In some there is a distinct febrile movement. The swelling of the lid becomes hard and tense, making it difficult for even the physician to open them, and of a dusky red color — the upper lid over-hanging the lower. The first stage, or stage of infilti^ation , lasts from two to four 196 DISEASES OF THE CONJUNCTIVA. days, in which the disease has reached its height. The second stage, or that oi pyorrhoea, succeeds in which the swelHng of the Uds and the tense infiltration of the conjunctiva decreases. With this there begins a profuse secretion of pus, which gradually lessens as the swelling subsides, and the mucous membrane finally returns to a normal condition in from four to six weeks. The great danger is an involvement of the cornea, which may occur in three ways, viz. : First, small facets are formed by a loss of the epithelium, which, if seen and watched, may be prevented from extending; if not, they extend deeper, unite and form an ulcer, which may terminate by perforation. Second, there appear toward the centre of the cornea grayish points of infiltration, which increase in size, fuse and tend to form an abscess. Third, infiltration takes place at the margin of the cornea in the form of a ring; and, if this occupies more than a third of the cornea, it in- dicates an affection of the nutrition and becomes the starting point of a general necrosis, which almost inevitably causes loss of the eye. The cause of this participation of the cornea is due to either direct action of the infectious matter on the cornea, to direct con- tinuity of inflammation to the substance of the cornea, or to the stoppage of the nutrition of the cornea by the chemosis. A clean cut ulcer will sometimes form at the extreme margin of the cornea, under the chemosis, which is liable to perforate, and is particu- larly dangerous because apt to be overlooked. Causes. — Contagion is undoubtedly the direct cause in nearly every case and the disease breaks out in from a few hours to three days after infection. In infants it usually results from a leu- corrhoeal or gonorrhoeal discharge at the time of birth. In adults the infection is introduced from the genitals, by touching the eyes with unclean fingers and is more often the result of infection from gonorrhoea. Girls have been affected from an ordinary leucor- rhoeal discharge. Secretions from a diphtheritic conjunctivitis, or an altered or decomposed discharge from a catarrhal con- junctivitis may cause a purulent ophthalmia. Prognosis is always serious if the cornea is affected, as perma- nent opacities, staphyloma of the cornea, or even complete destruc- tion of the eye may ensue. Even when the cornea is not affected, do not give a too favorable prognosis, as corneal complications may arise at any time. OPHTHALMEA NEONATORUM. 1 97 Ophthalmia Neonatorum. — The ophthalmia of the newly- born child is undoubtedl}^ solely the result of inoculation from a leucorrhoeal or gonorrhoeal discharge from the vagina or cervix and occurs during birth, or later from the soiled linen or sponges. It is only in cases where the eyes are prematurely opened that they contract the contagion, when due to contact with the virus during labor, and it usually manifests itself from the second to fourth day after birth. When resulting from soiled linen, etc., it is usually later in presenting its appearance, and, when begin- ning later than the first week, is almost certainly due to some ex- traneous source of inoculation. The symptoms are those just described under purulent conjunctivitis, and are generally less severe than under gonorrhoeal. The prognosis is therefore more favorable, because with less swelling there is less danger of cor- neal ulceration. Statistics have shown that in former years a very large propor- tion of all cases of blindness have resulted from this disease, in dif- ferent countries var3ing all the wa}^ from 20 to as high as 79 per cent. In late years the attention that has been paid to the pre- vention of this disease has very materially lowered the per cent. Still we are daily meeting cases of permanent blindness from this disease which should be attributed wholly to the ignorance of those attending these cases. Much of this fatality could be obviated by careful disinfection of the vagina at the time of par- turition and in cleanliness in the linen and the sponges used and the hands of those coming in contact wath the child or mother. In a/l cases of gonorrhoe il or leucorrhoeal discharge in the mother, the method recommended by Crede should ahuays be employed. This consists in carefully cleansing the child's eyes with clean water and then the instillation between the eyelids of a drop of the 2 per cent, solution, gr. x. ad si of nitrate of silver. This method is practiced by many obstetricians in all cases, and since its general adoption the percentage of cases of blindness from ophthalmia neonatorum have been greatly reduced. Conjunctivitis Gonorrhoica.— This disease is always due to infection. Its onset is often accompanied by a severe arthritis. The inflammatory process is usually very intense and runs a rapid course. The lids are greatly swollen, as is also the palpebral con- junctiva. There is excessive chemosis and purulent secretion. 1 98 DISEASES OF THE CONJUNCTIVA. The disease usually develops in about forty -eight hours; it may occur in either acute or chronic gonorrhoea, and the more active the gonorrhoea is, at the time of infection, the more severe will be the inflammation. The virus of gonorrhoea may also cause diph- theritic conjunctivitis. The right eye is more often first affected, and it is more fre- quently found in males than in females. The physician must always handle all cases of purulent conjunctivitis with extreme care, on account of possible infection. This variety of purulent conjunctivitis is more severe than when due to any other cause, as about one-half of all eyes attacked with this disease are lost, while hardly one-third of the other forms of purulent conjuncti- vitis are fatal. Treatment of Conjunctivitis Pitrulenta. — If the attack is very severe, the patient may be confined to a darkened room, or even to bed; if only one eye is affected, the other should be hermeti- cally closed in order to prevent any of the matter coming in con- tact with that eye, for this discharge is very contagious, especially in the gonorrhoeal form, and in that found in new-born children. The healthy eye is best protected by means of a watch-crystal held in place over the eye by strips of adhesive plaster. In this way the eye is hermetically sealed; the patient can use the eye for necessary vision, and it is always under the observation of the surgeon. The examination of the cornea to see if ulceration is present is always essential, but great care must be taken to make no pressure upon the eye in opening it, on account of the danger, if ulceration should be present, of causing rupture of the cornea and escape of the lens. There is also danger of some of the purulent secretion spurting into the eye of the surgeon. Owing to the contagiousness of the secretions great care should be exer- cised both by the nurse and physician, to protect their own eyes and those of others, by providing that the sponges, towels, etc., are used only by the patient; also, that their hands are thor- oughly cleansed before touching another eye, for often the physi- cian and other patients have been inoculated and vision destroyed through carelessness on this point. If, by accident, any of the discharge should have entered a healthy eye, lukewarm water should be at once injected under the lids to wash it away; after which, drop in a strong solution of chlorine water, or a weak CONJUNCTIVITIS GONORRHOICA. 1 99 solution of nitrate of silver (gr. ij . ad 5j ) . Fresh air and nourish- ing diet are important aids. But the special and primary point to be attended to in the treatment is clea7iliness. To ensure this, the discharges should be often removed by dropping warm water into the inner canthus until all the pus has been washed awa}^ or by cleansing with the palpebral syringe. This should be done at in- tervals of from fifteen minutes to an hour during the day, and oc-- casionally through the night, according to the severit}^ of the case. The use of peroxide of hydrogen is of great aid in the thorough cleansing of the eye, so essential in purulent affections. In the inflammator}^ stage of purulent conjunctivitis, ice com- presses will usuall}^ be found most valuable, often serving to abort an attack. Ice bags may be used on the eye, or when the weight of the ice bag is complained of, cold may be applied by means of four or five thicknesses of old linen, cut about three inches square and laid upon a large cake of ice; these pads are to be conveyed quickly from the ice to the eye and changed ever}^ one or two minutes so that the cold will be constant. Carbolic acid, a i to 200 solution, or other disinfectants, can be used in combination with the ice, by having a large piece of ice in a large vessel of the solution. Caustics are directly efficacious by the irritation of the vascular walls, and indirecth' by the contraction that follows a considerable discharge of serum, such as accompanies the shedding of the eschar. A 2 per cent, solution of the nitrate of silver applied once or twice a day is preferable to stronger solutions. The use of Chlorine water, Boracic acid and the like is frequently of great service. Astringents, especially a weak solution of nitrate of silver (2 to 5 grains to the ounce) ma\^ be required. If the patient is seen shortly after inoculation with gonorrhoeal virus, it may be aborted by one application to the everted lid of a strong solution of nitrate of silver (gr. xxx. ad 5J), washing it off with water. Scarification is sometimes needed. The incisions are not to be made deep, but long and parallel to each other, and ma}^ be re- peated every twenty-four hours, if needed; promote the bleeding b}' warm water and by kneading the lid. Aqua chlorinii, as an external application, has proved a very valuable remedy in the various forms of purulent ophthalmia. Cases have been relieved by it when used alone, as well as with 20O DISEASES OF THE CONJUNCTIVA. the indicated remedy. The strong solution is sometimes employed, though we usuall}^ dilute it one-half, one-third, or still weaker. When the cornea becomes ulcerated, some operative measure, paracentesis, or Ssemisch's incision or the use of Atropine or Eserine, may be required, according to the complication. Cantho- plasty may be necessary if the lids are much swollen and very tense to relieve the pressure upon the e^^eball and to permit of more thorough opening of the lids for the purpose of cleansing the eye. The most important remedies in this disease are Argent, nit., Hepar, Mercurius, Rhus tox., Calc. hypophos. , Aeon., Apis, Cham., Euphras., Nitric ac, PuLsat., Sulphur. For indications see Remedies in Conjunctivitis, page 214. Conjunctivitis Diphtheritica is perhaps one of the worst dis- eases of the eye we have to deal with. It is a purulent inflamma- tion, that spreads by infection and the secretion of which is con- tagious. It may exist alone or with diphtheria of the throat. PathoL'jGY. — It is a fibrinous infiltration throughout the en- tire thickness of the mucous membrane which seriously interferes with the circulation. Symptoms. — It commences with acute pain (due to strangula- tion of the nerves and vessels by the infiltration), a feeling of heat and lachrymation. The upper lid becomes very much swollen and sometimes of such a board-like hardness that it is impossible to evert it. The skin of the lid is smooth, shining and of a pale, rosy or livid hue. The upper lid falls down, over- lapping the lower, and it is impossible for the patient to raise it. The conjunctiva becomes congested and chemosed, due to an in- filtration of coagulated fibrin. There is a dryness of the eye, and on everting the upper lid we find it smooth and yellowish; upon re- moving a portion of the thickened membrane we find that it has the same appearance all through, due to the infiltration. Owing to a constriction of the blood-vessels, a deep incision will produce no bleeding. The whole lid has a lardaceous appearance in the most severe cases, while in the cases of partial diphtheria we will notice one or two smooth, depressed places of a grayish-yellow color where the exudate is excessive. The conjunctiva between these islands is swollen, red and bleeds easily. Occasionally diphtheritic patches are found on the external angles of the lids. COXJU^XTIVITIS DIPHTHERITICA. 20[ The secretion is sanious and contains flakes of diphtheritic matter. The disease so far has been one of infiltration, lasting from one to ten da3's, and is the most dangerous stage, on account of cor- neal complications. Then begins the second stage, that of puru- lent discharge. The lids lose their hardness and there is set up a copious discharge of fibrinous masses. The vessels reappear at points and the infiltration looks like white patches here and there. The chemosis loses its yellow appearance and stiffness, and the whole disease now looks like an ordinarj^ attack of purulent con- junctivitis. Instead of ending here, it enters a stage of cicatriza- tion, in which there is a slough of the gangrenous portions of the conjunctiva, followed b}- a granulating surface covered b}^ a new epithelial layer, which, extending from the neighboring conjunc- tiva, causes a drawing in or contraction of that membrane that re- sults in more or less adhesions between the lid and eyeball, and in some cases ends in xerophthalmia. The great danger in this disease is the liability of corneal com- plications, due to the infiltration of the conjunctiva shutting off the nutrition of the cornea. Causes. — Contagion is the principal cause, 3^et the disease must be looked upon as an expression of the general condition, for we find diphtheritic affections of other parts at the same time and we may have the general symptoms of fever, exacerbations, weak- ness, loss of appetite, etc. The good eye, though protected, will often become affected. It is most frequentl}' found from the sec- ond to the eighth years of life, and is rarely seen in adults. Prognosis depends upon the amount of infiltration, grayish chemosis and stiffness of the lids. It is always serious and as a rule, more serious in adults than in children. The earlier the cornea is affected the more serious is the prognosis. There is not only the probabilit}- of the loss of vision, but in addition the dan- ger of the loss of life. Cases caused by direct contagion are always much more serious. Treatment. — See Conjunctivitis Crouposa. Conjunctivitis Crouposa {^Conjundivitis Membranacea) . — This disease is characterized by an exudate on the surface of the tissue where it hardens into a membrane, while in diphtheria the exudate is within the tisue itself. In this disease there is the form- 202 DIvSEASES OF THE CONJUNCTIVA. ation of a membrane, which may be thrown off as a cast of the sac. The membrane may be peeled off and leaves a bleeding surface underneath, while in diphtheria the membrane cannot be peeled off. The swelling and injection is less than that of purulent oph- thalmia. The membrane has an especial affinity for the cul-de- sac, while the tarsus and globe are least affected. The lids, while red and swollen, are soft. The upper lid hangs down over the lower. There is at first a watery secretion mixed with mucus which later becomes more purulent. The membrane is similar microscopically to that of tracheal croup. The disease is always acute, and the formation of a fibrinous layer is the essential feature, which is cast off with a slight purulent discharge and cure rapidly follows. It occurs particularly in the spring and autumn, when there is apt to be an epidemic form of diphtheria, and is found especially among children. Treatment. — Although these tw^o forms of inflammation are wholly distinct from each other, they will be considered under the same section, as the treatment is not dissimilar in many points. If only one eye is involved, endeavor to prevent the ex- tension of the disease to the other eye by hermetically closing it, for the discharge is very contagious, though extension may take place through the general dyscrasia. Clea7ilmess is of the great- est importance, as in purulent conjunctivitis. It is better not to exercise any force in removing the false membrane, as it only leaves a raw surface, upon which a new membrane forms, thus doing more harm than good; though all loose shreds should be carefully removed whenever the eyes are washed. The application of caustic or strong astringents, especially in diphtheritic conjunctivitis, is always injurious except in the puru- lent stage, and then must be used very guardedly. Hot applica- tions are better than cold, which serve to still further constrict the blood-vessels, and may be used especially in the purulent stage. A solution of alcohol and water (5j ad 5ij) has been em- ployed locally with some benefit in dipththeritic inflammation; also a one per cent, solution of Carbolic acid. Solutions of both lactic and acetic acid have been used locally wdth benefit. Lemon juice brushed over the surface of the conjunctiva every six hours is highly recommended by a number of physicians. In croupous inflammation chlorine w^ater has been useful as an external appli- CONJUNCTIVITIS FOLLICULARIS. 203 cation. Corneal complications require especial attention. In the cicatricial stage palliate the desiccation of the tyQ by instillations of milk, boroglycerine, or the carbonate of soda, gr. xxx. ad 51. The most serviceable remedies are Acetic acid, Kali bich. , Apis, Merc, prot., Argent, nit., Arsen., Hepar, Lachesis, Phj'tolacca, etc. See Remedies in Conjunctivitis, page 214. Conjunctivitis Follicularis is very frequently found and presents a very similar appearance to that met in trachoma, and is often mistaken for it. Pathology. — It is a simple hypertrophy of the lymph follicles, which microscopically are found to have a delicate reticular con- nective tissue, in the meshes of which are found lymph corpus- cles and free nuclei, and are also permeated by fine capillaries. Symptoms. — The conjunctiva appears filled with small, round, pinkish prominences, occupying the cul-de-sacs especialh^ of the lower lid, where the}^ are first noticed and always more promi- nent. In advanced cases they are arranged in rows, running parallel with the margin of the lid, and later may involve the superior cul-de-sac and the angles of the tarsus. Occasionall}^ the\^ ma}' be found on the tarsus, where they appear as small, whitish, slightl}' raised patches. (See Chromo-Lithograph, Plate I, Fig. 3.) The condition comes on slowl}^ and lasts for months or years. It is unaccompanied by any discharge except in the acute cases when it simulates a catarrhal conjunctivitis, and has but slight photophobia, with occasional painful sensations, but no marked symptoms. Causes. — Usually results from bad hygienic surroundings and is often endemic in schools, asylums and prisons. The use of atropine in some cases will cause it. This disease is often com- plicated by a catarrhal conjunctivitis when we have the symp- toms of irritation, discharge, etc. The disease is mostly met with in children and appears to be contagious. Follicular conjunc- tivitis never leads to subsequent shrinking and cicatrization. Treatment. — Fresh air, change of climate and proper h}"- gienic surroundings are a great aid to the cure of the trouble. Local applications, such as those used in trachoma, have not proved of much benefit, although mild astringents will in some 204 DISEASES OF THE CONJUNCTIVA. cases be of help. Correct any errors of refraction that may be present. Pressing out the contents of the follicles between the thumb nails, or by Knapp's roller forceps, as described under trachoma, will cure the disease in a much shorter time than under any other method of treatment. We have seen a number of cases of follicular conjunctivitis promptly and quickly cured by the use of Knapp's forceps, with little or no reaction, and we be- lieve this operation is the best treatment at present known for ag- gravated cases of this disease. The use of electricity is also of much value; but, as each follicle has to be punctured with the needle, the treatment is necessarily very tedious. The local use of corrosive sublimate as described under trachoma is of much service in this disease. The internal administration of Natrum mur. , Euphras. , and Sepia has cured some of these cases. See Remedies in Conjunc- tivitis, page 214. Conjunctivitis Trachomatosa. — {Granular Lids , Trachoma, Egyptian Ophthalmia. ) Is an infectious inflammation of the con- junctiva, that is characterized by its chronic course and hypertro- phy of the conjunctiva with a purulent infectious secretion. This disease has received numerous sub-divisions and classifica- tions, we prefer that of granular diwd papillary. The great majority of cases, however, are of the mixed variety and so distributed that the most prominent feature over the lids is the papillary prolifera- tion, while the trachoma granules are more characteristic toward the cul-de-sacs. Pathology. — This has been the subject of much dispute and still does not seem to be definitely settled. Some claim it to be a circumscribed hyperplasia of the lymphatics normally found in the reticulated connective tissue of the conjunctiva, thus -forming true lymphoid follicles; while others claim they are new growths. They consist of small rounded masses made up of lymphoid and connective tissue cells, surrounded by a fibrous capsule and tra- versed by blood-vessels and connective tissue fibres. Swanzy * says: ' ' The trachoma bodies have no capsule as have the follicles, but seem to grow from or in the stroma of the conjunctiva. They are to be regarded as new growths in the conjunctiva." The granule may undergo fatty degeneration and its contents be * Diseases of the Eye, 1897, p. 112. CONJUNCTIVITIS TRACHOMATOSA. 205 pressed out, or the connective tissue of the granule may increase and, from ultimate contraction, result in entropium. De Wecker "^ says: " A granulation lives and dies feeding on the parent that gave it life — it consumes the conjunctiva." Hence it is a malig- nant product, while follicles or purulent conjunctivitis are essen- tially benign. Symptoms. — They appear as yellow or reddish-gray translucent, roundish elevations, looking like frog-spawn (Fig. 58), and are generally found in the retro-tarsal folds and at the angle of the lids in the earliest stages. When occurring in the conjunctiva over the tarsus they are smaller and less visible because the mem- brane is so closely adherent to the tarsus. In this situation they Fig. 58. Everted granular lids. appear as small bright-yellowish points deeph' imbedded in the membrane. As the disease advances they extend in the worst cases, over the ocular conjunctiva and even upon the cornea. They are oval in shape and broader and less prominent than the hypertrophied follicles. (See Chromo-Lithograph, Plate i, Fig. 4.) There is some drooping and swelling of the lids and a slight secretion of a purulent character, causing some agglutination of the lids in the morning. The irritation of the eye and the quantity of the discharge is much increased in fresh cases or in acute ag- gravations of old cases. Pain, photophobia and lachr3'mation may be present and, during acute aggravations, become very severe. * Ocular Therapeutics. 206 DISEASES OF THE CONJUNCTIVA. Course. — The disease is usually very insidious in its course. As it progresses the granulations increase in size and become covered with fine capillaries, the conjunctiva becomes red and in- filtrated and secretes a muco-purulent discharge, the papillae swell, increase in size and blend with the granules. We have then the conjunctiva appearing as a fleshy mass, in which we are no longer able to distinguish the individual granules or papillae. Then a retrograde process sets in, and terminates in a cicatricial state with contraction of the conjunctiva. The for- mation of cicatrices is shown first by narrow whitish striae in the red thickened conjunctiva. These striae unite to form a delicate network. These lines grow broader, the islands they en- close smaller until the whole conjunctiva becomes pale, thin and smooth. Sometimes the neoplasm appears as polypoid excres- cences or condylomatous masses. Causes. — Trachoma is the result of infection from the secre- tions of an infected eye b}^ some direct transfer, and is probably due to some micrococcus. In the majority of cases trachoma re- quires months or years to run its course. Trachoma may appear at all ages, except in the very young. It may be either acute or chronic, and we may have acute exacerbations of an existing chronic trachoma. It is usually met with in places where the population is over crowded, ill-fed and amid unfavorable hygienic surroundings. Negroes in this country seem to enjoy great im- munity from trachoma. True trachoma is very rarely seen among the better classes, but is often endemic in public institutions, asylums, etc. Complications. — The conjunctiva in long existing cases, un- dergoes fibroid degeneration, atrophies and appears as grayish white cicatricial bands, usually running parallel wnth the border of the lid. The most frequent sequelae of trachoma is the distor- tion of the lid due to the cicatricial contraction and resulting in trichiasis and entropium. Symblepharori may also result from the same cause. There may be also more or less dryness and shrivel- ling up of the conjunctiva, which sometimes goes on to complete destruction of the conjunctiva — xerosis. The roughened condi- tion of the conjunctiva causes a superficial vascularity of the cor- nea, with a proliferation of the epithelial cells between the epithe- lium and Bowman's membrane, resulting in an opacity of the cornea called pannus. I^ater the whole cornea may become CONJUNCTIVITIS TRACHOMATOSA. 207 softened, lose it resistance, yield to the intra-ocular pressure and bulge. Occasionally the granules extend and may even be found in the cornea. Ulcers and abscesses of the cornea or a catarrhal or purulent conjunctivitis are very frequently found associated with trachoma. Prognosis. — In the early stages, when under careful treat- ment, resolution may occur in a short time. Later, however, the disease is more stubborn, its duration almost unlimited and it leaves changes in the lid or cornea which may produce more or less serious disturbance of vision and even blindness. Differential Diagnosis. Conjunctivitis Trachomatosa. Papillary Trachoma. Affects especially the up- per lid — particularly the retro-tarsal fold. The granule is oval, reddish-gray and more or less opaque; it is im- bedded in the mem- brane, and is less prom- inent than the follicles, and it ma}' be found on the ocular conjunc- tiva and even the cor- nea. In the granular variety, the affection, as a rule, soon takes on the mixed form, characterized by the presence of follicular and papillary hyper- trophy in addition to the neoplasm. There is also general lym- phoid infiltration of the conjunctiva and of the deeper tissues of the lid, including the tarsus, great prolifera- tion of the epithelium and the formation of new vessels. Fre- quently accompanied by pannus. Ver}- sel- dom met with in chil- dren. Always leaves a cicatricial membrane. Its location is pre- dominantly over the surface of the tarsus instead of its bor- ders. The enlarged papillae are of a bright red or bluish- red color which gives the lid a velvety, in- jected appearance. Is more rapid in its onset. Conjunctivitis Follicularis. Affects especially the lower lid, particularly the cul-de-sacs. The follicle is round or elongated, pale and semi-transparent; it is more prominent and sharply raised above the surface of the con- junctiva, and can be removed or separated from it. Its general arrangement is in rows parallel to the free margin of the lid. Never causes pannus. Found especially in children. Entirely re- covers; leaves no cica- tricial membrane. 208 DISEASES OF THE CONJUNCTIVA. Papillary Trachoma, as described b}^ some, is a hyperaemia, inflammation and hypertrophy of the normal papillae of the con- junctiva. Their elevations are mostly found on the surface of the conjunctiva over the tarsus, which gives to it a velvety appearance, and is always most pronounced upon the upper lid. There is also a proliferation of the epithelium. This gives the conjunctiva at first a red, roughened appearance, and later that of a swollen, bright red mass, studded with elevations. If uncomplicated, the inflammatory product may be absorbed and the conjunctiva restored to its normal condition. Treatment. — As these forms of conjunctivitis are usually found among the lower classes or those who are constantly ex- posed to wind and dust, care should be taken that these exciting causes be removed as far as possible; cleanliness and proper hygienic measures are very important aids in the treatment of this affection. It should be remembered that the discharges from granular lids are contagious, and that whole families or a whole school may be inoculated from one member by an indiscriminate use of towels, etc.; therefore, strict attention should be paid to the prevention of its extension. All trachoma patients should have their own wash- ing materials, linen, bed, etc., and in schools, institutions, etc., the cases should be isolated from the other inmates. _ If a cure can be effected by internal medication it seems to be more permanent than if total reliance is placed upon local applica- tions, but I do not hesitate to use local remedies if there is no particular indication for any special drug, or if the case proves very obstinate. In acute trachoma or acute aggravations of chronic granular lids, ice compresses will prove very agreeable to the patient and aid materially in controlling the intensity of the inflammatory process. In chronic granular inflammation, of the conjunctiva, especially when complicated with pannus, which is usually present, local treatment will be found of the greatest service. The following topical applications have been followed by more favorable results in my hands than any others: 9;. Acidi Carbohci gtt vj Glycerini, 5J Misce. 9;. Acidi Tannici, gr. xv Glycerini, gj Misce. TREATMENT OF TRACHOMA. 209 They should be applied with a camel's hair brush to the everted lids once a day. Other applications which have also proved ben- eficial in individual cases are alum, used as a powder, in a satur- ated solution with gl5xerine and in the crude stick; cuprum aluminatum and sulphuricum used in crystals; nitrate of silver in a weak solution (gr. ij — x ad 5), and bichromate of potash in a saturated solution. The local use of corrosive sublimate in solutions of varying strengths, from i to 1000 to i to 200, gives extremely satisfactory results in man}' cases. It ma}" be used by simply rubbing the lids energetically with a hard wad of absorbent cotton moistened in the solution, or by making slight scarifications with the Johnson grattage-knife (Fig. 59) and then applying the solution. Under Fig Johnson's grattage knife. the use of cocaine there is but little if an}" pain, and but slight in- flammatory reaction occurs except possibly from the stronger solu- tions. The scrubbing of the lids with the bi-chloride solutions should be followed up two or three times a week, and if followed up yields the best results of any treatment we know of. A number of operative measures have been suggested from time to time which have been credited with more or less success by different authorities. We shall, however, refer to but one operation in detail which, in our experience, seems to be the most satisfactory, and that is the Fig. 60. Knapp's roller forceps. following, which may be called the operatio?i of expression of the viorbid substance with a roller forceps , and is described byKnapp.* He uses the roller-forceps (Fig. 60) made by having two steel Archiv. -Ophtbal. 14 -ol xxi., I, 1892. 2IO DISEASES OF THE CONJUNCTIVA. cylinders so inserted into the forked end of a small but strong pair of forceps that they roll upon each other. As the operation is rather long and more or less painful, a general angesthesia should be employed. The lower lid is everted and may be superficially scarified with the Johnson knife, although scarification is by no means indispensable. One roller of the forceps is then pushed deeply into the fornix, and the other ap- plied to the anterior portion of the everted lid, the forceps are then compressed and drawn forward, so that the tissue between the cylinders is milked out. The instrument is reinserted and the neighboring portion treated in the same way. This manipulation is repeated until the cylinders roll easil}^ and evenly over the evacuated conjunctiva. The upper lid is then treated in the same way. To reach the superior cul-de-sac, the tarsus may be drawn away from the eye with fixation forceps. Especial care should be taken to reach all parts of the conjunctiva at the fornix, and com- missures. The forceps should be frequently dipped into an anti- septic fluid in order to be kept clean and free from coagulated blood, which prevents the rollers from turning. Both lids of both eyes may be treated at the one operation, and but one operation is usually required. But slight reaction usually occurs, and the patient is not necessarily, though preferably, kept confined. The application of the corrosive sublimate solution, i to i,ooo, or weaker, may be used immediately after the operation, if desired. This method is of the greatest value in follicular conjunctivitis and in the cases of densely packed spawn-like granulations. When thoroughly done the conjunctiva is left perfectly smooth and assumes its normal appearance in from one to two months. Excision of the j^etro-tarsal fold, as advised by Jacobson, has been extensively practiced. Treitel* reported its trial in 170 cases with satisfactory results. It has at the same tirne been praised and condemned by many other authorities. From our own observation it has not given as favorable results by far as the operation detailed above. The once much-lauded Jequirity treatment seems now to be a thing of the past. At the same time local treatment is employed the carefully se- lected internal remedy (see page 214) should be administered. ^Therap. Monatshefte., 1889, 2 and 3. CONJUNCTIVITIS PHLYCTENUI.ARIS. 211 The selection will usually be from the following list: Aeon., Aurum., Mercurius, Rhus tox., Pulsat., Sulph., Nux vom., Argent, nit., Kali bich., iVlumen, Alumina, Arsen., Bell., Calcarea carb., Chininum mur. , Cuprum, Euphras. , Natrum mur., Thuja. Conjunctivitis Phlyctenularis. — {Pustular, Scrofulous, Stru7nous a?id Hei'petic Conjunctivitis. ) Pathology. — Consists of a collection of l3'mphoid cells just beneath the epithelium raising it up. The apex breaks down, leaving a minute ulcer. Symptoms and Course. — In the most simple form we find on the ocular conjunctiva a slight triangular-shaped injection, at the apex of which there is a small reddish eminence. There is gen- erally several of these, which may become absorbed, leaving no trace behind them; but usually the epithelial' covering breaks down, forming an ulcer at the apex of the cone, which gradually sinks to the level of the conjunctiva and then quickly heals. The smaller the nodules the greater the number as a rule, and the small ones disappear by absorption. Again we may find a very pronounced redness with the formation of a very large phlyctenule Fig. 6i. Conjunctivitis phlyctenularis. at the border of the cornea itself. (Fig. 6i.) There may be sev- eral of these at a time or they ma}^ form successively. They break down and form large ulcerations that ma}- be some weeks in healing, or they ma}^ perforate and cause staphyloma. Some- times this form may be accompanied by a yellowish infiltration or abscess of the cornea. Finally, very large phlyctnules may form 212 DISEASES OF THE CONJUNCTIVA. on the ocular conjunctiva; the inflammation extends, grows deeper and involves the sclera. They often ulcerate, but usually only affect the superficial layers of the sclerotic and are of long duration. There are sometimes no subjective symptoms, but usually ex- cessive lachrymation, violent pain, intense photophobia and blepharospasm. Frequently the child will lay with the eyes closed and the face buried in the pillow all day long. There is always a great tendency to relapses. The disease will usually run its course in from eight to fourteen days, but, as relapses or successive crops are particularly liable to occur, the eye may not be entirely free from the trouble at any time for months or even years. The parents should always be warned that the child is liable to have recurrent attacks for years, often continuing until and ceasing with puberty. The prognosis is always favorable so far as the cure of individual attacks, the only danger being that subsequent attacks may involve the cornea and, leaving a macula over the pupil, affect in this way the vision. Causes. — Especially apt to occur in children and may be found in the perfectly healthy child as well as the weak and delicate ones. It is, however, most frequently seen in children of a scrofulous diathesis. Any irritating influence may cause it, such as errors in refraction, etc. It is again frequently observed associated with or following the exanthematous diseases. Bissell^ calls attention Differential Diagnosis. Conjunctivitis Phlyctenularis. One or more small nod- ules usually at the corneal border. The phlyctenule forms the apex of a triangular- shaped congestion, the vessels running to the nodule. The vessels are more superficial and movable on pres- sure. No discharge. Runs a rapid course and heals by ulcera- tion. Conjunctivitis Catarrhalis. Has no localized eleva- tions. The inflam- m a t ion is general and of the conjunc- tival vessels alone. Discharge is more or less profuse. Episcleritis. The elevation has a very much larger base, its color is darker and shows no tendency to ulcerate. The conges- tion is much deeper, more of a bluish tint, and overlaying the scleral vessels are seen the conjunctival ves- sels, which by pressure are made to move over the swelling. Little or no discharge. Course very chronic. *The Homoeopathic Eye, Ear and Throat Journal, Vol. ii, p. lo, 1896. CONJUNCTIVITIS PHLYCTENUI.ARIS. 21 3 to intra-nasal conditions as playing a ver}^ important factor in the causation of this trouble. Treatment. — It has been thought best to include under this head the various forms of phlyctenular inflammation of the eye, whether affecting the cornea or conjunctiva, as the aetiology, symptomatolog}^ course and treatment varj^ little in either case; in fact, those remedies which have been found useful when the cornea is invaded are also our chief reliance in this form of inflam- mation of the conjunctiva. The first points to be attended to are cleanliness and careful reg- ulation of the diet. It is our rule to always prohibit all sweets and fats from the diet and confining the child mainly to milk, eggs, beef, mutton, etc. The eyes should be bathed often in lukewarm water, and any little scabs which may have formed on the lids immediately removed, as they only prove a source of irri- tation. If there is considerable photophobia, and the child is rubbing the eyes constantly, a compress bandage will prevent this, and at the same time, by keeping the lids closed, will relieve the irritation to the eyeball occasioned b}^ their constant opening and closing; it also excludes the light, relieving the photophobia, soaks up the tears and so prevents their running over the cheek, making it sore and excoriated. The bandage is very seldom required, hut when it is, should be removed every four or five hours and the eyes cleansed. External applications should not, as a rule, be emploj-ed, as we can usually cure better and quicker with internal remedies alone, if we are careful in the selec- tion of our drugs. Occasionally, however, a case will be found which has proved very obstinate to treatment, where the ciliary in- jection is great, photophobia intense, and pupil a little sluggish — in which a weak solution oi Atropine dropped into the eye once or twice a daj^ will be of great benefit. In* some slow, indolent cases, the use of the following to stimulate into a more active condition is of value: V^. Hydrarg. oxid. flav. , gr. iv VaseHn, • • • SJ Misce. Of this, a very small piece, not larger than the head of a pin, may be placed within the eye once or twice a day. 214 DISEASES OF THE CONJUNCTIVA. The most frequently indicated remedies are Pulsat., Sulphur, Hepar, Ipecac, Graph., Calc. carb. , Calc. iod., Cham., Conium, Mercurius, Arsen., Rhustox., Euphras., Antimon. crud., Aurum, Kali bich., Nux vom., Segia, Apis, Baryta, Natrum mur., Psorinum. See Remedies in Conjunctivitis. Remedies in Conjunctivitis. Acetic acid. — A remedy of the first importance in croiipous conjunctivitis in which the false membrane is dense, yellow-white^ tough, and so closely adhere^it that removal is almost impossible. The lids are oedematously swollen and red. Although the mem- brane is closely adherent, it is not iyi the tissue, and so does not correspond to diphtheritic conjunctivitis. Aconite. — Is especially indicated in "C^^ first stage of an 5^ in- flammation of the conjunctiva when the eyes are red, burning^ very pai7tful and with great dry?iess. The conjunctiva is intensely hypersemic, may be oedematous and even chemosed. The eyes are usually dry, but may be useful when there is a moderate lachrymation and a muco-purulent discharge. The pain is gen- erally described as smarting, bunting, with sensitiveness to the air, but there is often an aching or bruised pain, with the feeling as if the eyeball was enlarged and protruding, making the lids tense. Kspecially useful in an inflainmatio?i fro^n a foreign ^ody, in acute catarrhal or aii acute aggravatioii of grajiular lids and payinus, particularly when induced by overheating, violent exercise, or by exposure to dry, cold air. It is in the Aconite cases that ice is especially serviceable. Allium cepa. — Of use in acute ra/arr/z^/ conjunctivitis asso- ciated with a similar condition of the air passages, as in hay fever; the lachrymation is scalding, profuse and not excoriating, though the nasal discharge is so (reverse of Euphrasia) . ' Alumina. — In chronic granular lids where there is much marked dryness of the lids and eyes, especially in the evening, with burning, itching and pressure always aggravated from over- use of the eyes, and accompanied by a sensation of dryness, with a moderate discharge and a heavy feeling in the lids. Antimonium crud. — In phlycteyiular or pustular conjuncti- vitis, especially in cross children who are afflicted with pustules on the face and moist eruptions behind the ears. The lids are red, REMEDIES IN CONJUNCTIVITIS. 215 swollen and excoriated by the profuse mucous discharges and lachrymation. Excoriation of the nostrils and swollen upper lip. (Similar to Graphites.) Apis mel. — May be indicated in any form of conjunctivitis if there is great swelling (^(Edematous) of the lids and adjacent cellular tissue. The conjunctiva is congested and of a dark, red, puffy condition. The discharge is moderate, while the lachrymation is profuse, hot and burning, with photophobia (Rhus). The tears while hot and burning do not excoriate the lids, as in cases in which Arsenicum is indicated. The character of the pains, which are stingiyig and shooting, is an important indication, and serve to distinguish between Apis and Rhus cases which objectivel}' are very similar. The symptoms are aggravated in the evening and often concomitant symptoms, such as drowsiness, absence of thirst, and dropsy, are present. Argentum nit. — This is the most serviceable remedy in the whole materia medica for any form of purulent inflammation of the conjunctiva. The most intense chemosis with strangulated vessels, profuse purulent discharge and commencing haziness of the cornea, with a tendc^ncy to slough, have been seen to subside rapidly under this remedy. The absence of subjective symptoms, with the profuse purulent discharge, and the swollen lids, swollen from being distended by a collection of pus in the eye, or from swelling of the sub-conjunctival tissues, and not from infiltration of the connective tissues of the lids themselves (as in Rhus or Apis), in- dicates the drug. In the blenorrhoeal stages of conjunctivitis when the discharge becomes profuse and assumes a purulent char- acter. In some chronic forms of conjunctivitis when the con- junctiva is scarlet-red and the papillae hypertrophied. The in- flammatory S3^mptoms usuall}^ subside in the open air and are ag- gravated in a warm room. In the early stages of acute granular conjunctivitis, if the conjunctiva is intensely pink or scarlet-red and the discharge is profuse. The use of a solution of five or ten grains of the first decimal trituration to two drachms of water, as a local application, after the very profuse discharge has subsided, is often of very great value. Arsenicum. — Especially of service in phlyctenular ^orv]\xx\QX!iv- itis after the pustules have broken leaving a superficial ulceration. Also in acute catarrhal conjunctivitis with chemosis, much hot, 2l6 DISEASES OF THE CONJUNCTIVA. scalding lachrymation, burimig pains, especially at nighty and an cedematous condition of the lids, particularly the lower. Indicated in chronic granular lids, when the palpebral conjunctiva only is inflamed; the lids are painful, dry, and rub against the ball; they burn and can scarcely be opened. In chronic forms if the lachry- mation and discharges are thin and acrid excoriating the lids and cheek. The photophobia is usually intense, and often relieved in the open air. The lids may be cedematous and spasmodically closed, or else inflamed and excoriated by the acrid discharges. The nostrils and upper lip are usually excoriated by the acrid coryza. It is especially indicated in low, cachectic conditions, and the ill-nourished, scrofulous children of the poor. Great restless ness and thirst for small quantities of water are commonly noticed. Warm applications generally relieve. The attacks of inflamma- tion are frequently periodic and often alternate from one eye to the other. Aurum met. — Scrofulous ophthalmia, with ulceration and vascularity of the cornea. Useful in trachoma, either with or without pannus (especially when pannus is present); there is probably no other remed}^ given internally alone that has cured more cases. Photophobia severe, lachrymation profuse and scald- ing; eyes very sensitive to touch. The pains are from without inward, and worse upon touch (reverse of Asafoetida). The cer- vical glands are usually swollen; patient very irritable and sensi- tive to noise. The muriate of gold is frequently emplo)^ed, though the symp- toms, as far as known, vary but slightly from those of the metal. Baryta iod. — In scrofulous ophthalmia when enlarged cervical glands are present. Belladonna. — In the early stages of catarrhal conjunctivitis, if there is great dr3mess of the eyes, with a sense of dryness and stiffness in the thickened red lids and smarting, burning pain in the eyes. Photophobia is marked. Concomitant symptoms of headache, red face, etc. Calcarea carb. — Particularly indicated \n phlyctenular keratitis and conjunctivitis and in some cases of trachoma, when due to exposure to wet. There is usually excessive photophobia and lachrymation (often acrid). The lids may be red, swollen and agglutinated in the morning. The eye symptoms are aggravated REMEDIES IN CONJUNCTIVITIS. 217 during da^np iveather, or from the least cold, to which the patient is ver}^ sensitive. In fat, icnhealthy, strumous children with en- larged glands, distended abdomen, pale flabby skin, eruptions on the head and body which burn and itch, and cold sweat of the head. Occasionally useful in catarrhal conjunctivitis caused b}^ working in water. Usually prescribed upon the concomitant symptoms. As the discharges are often profuse, it has been used with advantage in purule^it ophthalmia, especially neonatorum, characterized by a profuse yellowish-white discharge, oedema of the lids and ulceration of the cornea. Oalcarea iod. — Indications are similar to Calcarea carb., but especially in cases where we have considerable swelling of the tonsils and cervical glands. Oalcarea hj^-pophos. — Purulent conjunctivitis, with ulcer- ation of the cornea, occurring in patients who are very much debilitated, and who have little vitality. In one case of gonor- rhoeal ophthalmia treated by Dr. George S. Norton, ''- where there was a moderate discharge and no pain, but with excessive che- mosis, tendenc}^ to perforation at peripher}^ of the cornea, and, in fact, the whole cornea seemed to be sloughing, Eserine i to 200 was instilled, and Calcarea hypophos. given with immediate and remarkable improvement of the whole condition. Chamomilla. — Scrofulous ophthalmia in cross, peevish children during dentition and will often relieve the severity of the symp- toms, even though it does not complete the cure. In ophthalmia neonatorum is often of service as an intercurrent remed\", even if does not remove the whole trouble. The cornea is usually in- vaded, and we have great intolerance of light, considerable red- ness and lachrymation. Sometimes the conjunctiva is so much congested that blood may ooze out, drop by drop, from^ between * the swollen lids, especially upon an}' attempt to open them (Nux). Oinnabaris. — When the characteristic symptom of pain above the eye, extending from the internal to the external canthus (usually above, though sometimes below). The cornea is generalh^ impli- cated and the s3^mptoms of photophobia, lachrymation, etc., are severe. Oonium mac. — \x\ phlyctenular inflammation, especiall}^ when the cornea is implicated. There is intense photophobia and profuse , * Transactions Horn. Med. Soc. State of New York, 1884. 2l8 DISEASES OF THE CONJUNCTIVA. lachrymation upon any attempt to open the spasmodically closed lids. The pains are various, but generally worse at night. With all this intense photophobia there is very slight or no redness of the conjimctiva. Oroton tig. — In phlyctenular ophthalmia associated with a vesicular eruption on the face and lids; the eyes and face feel hot and burning, especially at night; the photophobia is marked, cil- iary injection like iritis often present, and considerable pain in and around the eye, usually worse at night. Duboisin. — Chronic hypercsmia of the palpebral conjunctiva in hyper opes. Euphrasia. — In catarrhal conjunctivitis, especially acute, when caused by exposure to cold, and in those cases occurring during the first stages of the exanthematous diseases. In phlyc- tenular ophthalmia and trachoma when the characteristic objective symptoms are present. The lachrymation is excessive, acrid a?id burning. The discharge is profuse, thick, yellow, muco-puruleyit and acrid, making the lids sore a?id excoriated. (The secretion is also excoriating under Arsenic and Mercurius, but thinner.) Intoler- ance of light is generally present, though not always, and the con- junctiva may be red, even chemosis. Fluent, acrid coryza often accompanies the above symptoms. Graphites. — Is one of our most important remedies in phlycten- ular conjunctivitis and keratitis in both acute and chronic forms, but perhaps more often the chronic recurrent form. It may also be of service in the chronic 2, which seet?is to be deep in the bones surrounding the eye, of a tearing, pressing nature, often extending down into the eyeball, with burning heat, especially on trying to open the eyes; the pressing pain is usually from above dowjiward and from ivithout inwat^d, aggravated on touch. The mental condition of the patient is that of great de- pression; this, together with the bone pains in other portions, aid us materially in our choice. Cinnabaris. — Of great value in the treatment of iritis, particu- larly syphilitic and if gummata are present in the iris. The 29» DISEASES OF THE IRIS. characteristic pain commences at the i7iner canthus and exte7ids across the brow or even passes around the eye, though there may be shooting pains through the e3^e into the head, especially at the inner canthus. Sharp pain over the eye, or soreness along the course of the supra-orbital nerve and corresponding side of the head. Like mercury, the ?ioctur7ial aggravatioyi is usually marked and the symptoms intermit in severity. Hepar. — Especially serviceable if the inflammation has ex- tended to the neighboring tissues, cornea (kerato-iritis) and ciliary body (irido-cyclitis) or after gummata have ruptured, and if there is pus in the ayiterior chamber (^hypopyo7i) . Especiallj^ in sup- purative iritis. It is also of value in purule?it irido -capsulitis after cataract extraction. The pains are pressing, boring or throbbing in the eye, ameliorated by warmth and aggravated by motion. The eye is very teyider to touch. There is usually much photo- phobia and great redness of the conjunctiva, even chemosis, while the lids may be red, swollen, spasmodically closed and sore to touch. The patient feels chill}^ and wants to keep warml}^ cov- ered. Rhus tox. — Idiopathic or rheumatic iritis, if caused by ex- posure to wet, or if found in a rheumatic patient. Suppurative iritis, particularly if of traumatic origin, as after cataract extraction, more often calls for Rhus than any other remedy. Also useful in kerato-iritis. The lids are oedematously swollen, spasmodically closed, ayid, upon opefiing than, a profuse gnsh of tears takes place. There is chemosis, the photophobia is marked and the pains are various, both in and around the eye, worse at ?iight, especially after midnight, and in damp weather. The swelling of the lids often involves the corresponding side of the face and may be cov- ered by a vesicular eruption. Concomitants must be taken into consideration. Bryonia. — Iritis resulting from exposure to cold not infrequ- ently calls for this drug, especially if occurring with a rheumatic diathesis. The pains may be sharp and shooting in the eyes, ex- te?iding through into the head, or down into the face, or there may be a sensation of soreness and aching in and around the ball, especially behind it, extending through to occiput; the patient also sometimes describes the pain '' as if the eye was being forced out of the socket.'' All the pains are generally aggravated by REMEDIES IN IRITIS. 299 Tnoving the eyes 171 their sockets, or upon any exertion of them, a?id at night. The seat of pain often becomes sore to touch. In the serous form it also proves serviceable. AsafoGtida. — Especially indicated in the syphilitic variety and after the abuse of Tnerciiry. The pains are severe in the eye, above it and in the temples, of a throbbi7ig, pulsating, pressing, burning or sticking character and tend to become periodic; they extend usually from within outivard and are 7'elieved by rest a7id p7'essure (reverse of Aurum). Thuja. — Syphilitic iritis, with gu77i77iata 07i the iris. Large wart-like excrescences on the iris, with severe, sharp, sticki7ig pains in the eye, aggravated at jiight a7id ameliorated by warmth. Usually accompanying the above we find 77iuch heat above and around the eye and in the corresponding side of the head; there may also be tearing, dull, aching pains in the brow, or a pain above the eye (left) as if a nail were being driven in. Ciliary injectio7i decided, even in some cases amounting to inflammation of the sclera. Lids may be indurated, noises in the head, etc. Cedron. — This remedy is particularly of value in relieving the severe ciliary 7ieuralgia observed in iritis, if supra-orbital, seeming to follow the course of the supra-orbital nerve, especially if there is marked periodicity. China. — Iritis dependent upon the loss of vital fluids, or malaria. The pains are variable, but have a marked periodicity . The 77iuriate of quini7ie, in appreciable doses, will often relieve severity of the pains, especially when of an intermitte7it type a7id acco77ipanied by chills and fever. Nitric acid. — Chronic syphilitic iritis of a low degree, with very little or no nightly pain. The pains may be worse during the day and are of a pressing, stinging character. Posterior synechiae will be found. Arsenicum. — Iritis, with periodic burning pai7is, worse at night, after 77iidnight, ameliorated by warm applications. Fre- quently indicated in serous iritis. Aconite. — In the very first stage, or, in a sudden reappear- ance, this remedy is often of the greatest value, especially if oc- curring in young, full-blooded patients and when the cause can be traced to an exposure to a cold d7'aught of air. It is the most commonly indicated remedy in traumatic i7^itis. The ciliary injec- 300 DISEASEvS OF THE IRIS. tion is usually marked, pupils contracted and pains often severe, beating and throbbing, especially at night. There is a sensation of great heat, burning and dryness in the eyes. Arnica. — Rheumatic iritis has been benefited, though its special sphere of action is in the trau7natic variety^ in which it may be employed with advantage. Belladonna. — Early stages of iritis, caused from a cold; or chronic plastic iritis, following cataract extraction, with much redness and severe throbbing pain in the eye and head, worse at night Sensitiveness of the eyeball to touch, congestion of the face, etc. Clematis. — By some, this drug is considered to be as fre- quently called for as Mercury, in iritis and kerato-iritis, though we have never used it to the same extent. Chronic syphilitic iritis, with very little pain. The pains are similar to those of Mercurius, but there is usually much heat and dryness in the eye and great sensitiveness to cold air, to light and bathing. Conium. — Descemetitis, with excessive photophobia and but little redness or apparent inflammation. Euphrasia. — Rheumatic iritis, with constant aching and occa- sional darting pain in the eye, always worse at night; ciliary in- jection and photophobia great; aqueous cloudy; iris discolored and bound down by adhesions. Gelsemium. — In serous iritis alone or complicated with cho- roidal inflammation, Gelsemium is the most prominent remedy. There is hj^persecretion and cloudiness of the aqueous, with mod- erate ciliary injection and pain. Hamamelis. — Iritis traumatica, or other forms in which hcsmor- rhage has taken place into the iris or anterior chamber. Kali bichrom. — It is the remedy for true descemetitis charac- terized by fine punctate spots on the posterior surface of the cornea, especially over the pupil, with moderate redness and very little photophobia. May be required in syphilitic iritis. Natrum salicyl. — Iritis with intense ciliary neuralgia, espe- cially resulting from operations on the eye. Nux vom. — May be useful at the beginning of the disease or as an intercurrent, especially in the syphilitic form, if there is much photophobia, lachrymation, etc., in the morning. Petroleum. — Syphilitic iritis accompanied by occipital headache. TUMORS OF THE IRIS. 301 Pain in eyes pressing or stitching and skin around the eyes dr}' and scurfy. Spigelia. — Rheumatic iritis, if the pains are sharp and shooting both 171 and around the eye, especially if they seein to radiate frojn one point. Sulphur. — Iritis, particularly if chronic and found in strumous subjects, may find its remed}' in Sulph., also if hypopyon compli- cates the trouble. May be of service as an intercurrent, even if it does not complete the cure. The pains are usually of a sharp, sticking character, worse at night and toward morning. General indications will decide our choice. Terebinth. — Rheumatic iritis with intense pains in the eye and head, especiall}- if resulting from suppressed perspiration of the feet. Pain in the back and dark urine will be present. The following remedies have also been emplo^'ed in occasional cases with favorable results. Their meagre indications can be found b\^ reference to Part II. Arg. nit., Crot. tig., Prunus sp., Puis., Sil., Staph, and Zinc. Tumors of the Iris. — Both simple and malignant tumors are met with in the iris. Cysts, both epidermoid ^ndi serous, are in the large majority of instances due to traumatism. The epidermoid is usually the result of a penetrating wound, by which one of the cilia is carried into the iris and is found to consist of cells covered with pavement epithelium and sometimes surrounded b}' a thin connective tissue membrane. The appearance is that of a jxUow, opaque tumor, and it ma}' undergo fatty degeneration. The serous cyst is mereh^ distended iris tissue, which may become so thin as to be simply a structureless membrane. The appearance is that of a graj'ish- white or translucent tumor and its contents are similar to the aqueous humor. The treatment consists of excising them as early as possible, and care should be taken not to rupture the cyst wall during removal. Melanoma is an extremely rare form of tumor affecting the iris. It is merely a hj-perplasia of the pigmented cells of the stroma of the iris and appears as a small black tumor. They are benign, usually congenital, more or less stationary- and produce no irrita- tion. Rarely they have been seen to develop into a melano- sarcoma. 302 DISKASKS OF THK IRIS. Gramiloma may very rarely appear in children as a pale red or yellow vascular tumor, which may gradually increase, in- volve the cornea and perforate, when it appears like a spongy mass, bleeding easily and resembling a sarcoma. They may also occur from a prolapse of the iris or after operations. They have been found to consist of numerous small, round, irregular or spindle- shaped cells, with a few large nucleated cells and may be covered with epithelium. Sarcoma are very rarely found occurring primarily in the iris. One reported by Andrews* was first excised with a piece of the iris and one week later the eye enucleated. They are usually an extension from the choroid or cilary body and are most frequently of the pigmented variety. Limbourgf reports a case of leuco- sarcoma with complete details of the microscopical examination. The eye should be enucleated. Tubercles appear chiefly in children and most frequentl}^ at the periphery of the iris and are accompanied by more or less inflam- mation. They appear in two forms, either as miliary tuberculosis characterized by a number of grayish semi-translucent nodules, which may subside spontaneously, or as a solitary tubercle of a yellowish-white color, which may increase to such a size as to finally perforate the cornea. The treatment when they are in- creasing in size is either to excise by an iridectomy or enucleation. They may increase in size and number and should be either ex- cised or the eye enucleated. Mydriasis. — Dilatation of the pupil may occur in one eye or both, and may result from various causes. Irritatio7i mydriasis occurs from intestinal irritation, as in worms; from spinal or cerebral irritation, as in hyperaemia or new growths and in acute mania or melancholia. It is also found in hysteria and sexual irritation. Paralytic mydriasis is found in diseased processes at the base of the brain, in orbital processes, or intra-ocular tumors where there is pressure on the ciliary nerves, in glaucoma, diphtheria, syphilis, etc., from injuries, simple cold or draughts of air. Von GraefeJ •5^ N. Y. Med. Journ., June i, 1889. t Archiv. Ophthal., vol. xix., p. 239, 1890. lArchiv. f. Ophthal., Ill, pt. Ill, p. 350. MYOSIS. 303 considers unilateral mydriasis occurring at short intervals, first in one eye then the other, as a premonitor}^ sign of mental derange- ment/ Mydriasis occurs as a paralytic affection of the third nerve or as a result of some irritation of the sympathetic. It causes a dimness of vision from too much light and an increase of the circles of diffusion. This functional disturbance of the pupil is, therefore, usually merely a symptom of deeper and more serious trouble and re- quires remedies adapted to that condition. It is, however, some- times found uncomplicated with other disorders, being dependent upon cold, trauma, etc., in which case Arnica, Bell., Caust. and a score of remedies may be indicated. The instillation of sul- phate of Eserine is often also of great service. As m3'driasis is generally associated with paralysis of one or more of the ocular muscles, refer for treatment to paralysis of the muscles. Myosis.— Contraction of the pupil is, physiologically, greater in infants and old age than in middle life; is greater in h3^peropes than in myopes and in those who use the eyes steadily at fine work. Spastic myosis or contraction of the pupil due to spasm of the third nerve may be dependent upon some irritation or inflamma- tion of the eye, as in hyperaemia of the iris, or from some irrita- tion of the cerebral centre, as in the early stages of inflammation of the brain or its meninges and when this myosis gives way to mydriasis it is a serious prognostic sign indicating the stage of depression with paralysis of the third nerve. It also occurs in the early stage of apoplexy, intra-cranial tumors, hysteria or in epileptic attack and in tobacco or alcoholic amblyopia. Paralytic myosis occurs in spinal lesions above the dorsal verte- brae, in general paralysis of the insane, and is a prognostic sign of general paralysis approaching when it follows the dilated pupil of acute mania and may be due to a paralysis of the cervical sympathetic from injury. Spinal myosis is nearly alwaj-s bilateral and may be preceded or accompanied by atrophy of the optic nerve and contraction of the field of vision. This form of myosis is seen in tabes dorsalis, and, from the peculiarity of the contraction of the pupil, it is 304 DISEASES OF THE IRIS. called the Argyll Robertson pupil, as he first called attention to it in 1869. In this, the pnpil is contracted, and, while not re- sponding at all or very feebly to light, responds actively to con- vergence and is always indicative of a serious central lesion. Contraction of the pupil unassociated with more serious disturb- ance is of rare occurrence; the cause, therefore, usually demands our attention. Atropine instilled into the eye may be emploj^ed, though it generall}^ gives only temporary relief. Jaborandi and Physostigma ven. are especially recommended for this condition, though various remedies which produce con- traction of the pupil may be thought of. Hippus. — Is a spasmodic pupillary movement irrespective of light or accommodation. There is an alternate contraction and dilatation of pupil which may occur in nystagmus, in multiple sclerosis, acute meningitis, after epileptic attacks, in hysterical spasms, etc. Iridodonesis. — Tremulousness of the iris is dependent upon loss of support of the iris and is usually the result of a partial or total dislocation or absence of the lens. It may also occur in hydrophthalmus, or when there is an increased amount of fluid in the posterior chamber. There is nothing to be done for it. IridonCOSis. — Atrophy of the iris is the result of inflammation, usually a chronic parenchymatous iritis, and sometimes occurs after perforation of the cornea where the anterior synechiae have kept up the inflammation. It consists of a fatty degeneration. Hypaemia. — Blood in the anterior chamber is usually of traumatic origin, although may be spontaneus, as a result of some intra-ocular inflammation, as iritis. It may be but slight, or sufficient to entirely fill the anterior chamber, and is usually rapidly absorbed b}^ the application of a compress-bandage and the internal administradon of Arn., Aurum, Ham. or Ledum. Iridodialysis. — A separation of the iris from its peripheral at- tachment is usually traumatic, as from a blow on the e3^e, which spreads the cornea at the corneo-scleral junction, causing a separa- tion, or from operation, as in iridectomy. COLOBOMA IRIDIS. 305 Coloboma Iridis. — Congenital absence, due to an arrest of development of a part of the iris, of either one or both ej^es, is not uncommon. It is usually complicated with other congenital anomalies, especially of the choroid, or may be of the lens, or optic nerve, or in microphthalmos. It may extend to the periphery or not, and is usually downward, or downward and in- ward, and may be of various shapes. Pollak* reports three cases and gives the literature upon coloboma of the iris. Irideraemia {A7iiridia). — Absence of the iris may be total or partial, but it is usually total and in both eyes. When complete, we may be able to see the ciliary processes, unless small or atrophied. The lens usually becomes opaque, vision is decreased and nystagmus often accompanies it. Stenopaic glasses may im- prove. Membrana Pupillaris Persistans consists of the presence of two or three fibres running across the pupil which are attached on the anterior surface of the iris and external to the sphincter. During the greater part of intra-uterine life the pupillary mem- brane stretches across the pupil, and in normal eyes it remains permanent after birth only in that part which covers the iris, whose endothelial layer it becomes; but occasionally small shreds will remain and are called persistent pupillary membrane. Heterochroma is the term applied to variations in the color of the iris. In one eye the iris may be black or brown and in the other blue, or the two colors may exist in different sections of the same iris. Corectopia, an anomalous position of the pupil; Diplokoria, double pupil, and Polycoria, many pupils, are all congenital anom- alies which are sometimes met with. Operations on the Iris — Iridectomy. — This operation, con- sisting in the excision of a portion of the iris, is the one most fre- quently made for both therapeutic and optical measures. It is in- dicated for therapeutic purposes in glaucoma, staphyloma, posterior synechise and sometimes may be of value in obstinate cases of re- *Archiv. Ophthal,, vol. xx., p. 410, 1891. 20 3o6 DISKASKS OF THE IRIS. current iritis, or in keratitis with deep ulceration or hypopyon. It is also indicated in tumors of the iris or for foreign bodies in the iris and is frequentlj^ performed preliminary to cataract ex- traction. For optical purposes it may be indicated in opacity of the cornea, occlusion of the pupil, central opacity or dislocation of the lens and in cataract extraction. Iridectomy, when made for visual purposes, should of course be made where there is the least opacity of the cornea and lens, preferably below and a little to the inner side, if possible. When made for therapeutical purposes it is preferably above, that the upper lid may cover the deformity as much as possible. The size of the iridectomy, when made for optical purposes, should be small and large when made as a thera- peutical measure. Fig. 67. Fig. Fig. 69. Fig. 70. Fig. 71. Angular keratome. Curved iris forceps. Straight iris forceps. Curved iris scissors. Straight keratome. IRIDECTOMY. 307 The instruments needed for this operation are a speculum (see Fig. 49), fixation forceps (see Fig. 50), an angular or straight keratome (Figs. 67 and 68), or Graefe cataract knife; either curved or straight iris forceps (Figs. 69 and 70) and a pair of iris scissors (Fig. 71). Cocaine anaesthesia is usually sufficient in all cases, excepting, possibl}^, in glaucoma or an especially nervous subject, when a general anaesthetic should be administered. The eyelids are kept open with the speculum and the eye steadied by a firm hold with the fixation forceps directly opposite the point at which the incision is to be made. The keratome is then inserted in the sclerotic at the corneo- scleral margin (except when made for therapeutical purposes, when it should be from one to two mm. Fig. 72. Iridectoni}- — The incision. from the edge of the cornea) obliquely and in such a direction that, if continued, it would wound the iris and lens; but, as soon as the point is seen in the anterior chamber, the handle is de- pressed so as to bring the blade into a plane anterior and parallel to that of the iris and the blade is pushed forward into the anterior chamber until an external wound of sufficient size has been at- tained. The keratome is now to be slowl}" withdrawn, with its apex toward the cornea and well away from the iris and lens. The aqueous escapes with the withdrawal of the knife and should be allowed to pass off slowly. The iris forceps are now entered, closed, into the anterior chamber, opened, and the iris seized near 3o8 DISKASES OF THE lEIS. its pupillary edge, drawn out and cut off by an assistant at one cut of the scissors, or, as some prefer, drawing it to one side of the wound and partially snip it off and then drawn to the other angle, where the excision is completed (Figs. 72 and 73). Care should be taken to see that the cut edges of the iris go back into place, if not they may be pushed in with a hard rubber spoon, as none of the iris should be allowed to remain in the wound. The eye is then closed and a compress bandage applied. The Accidents from Iridectomy are first, from an injury of the lens by the keratome. This is a very serious accident which will be followed by partial or complete cataract and possibly glaucoma from swelling of the lens. Sometimes the keratome will enter the layers of the cornea instead of the anterior chamber when making the incision, due to its being held too obliquely. When this is discovered, the instrument should be withdrawn and a fresh in- FiG. 73. Iridectomy — Cutting the iris. cision made. Haemorrhage into the anterior chamber-, if occur- ring after the excision of the iris, requires no attention, as it will be rapidly absorbed, and if it occurs before the iris is cut, the blood can usually be made to flow out by depressing the edge of the wound. Haemorrhage into the fundus of the eye is apt to occur during iridectomy for glaucoma and is of serious import. It results from a too rapid escape of the aqueous on the withdrawal of the kera- tome. Iridotomy {Iritomy) consists in the formation of an artificial pupil OPERATIONS ON THE IRIS. 309 by simple incision of the iris. It is onlj^ occasionally adopted, and that in cases of absence of the lens, when the pupil is closed and the iris adherent to the lens-capsule, as may sometimes occur after cataract operation, where the iris has been put on the stretch by being drawn upward b}^ the cicatrix. It is best made after De Wecker's method, — a vertical incision about 3 mm. long is made in the cornea about the same distance from its margin with a keratome. De Wecker's forceps-scissors are then entered, closed, into the anterior chamber. The blades are opened and the sharp point of one is forced through the iris, by closing the blades the tightly stretched iris-fibres are cut through and from their retrac- tion a central clear pupil is formed. h'idodialysis is a tearing awa}^ of the periphery of the iris. This operation is rarely done and only when the extreme margin of the cornea is the only clear portion. Iridavidsioii . — Removal of the entire iris by tearing it from its periphery has been performed with remarkable effect by Noyes in cases of hydrophthalmus. The iris should be seized by the forceps or hook at its periphery opposite to the point of opening of the cornea and drawn out. Care must be taken not to injure the lens. Corelysis. — The breaking of pupillary adhesions by the hook or toothless forceps has not proved a great success, owing to their tendency to re-form and the danger of wounding the lens. Iridodesis consist in drawing the pupillary edge of the iris through a small opening in the margin of the cornea and securing it by a fine silk suture on the outside. This operation was formerly prac- ticed by Critchett and others, but has fallen into disuse from the possible danger of sj^mpathetic ophthalmia. 3IO DISEASES OF THE CII.IARY BODY. CHAPTER XV. Diseases of the Ciliary Body. Anatomy. — The ciliary body is that part of the uveal tract extending from the periphery of the iris to the choroid, and con- sists of the ciliary processes and ciliary muscle. Fig. 74- A section through the cihary region. The Ciliary Processes, some seventy or eighty in number, are composed of a connective tissue stroma, continuous with that of the iris and ligamentum pectinatum, of blood-vessels arranged in convolutions or folds, and overlaying these folds is a densely pig- mented layer. The tips of the ciliarj^ processes lay a little in front ANATOMY. 311 of the edge of the lens, but are not in contact with it. From the posterior surface of the processes extends a transparent structure called the zonule of Zinn or suspensory ligament of the lens. This is derived from the hyaline layer on the inner surface of the ciliary body, and, as it passes to the border of the lens, it splits up to go to each surface of the lens, leaving a small triangular space called the canal of Petit. Through this structure trans- fusion from the vitreous to the aqueous humor takes place. The ciliary processes, while not erectile, enlarge or shrink with varia- tions of blood pressure. The Ciliary Muscle is composed of three sets of unstriped fibres: The meridional, running parallel to the sclerotic; the circular, forming a ring parallel to the cornea; and the radiating fibres. Iwanoff has shown that in certain m3^opic eyes, the circular fibres may be entirely lacking, and, on the contrary, in hyperopic eyes are so highly developed that they form one-third of the ciliary muscle. As to the action of this muscle Heinrich Miiller ascribes a different action to each set of fibres: 1. "The circular fibres of the ciliary muscle exert a pressure upon the edge of the lens, by means of which the latter becomes thicker." 2. " The longitudinal fibres of the muscle cause an increase of tension in the vitreous humor, on account of which the posterior surface of the lens is prevented from shifting and the action of the peripheral pressure is chiefly confined to the anterior surface," and also, that, "The arching forward of the centre of the an- terior surface of the lens is rendered possible and favored by the recession of the peripheral portion of the iris, which is accom- panied by a contraction of the deeper (circular) layer of the ciliary muscle and the iris." Thus we see that the circular fibres of the ciliary muscle are the ones by which the act of accommo- dation is chiefly caused, and, further, that these circular fibres are especiall}^ developed in hyperopic eyes. The vessels supplying the ciliary body are the posterior and anterior ciliary. The nerves are from the ciliary, forming a net- w^ork in which are multi-polar ganglion cells containing sensitive, motor and sympathetic filaments. From this plexus fibres pass to supply the ciliary body, iris and the cornea. 312 DISEASES OF THE CILIARY BODY. Cyclitis. — Inflammation of the ciliary body is very rarely found uncomplicated with other diseases and usually, except when caused by wounds, is an extension of a choroiditis, or iritis, and when the inflammation commences in the ciliary body it usually extends to these other parts, and in fact the iris is always more or less involved. The recognition of cyclitis is essential on account of the danger to vision it threatens. The distinction be- tween cyclitis and iritis is not an easy one, and it is necessary, therefore, to search carefully for the characteristic signs, which are the extreme sensitiveness to touch, cloudiness of the vitre- ous and the change in the tension, which is first increased and later decreased. Cyclitis may occur as either a plastic, serous or purulent inflammation. Cyclitis Plastica. — Pathology. — The pathological changes are the same as those found in plastic inflammation of the iris, viz. : Hyperaemia, swelling of the stroma cells, accumulations of wandering cells and an exudation of an amorphous mass, especially on the inner surface of the ciliary bod3\ The exuda- tion m.ay extend forward upon the posterior surface of the iris and may fill the whole of the posterior chamber. It may be de- posited on the posterior surface of the cornea, floating about in the aqueous, or be found in the iritic angle. There is also an exudation into the vitreous, especially in its anterior portion, causing it to become hazy, which, as it gradually absorbs, leaves opacities floating in the vitreous that may become membranous. If the disease goes on, the retina and choroid become affected and the retina detached from the contractions of the pathological mem- brane and filled with a sero-albuminous fluid. In the late stages the ciliary processes may become detached from the sclera. The exudation is the same, only more extensive than in iritis. Symptoms. — There is ciliary injection and often chemosis. The iris may be discolored and the pupil contracted, but there are no synechise, unless the iris is involved. The veins of the iris are engorged, owing to the swelling of the ciliary body preventing a return of the blood from the iris. Pain is usually a prominent symptom; it is generally quite severe in and around the eye and often extending into the head — in fact, about the same as that in iritis. The most characteristic symptom is the extreme sensitive- CYCLITIS SEROSA. 313 ness of 'the eye to touch. There may or may not be haziness of the aqueous, but the haziness of the vitreous is almost invariably present in the early stages, appearing on weak illumination like fine dust floating in the anterior part of the vitreous. The anterior chamber may be deepened in the earlier stages, and later it may be shallow from fluid or exudation behind the iris or lens pressing it forward. There is a rapid loss of vision and the ac- commodation is impaired. The tension may be either increased, decreased, or normal. Oyclitis Serosa. — In this we have the same pathological changes as in serous iritis and it is alwa3's invariably accompanied by serous infiltration of other parts of the uveal tract. The symp- toms are the same as just described, but less severe. The tension, however, in serous cyclitis is apt to be increased and the pupil is usually dilated. (See Choroiditis Serosa.^ Cyclitis Purulenta — In this there is a very marked lymphoid infiltration. The pus will extend into the aqueous humor, form- ing an hypopyon, which in purulent cyclitis ma}^ come and go very quickly. The disease, as a rule, passes over into panoph- thalmitis, in which there is a suppuration of the whole eyeball with subsequent atrophy. In sub-acute cases we may find a diminished tension, but there is generally increased tension. All the symptoms of the plastic form are present in this, and even of a higher degree. Causes. — Cyclitis, when not dependent upon other inflamma- tions, most frequently results from some form of injury, as in con- tusions of the e3^e or penetrating wounds in the ciliar\^ region; after cataract operations where the incision was far back in the sclera: from dislocation or swelling of the lens from rupture of its capsule. It ma}^ occur from a prolapse of the vitreous through a scleral wound, or from a contraction of scars in the ciliary region. It may, however, be spontaneous so far as any direct cause can be determined, and is often from sympathetic inflammation. It chiefly occurs as secondary to inflammations of the iris or choroid. Prognosis is most unfavorable in the purulent form, as it gen- erally leads to suppuration of the entire eye. In the plastic form the prognosis is also unfavorable, because from its pathological 314 DISEASES OF THE CILIARY BODY. changes, the vitreous loses its nutrition, becomes fluid, the retina detached, lens cataractous and the eyeball becomes atrophied. Treatment should first be directed to the cause. If depend- ent upon a foreign body, it may be removed by the magnet; if due to a dislocation or swelling of the lens, remove it; if there is a wound with a prolapse of the iris, it should be drawn out and cut off and a compress bandage applied. The treatment of inflammation in this portion of the uveal tract will depend almost exclusively upon internal medication. The eye must be kept warm, as in iritis, and Atropine may be neces- sary, as the iris is liable to become involved, but must be used with caution from the danger of increased tension. Special indi- cations for remedies are to be found under Iritis, page 296. Injuries Implicating the Ciliary Region are not only dan- gerous on account of inflammatory complications, but as a cause of sympathetic ophthalmia. Simple incised wounds ma}^ readily unite by keeping the eye at rest, or it may be necessary to use a fine suture, which should be inserted from within outward in both edges of the wound. Extensive injuries in this region will usually necessitate enucleation, though under certain circum- stances the eye may be preserved, providing the patient is in- telligent and will attend to the first unfavorable symptoms which may arise. Foreign bodies must be removed, if it is possible, wittyout too much injury to the tissues, or the eye must be sacri- ficed. Nettleship has called the region of about 5 mm. around the cornea the " dangerous zone," because an injury of this zone is almost certain to implicate the ciliary body. Paresis Musculi Ciliaris. — Paralysis of the Accommodation. — This may be either partial or complete, and the cause may be either local or general. If but one eye is affected, the cause is more apt to be local, affecting the third nerve in some part of its course, and the primary cause may be syphilis. Some injury of the eye or orbit may cause it, through some reflex influence, as may also some irritation of the fifth nerve, as in decayed teeth, etc. Exposure to draughts of, air may also cause a one-sided paralysis of the accommodation. When the paresis affects the ciliary muscle of both eyes the cause is more apt to be general and PARESIS MUSCULI CII.IARIS. 315 often from some constitutional disorder. The most frequent cause is diphtheria and comes on usually during convalescence or some time after. Paralysis of the accommodation is also seen after fevers, such as typhoid and recurrent fever. It also occurs in diabetes, articular rheumatism, locomotor ataxia, after debili- tating excesses, as masturbation, sexual indulgence, etc. It is sometimes found due to uterine disease and from syphilis. Ex- posure to draught is a very frequent cause, and it has often been seen following la grippe. It is also present with paralysis of the external muscles in total paralysis of the third nerve. The diagnosis of paralysis of the ciliary muscle depends upon the one constant sjmiptom, viz., the diminution or complete abolition of the amplitude of accommodation from a recession of the near point. This will always be suspected in subjects who formerly had good vision for near objects, but find they can only see well at a distance. The pupil will usually, at the same time, be dilated, though frequentl}' there will be a paresis of ac- commodation without mydriasis. Prognosis is, as a rule, in these cases favorable, for as the ma- jority of cases result from diphtheria, fevers, etc., the proper treatment will effect a relief. It must be borne in mind, however, that the paral5'sis of the accommodation may be the forerunner of some grave general condition which may be of serious import to the life of the patient, as, for example, when due to diabetes, to some obscure cerebral or spinal disease, etc. Hence the progno-is always depends upon a correct diagnosis as to the cause of the malady. Treatment. — The cause of the parah'sis must be sought out and given due consideration in the treatment. As precautionary measures, all convalescents should be carefuU}^ warned of the danger of overtaxing the e3"es. The use localh^ of Eserine or Pilocarpine, of sufficient strength to slightly contract the pupil and stimulate the accommodation, is of great value. Eserine is the most active of the two, and the best results are had from a weak solution of the sulphate. A one -tenth to one-half grain to the ounce solution, instilled once or twice a day, is sufficient and usually better than a more concentrated solution. Pilocarpine is less energetic, and a solution of from two to four grains of the muriate to the ounce ma}^ be instilled once or twice a day if any unpleasantness is experienced from the Eserine. 3l6 DISEASES OF THE CILIARY BODY. Galvanism should also be employed, using from two to five milliamperes, with the positive pole applied to the base of the occiput and the negative over the closed lids. The current should be applied for two or three minutes daily. Patients may also be allowed moderate use of the eyes for necessary work with the proper convex glass. The use of the appropriate remedy will also be of much service, and attention is especially directed to Aeon., Argent, nit., Canst., Gels., Opium, Paris quad, and Physostig. See indications under Paralysis of the Ocular Muscles, page i6o. Spasmus Musculi Oiliaris. — Spasm of the Accommodation. — This may be clonic, when existing only during convergence, or during fixation for distinct vision and ceases when the eye is in repose; or tonic, when it is permanent and only yielding to mydri- atics. Spasm usually affects both eyes in an equal degree, but may exist in one alone, or be of a greater degree in one eye than in the other. Spasm of the ciliary may occur in normal eyes or in any refractive error of the eyes. It causes a decrease of the hypermetropia and an increase of the existing myopia. It may produce an apparent astigmatism or conceal a real one. Patients will usually complain of an indistinctness of distant objects, while near objects are held closer to the eye than they should be, and they will have tired, strained feelings of the eyes together, with headaches upon using the eyes. There may be in some cases a tendency to convergence of the eyes, owing to the intimate relation between accommodation and convergence. Spasm of the accomaiodation is frequently found in children wnth hypermetropia from the strain occasioned by use of the eyes; it may be produced in emmetropes from prolonged use of the eyes and in myopes from the use of too strong glasses. As other local causes we find it in injuries of the eye, in inflam- mation of the cornea, conjunctiva, sclera or lids. It may occur as symptomatic of affections of the central nervous system, as in epi- lepsy and hysteria. Spasm of the ciliary muscle may or may not be associated with contraction of the pupil. The condition occurs most frequently among asthenic subjects and more especially among young girls. The diagnosis of spasm depends upon a comparison of the apparent refraction with that which is real, as IRIDO-CHOROIDITIS. 317 determined by an examination under the influence of a mydriatic. Treatment. — In aggravated cases of spasm of the ciliary mus- cle the regular and prolonged use of Atropine or the constant use of convex glasses may be necessary, but usually internal medica- tion, with rest of the eyes for near work, will sufi&ce to diminish the spasm; after which any anomal}^ of refraction may be cor- rected. Jaborandi. — In spasm of the accommodation, or irritability of the ciliary muscle, there is no remedy so frequently useful as this. Many cases of simulated myopia have yielded to its use. Every- thing at a distance is blurred without concave glasses, though near objects are seen distinctly. The vision may be constantly changing. Nausea or vertigo 07t using the eyes. Eyes tire easily and are irri- table, especially on sewing. Twitching of the lids and pain in the eyeballs. Spasm of the internal recti muscles. Eserine. — Dr N. L. Macbride has pointed out the value of this drug in spasm of the accommodation, and has found it of much value in young hyperopes of slight degree, associated with headache and general asthenopic symptoms. The physiological action of Eserine is to produce an almost perfect picture of spasm of the accommodation. Physostigma ven. — In its proving there has been developed marked spasmodic action of the ciliary muscle and muscles of the lid. It has, therefore, been used with manifest advantage in these conditions, particularly the former. The patient cannot read long on account of this spasm and must bring the book near the eyes. There is also generally to be seen twitching s in the lids and around the eyes when Physostigma is required. The pupil is contracted. Agaricus. — In spasm of the ciliary muscle especially if asso- ciated with spasm of the lids or general chorea. Tzvitchings of the eyelids. Lilium tig. — Spasm of the accommodation in low degrees of myopic astigmatism, when the cylindrical glasses are not worn with comfort. Nux, Puis, and Sulph. have also been used with benefit, as may any of that class of remedies denominated as antispasmodics. Irido-choroiditis {Irido-cycHtis) .—0^\xi% to the fact that the iris, ciliary body and choroid form one continuous tissue, any in- 3l8 DISEASES OF THE CILIARY BODY. flammation involving one structure is prone to extend through the whole uveal tract. There are in irido-choroiditis, as in both iritis and cyclitis, three pathological changes that may occur, viz.: Plastic, serous and suppurative, each taking on the same changes as have already been detailed under the iris. Clinically the disease may be divided into two forms. The first form is the result of an iritis in which there has been posterior synechiae, with exclusion of the pupil. In this the pupil may remain clear, but there is soon noticed a gradual bulging for- ward of the iris, in one portion, in knob-like protuberances which may be confined there or extend, involving nearly the whole iris. The bulging is due to an accumulation of fluid in the posterior chamber and occurs in spots, because the inflammation of the iris has weakened the tissue at these points. The iris is discolored, its fibrillae appear stretched and its veins are enlarged and tortuous in their course. The tension soon becomes increased, but, as the disease advances toward an atrophied ball, becomes diminished. The vitreous is diffusely clouded, there is ciliary injection, con- siderable pain, which is usually worse at night; the eyeball very sensitive to touch and the anterior chamber is shallow, due to the bulging of the iris. The second form of irido-choroiditis may be called a parenchyma- tous variety; as there is a considerable swelling and proliferation of the connective tissue, with an engorgement of the vessels throughout the whole uveal tract. There is occlusion of the pupil and gummata may be found. A false membrane, tough and tena- cious, forms behind the iris and may extend back over the ciliary processes and choroid. This membrane becomes organized, ad- heres closely to the capsule of the lens and may undergo second- ary contraction, causing possibly a rupture of the capsule of the lens or detachment of the ciliary body. In the later stages the retina may be detached and the plastic exudation on the choroid may become cartilaginous or bony. In this form there is no bulging. The iris is perfectly straight, though it may be pressed forward, with occlusion of the pupil. The anterior chamber is shallow. The iris is discolored, appear- ing of a dirty-red; its tissue is stretched, and large vessels are seen coursing across it. The tension is increased at first and later diminished. The vision is destroj^ed, and, when it is lost early in IRIDO-CHOROIDITIS. 319 the disease, the choroid is probably the seat of the original inflam- mation, as when the disease commences in the iris the loss of vision does not come on as rapidl3\ Course. — Irido-choroiditis is usually chronic in its course and the disease generally terminates in an atrophy of the ej^eball. In rare cases it may, however, come to a standstill, the form of the eye be saved and still more rarely some vision be restored. Causes. — The most frequent causes are the adhesions between the iris and lens, which result in frequent recurring attacks of iritis with more and stronger adhesions until there becomes an oc- clusion of the pupil, and, if then another attack of iritis occurs, it will almost inevitably lead to an involvement of the ciliary body and choroid. Trousseau^ describes a peculiar form of irido- choroiditis with h3'pop3'on recurring regularh^ a few days before the menses and disappearing in a few da^'s. The condition lasted for a long time, extending through the period of one pregnancy, ceasing with the menses during gestation and returning again after pregnanc3^ Similar cases were reported by others, Irido- choroiditis may also arise from injuries or wounds of the e^'e, as from foreign bodies, after operations, especiall}^ cataract extrac- tions. It also is apt to occur as sympathetic ophthalmia in conse- quence of an injur}- to the other e3^e. Prognosis. — As a rule the prognosis in irido-choroiditis is un- favorable, but depends somewhat upon the extent of the intra- ocular changes. If seen early, before the vision and field of vision have become much impaired and there are but slight changes in the iris, it ma}^ be more favorable. Treatment. — Our first object should be to prevent the disease, if possible, by pfoperh- treating every case of iritis, so that no pos- terior synechiae ma}^ remain to cause inflammation. In order to do this and also to prevent or break up adhesions which ma}' tend to form betw^een the iris and lens. Atropine should be energetic- ally employed as early as possible and continued during the course of the disease, unless there is exclusion or occlusion of the pupil, where it will be of little service. Leplat f reports several cases of irido-cyclitis in elderly people and cautions against the use of Atropine in such cases where the tension is increased, and claims better results are to be had from using Eserine, and, if necessar}-, *Soc. d'Opht de Paris, June 3, 1890. t Ann. de la Soc. med.-chir., de Liege, 1889. 320 DISEASES OF THE CII.IARY BODY. puncture, combined with subcutaneous injections of Pilocarpine. If we have to deal with that form of irido-choroiditis in which the iris is bulged forward in knob-like protuberances, with complete adhesion of the pupillary edge of the iris to the lens, an iridectomy is indicated; but if it is the parenchymatous variety, with adhe- sion of the whole of the posterior surface of the iris to the lens, iridectomy will do more harm than good. If a foreign body should be the cause of the inflammation, it must be removed if possible, though when the injury in the ciliary region is very great, it is better to enucleate the eye in order to prevent trouble in the other. If the inflammation of the uveal tract is caused by sympathetic irri- tation from an injured eye — and this is the most common form of sympathetic ophthalmia — the injured eye, especially if sight is lost, should be removed upon the first symptoms of irritation or as early as possible, unless the inflammatory process is very severe, when it may be better to wait until it has subsided in some de- gree. If there is some sight in the injured eye, it is often difficult to decide whether enucleation is advisable or not. As a rule, an eye that has been lost from any cause and which remains painful, even if there are no symptoms of irritation in the healthy eye, should be removed. The irritation being probably transmitted by the ciliary nerves, division of these nerves (optico-ciliary neurotomy) has been recently proposed as a substitute for enuclea- tion. It may be adapted to rare cases. In old cases, in which the lens has become cataractous, it should be removed. In the treatment of all forms of inflammation of the uveal tract complete rest of the eye for a long period must be insisted upon. In acute cases the patient should be confined to the house and treated as for iritis. In chronic cases it is better to allow moderate exercise in the open air, with the eyes protected by a bandage or colored glasses. The diet should be nutritious and generous, especially if the patient is feeble and ill-nourished. The chief reliance must be placed upon internal medication, but for special indications refer to the therapeutics of iritis and choroid- itis. The following remedies, however, have been more commonly used with advantage and would be among the first suggested to our minds: Rhus, Gels. , Kali iod. , Bry. , Merc. corr. and iod. , Bell. , Sil., Hepar, Apis, Ars. , Asaf., Aur., Prunus spin., Sulph., and Thuja. SYMPATHETIC OPHTHALMIA. ^21 CHAPTER XVI. Sympathetic Ophthalmia. Numerous affections of the eye are supposed to be due to a pre- existing inflammator}^ condition of the other eye and hence are called sympathetic. The most frequent form of sympathetic in- flammation is that of irido-cyclitis, or irido-choroiditis. It is claimed by many writers that we maj' have a sympathetic iritis, keratitis, choroiditis, neuritis, retinitis, etc. Fuchs and some others, however, question if these diseases are the result of sympa- thetic involvement. Glaucoma even has been considered by some as possibly occurring from sympathetic irritation, although this is now disputed by the best authorities. As the disease may as- sume so many varying forms and may result in pathological changes in nearly all the structures of the eye, a special study of its pathology is therefore too complex to be undertaken here. We will, consequently, content ourselves with simply referring to the pathological processes detailed under the study of the other diseases and especialh^ those of the uveal tract. This disease, in its more serious form, is of the greatest importance, for, if not cut short in its earlier stages, it almost inevitabh' leads to blind- ness. The disease has what may be termed a prodromal stage, during which it is called sy7npathetic irritation. At this time the patient complains that the eye soon grows tired on using it. There is more or less sensitiveness to light, lachrymation and slight peri- corneal redness. The most important symptoms at this period are, a failure in the vision and a diminution in the range of accommo- dation, ownng to the affection commencing usually in the ciliarj^ body. During this stage there is also apt to be found a more or less sensitive spot in the diseased eye. These symptoms of slight irritation of the eye may exist for a long period, or possibh' might never lead to the dreaded sympathetic inflammation, but as a rule there is a gradual increase of the pain and cloudiness of the aque- 21 322 SYMPATHETIC OPHTHALMIA. ous with a decrease of the visual acuity, as the stage of sympa- thetic inflammation sets in. Sympathetic ophthalmia may also set in without any of the previous symptoms of sympathetic irri- tation. Symptoms. — There is a loss of vision, due to haziness of the vitreous, which in the early stages is diffuse, but later we find large opacities floating about. Photophobia, lachrymation and ciliary neuralgia are present in varying degrees in different cases. The ciliary region is very sensitive to touch. The range of ac- commodation, when it can be tested, is much diminished. There may be ciliary injection, or chemosis and the lids may be red and swollen. On examination of the eye we find the aqueous is hazy, due to the exudation into the aqueous from the ciliary processes, and this exudation may be deposited in masses on the endothe- lial layer of the cornea. The exudation extends into the iris and we have posterior synechiae, which form very rapidly, even re- sulting in complete exclusion within twenty-four hours, but may be more gradual. As the exudation goes on the iris becomes very much swollen, a false membrane forms attaching it to the lens throughout its entire extent, resulting in complete occlusion of the pupil. There is a venous engorgement of the iris, and its en- tire structure becomes degenerated The anterior chamber be- comes shallow, the opacities in the vitreous increase all the time, the choroid becomes affected and we have an inflammation of both the choroid and retina. The periphery of the iris is drawn back and its pupillary edge, together with the lens, is pushed forward. Vision at last becomes entirely lost. The tension is in- creased during the early stages, but later becomes diminished. The field of vision becomes contracted very early in the course ■of the disease. The foregoing describes a marked or severe form of sympathetic inflammation, but we may have a more mild type of the disease, which assumes a serous rather than a plastic form of inflammation. In this there will be some pericorneal injection, the iris somewhat discolored, with a few slight adhesions and the sight slightly re- duced In some cases there may be a papillitis or neuro-retinitis, and in these light cases the eye may entirely recover. Other more rare conditions, such as conjunctivitis, keratitis, etc. , have been reported as due to sympathetic irritation and have been relieved upon removal of the diseased or exciting eye. SYMPATHETIC OPHTHALMIA. 323 Causes. — The most frequent causes of sympathetic inflamma- tion are foreign bodies and injuries, especially when occurring in the ciliary region; operations at the corneo-scleral junction, as in cataract extractions, contraction of scars, or rupture of the sclera at the ciliary region, previous inflammations of the e5^e where the eye has become atrophied and especially when accompanied by chalky or bony formations within the eye, intra-ocular haemor- rhages or contusions of the eye, prolapse of the iris and anterior synechiae, external irritation of an atrophied ball, as when an arti- ficial eye is worn upon a shrunken stump, and in fact any eye that has been lost and is painful may awaken a dormant tendenc}^ to sympathetic inflammation. The period during which there is a danger of transmission of S3'mpathetic inflammation varies from two weeks to thirty years; the most frequent period, however, seems to be from four to eight weeks. There is, then, practically no period during which an in- jured or diseased eye may not be the cause of sympathetic irrita- tion of its fellow. From the statistics of this disease by Gunn and others there seems to be no difference in the result or severity of the sympathetic inflammation, whether there is a short or a long interval between the primary lesion and the onset of the sympa- thetic disease of the other eyQ, According to some there is a greater tendency to sympathetic ophthalmia in young individuals, while others hold that there is less. It is also claimed by some that it never occurs unless there is a perforating lesion of the ex- citing eye; or, at any rate, that it is extremel}" rare. As to the method of transmission of the sympathetic irritation very much has been written and man}- experiments made, still the exact mode is far from being definitely settled. The condition , it seems to us, from the experiments of the various investigators of this subject, may be transmitted either through the ciliar}^ or the optic nerves, with the weight of the evidence in favor of the former. Mackenzie in 1840, and followed later by Alt, Leber and Deutschmann, by means of experiments and microscopi : examina- tions, have argued in favor of the optic nerve being the path along which the affection extends. Deutschmann* made experiments upon rabbits, first by injections of spores of the aspergillus fumi- *v, Gra-efe's Archiv. fiir Ophthalmol ogle, xxviii., 2; xxix., 4; xxx., 4. 324 SYMPATHETIC OPHTHAI^MIA. gatus into the vitreous, with the result of causing choroido-iritis in the injected eye, and four weeks later the same condition, to- gether with opacities in the vitreous, was found in the other eye. Microscopic examination revealed an interstitial neuritis extend- ing up to the chiasm and down to the other eye by way of the optic nerve. Later he resorted to the pus organisms for the inocu- lating material and made injections of a suspension of staphylo- coccus pyogenes aureus. Subsequent microscopic examination reveals purulent infiltration of the optic nerve, with diminishing intensity up to the chiasm, and then with increasing intensity down to the other eye. He, therefore, concludes that sympathetic ophthalmia is propagated through the optic nerve. A few years later Deutschmann* published his views in a very complete paper and claims that the disease is a process of microphj^tic origin, passing from one eye to the other through the optic nerve appa- ratus and suggests that the name ophthahnia migratoria better expresses the character of the disease than does sympathetic ophthalmia. He also claims that it should be kept separate from an affection of the other eye dependent upon an irritation of the ciliary nerves of the first eye, and which should be called reflex irritation. In opposition to these theories of optic nerve trans- mission we find H. Mullerf pronouncing in favor of the ciliary nerves. Randolph J details numerous exhaustive experiments upon both dogs and rabbits, made with the expectancy of confirming Deutschmann's results, but in no instance was sympathetic oph- thalmia a sequel of the operation, and hence his results were en- tirely negative so far as confirming those obtained by Deutschmann. Galezowski§ thinks the inflammation is carried from one eye to the other through the ciliary nerves and their lymph channels and not through the optic nerve. Further, the fact that sympathetic ophthalmia is most frequently apt to occur after wounds in the ciliary region, and also that it never, or very rarely, occurs in sup- purative diseases of the eye, such as panophthalmitis, where the ciliary nerves are destroyed, leads us to think that the most fre- quent path of the transmission is through the ciliary nerves. * On Ophthalmia Migratoria (sympathetic ophthalmia) Hamburg and Leipzig, 1889. t-'^i'chiv. Ophthal. (Graefe), vol. iv., i, 1858. JArchiv. Ophthal., June, 1888, p. 188. I Soc. d'Opht. de Paris, October 7, 1890. SYMPATHETIC OPHTHALMIA. 325 Prognosis. — In the prodromal stage, or that of sympathetic ir- ritation, the prognosis ma}^ always be considered favorable; but if later, after exudation has taken place, it is unfavorable, as in the majority of cases the disease leads to blindness. The prognosis is always more favorable when the course of the disease is slow, rather than rapid, and more favorable in the serous than in the plastic form. Treatment. — Our attention should first be directed to the ex- citing eye, and in all eyes where we find it at all irritable, sensi- tive to touch and the vision lost, an enucleation of that e^'e should at once be made. If the affected eye is only in the stage of pro- dromal irritation, the removal of the eye which is creating the sj'mpathetic irritation will usually result in at once checking the disease and restoring the eye to its normal condition. If the ex- citing e3'e contains a foreign bod}^ which cannot be independently removed and is itself undergoing inflammatory changes, it should be removed, even though possessing more or less vision, as that eye will probably be lost, and, by its removal, the other may be saved. The advisability of removing an exciting eye when it has a certain amount of vision, in a plastic form of sympathetic ophthalmia, is ^ decidedly delicate question, because there is a ver}^ grave probability of losing the sympathetic eye, while the eye originally causing the irritation may come out with the best vision. Enucleation should alwa3's be practiced in the irritative stage, if possible, as often, if delayed until the sympathetic eye has be- come actively inflamed, its removal then will not serve to check the progress of the disease. In all cases where one eye has be- come lost, and especially when from injuries or wounds in the ciliar}- region, the patient should be thoroughly cautioned as to the possibilit}^ of its serving at any time to cause destruction of the other eye from sympathetic ophthalmia and its removal ad- vised. If enucleation is not submitted to at this time, they should be warned of the importance of immediate attention upon the slightest sign of any pain or irritation. EniicleatioJi or Evisceration as described on page 271 is the best operative measure for sympathetic ophthalmia. Op tico- Ciliary Neurectomy . — The operation of division of the optic and ciliary nerves behind the eyeball has been advised 326 SYMPATHETIC OPHTHALMIA. and practiced by some. Its only claimed value is in the retention of the eye. Schweigger and others recommend it as a preventive measure; but, as a remedy in the inflammatory type, it is untrust worthy, and even in the stage of irritation it ranks below enuclea- tion. The operation is best performed by division of the internal rectus muscle, and dissecting back with the blunt scissors to the vicinity of the optic nerve. Then, by rotating the globe outward, insert a strabismus hook, with which you catch up the optic nerve and drag it out as far as possible. The scissors are now inserted over the hook and the nerve severed as near to the apex of the orbit as possible; the nerve is then drawn out, and, with the for- ceps and scissors, cut off all the nerve tissue possible close to the eye. The e3^e is then restored to its place and the muscle and conjunctival wound closed with sutures. Profuse haemorrhage and reaction are apt to follow from this operation. In addition to the operative measures when an eye is sympathet- ically inflamed it should be given the same treatment as that for irido-choroiditis. The use of Atropine to dilate the pupil and relieve the pain may be tried, if there is not an exclusion of the pupil, when it had better not be used. The patient should be kept at rest in a darkened room. Hot fomentations or the cotton pad may be applied. Ice has been employed in some cases, though as a rule it is not advisable. Recently the sub-conjunctival injection of the bichloride of mercury has been greatly lauded by Darier and others in diseases of the uveal tract. My own ex- perience has given me no beneficial results from these injections. Iridectomy has been recommended, but sclerotomy is better, if the tension is increased and the eye painful, but it is far better to make no operation upon the affected eye during the inflammatory stage and not until long after it has become quiescent, as there is grave danger of lighting up another attack. The remedies most apt to be of value are Bell., Merc, Sil., Kali iod. , Rhus tox. and Bry. For special indications see Part II. ANATOMY. 327 CHAPTER XVII. Diseases of the Choroid. Anatomy. — The choroid is that portion of the uveal tract ex- tending from the ciHary body backward to the optic nerve. It Hes between the retina and the sclera and is principally composed of blood-vessels and pigment. The choroid may be considered the nutrient membrane for the interior structure of the eyeball, and consists of four layers. The outermost layer is composed of loose connective tissue and of irregular shaped pigment cells; these con- nective tissue fibres extend into, and are derived from, the sclerotic, and the meshes of these fibres form spaces conveying lymph. This lymph space is held to be in direct communication with that of the capsule of Tenon and the other lymph-spaces of the eyeball. In separating the choroid from the sclera, these fibres are necessarily torn, and that portion remaining adherent to the choroid has been termed the lamina supra-choroidea, and that part remaining at- tached to the sclerotic, the lamina fusca. The next layer is that of the tunica vasculosa — a laj^er of large blood-vessels which forms a large portion of the parenchyma of the choroid. The third layer, known as the chorio-capillaris, is made up of the finer branches or capillaries of the arteries and veins of the tunica vasculosa. These two la3^ers, together with a small amount of connective tissue, some elastic fibrillae, and cells, both pigmented and unpigmented, form the parenchyma of the choroid. The blood supply of the choroid (see Fig. 65) is chiefl}^ derived from the short posterior ciliary arteries, which pierce the sclerotic obliquely and enter the choroid and branch off, anastomosing with the long posterior and the anterior ciliary arteries. The veins, beginning as capillaries in the chorio-capillaris, take, in the tunica vasculosa, a whorl-like form and uniting into from four to six large trunks called the venae vorticosae, pass obliquely 328 DISEASES OF THE CHOROID. through the sclera at about the equatorial region of the eye and empty in the ophthalmic vein. A small amount of the blood from the anterior part of the choroid passes out through the anterior ciliary veins. The parenchyma of the choroid also contains a great many nerves coming from the short and long ciliary nerves and which form in the choroid fine plexuses of nerves with many ganglionic cells. The most internal layer of the choroid is called the lamina vitrea or elastica. It is an elastic and perfectly trans- parent membrane, upon which the (uveal) pigmented epithelium lies. This pigmented epithelium, lying between the choroid and retina belongs to the latter but remains attached to the choroid when the retina is removed from the eye. Nearly every patho- logical condition of the choroid exerts an influence upon this la37er of pigment, while important changes are apt to occur in the retina without any alteration in these pigmented epithelial cells. As it is anatomically a part of the retina, we will consider its further description under that membrane. Hyperaemia of the Choroid. — Owing to the general con- tinuity of tissue with the ciliary body and iris, and to its excessive vascularity, the choroid is necessarily very apt to become hyper- aemic from almost any inflammatory changes of the eye. In fact, hyperaemia of the choroid undoubtedly is present more often than is generally recognized. The diagnosis is difiicult to~make on ac- count of the pigment layer in front of it, and is especially so in dark people. In blondes and albinos the choroidal vessels may be seen and the diagnosis aided. The only symptoms, however, of diagnostic value are a diffuse hypersemia of the optic disc and a woolly appearance of the pigment layer. Hypersemia of the choroid is distinguished from a hyperaemia of the optic nerve and retina by the fact that in the former the redness of the disc is diffuse and its outlines are sharp and well defined, while in hypersemia of the nerve and retina the outlines of the disc are ill- defined and the redness has more of a striated appearance. The treatment is detailed under that of choroiditis in general. Choroiditis. — The appearance of the healthy choroid must first be carefully studied before one can fully appreciate changes, whether inflammatory or otherwise, of its structure. The color CHOROIDITIS SEROSA. 329 of the fundus of the eye, when examined with the ophthalmo- scope, varies in different individuals according to the amount of pigment granules contained within the pigment or uveal layer. In fair persons we find the fundus appearing of a yellowish-red color and the vessels of the choroid can usually be plainly seen (See Chromo Lithograph, Plate ii. Fig. i.); in darker persons and negroes the color varies from a brownish red to a slate-color and the choroidal vessels are entirel}" hidden by the pigment layer. The color and intensity of the light used and the extent of the dilatation of the pupil also serve to affect somewhat the color of the fundus. Great alteration ma}'- take place in the choroid and nothing be discernible; in fact, in some cases it is onlj^ when the retinal pig- ment-cells have become affected b}^ the pathological process that ophthalmoscopic changes are observed. Hence, characteristic appearances of choroiditis are onl}^ seen w^hen the retina has be- come affected as well; that is, when the disease has become a choroido-retinitis. Clinically, however, the disease is still a choroiditis, even though the outer layer of the retina has become secondarily affected. In choroiditis the eye shows no external evidence of disease (except in suppurative choroiditis), and is only manifested to the patient by a loss of vision and to the physician by the ophthalmoscopic appearance. Inflammation of the chor- oid may be the same as in other divisions of the uveal tract, of a serous, plastic or purulent type. Choroiditis Serosa. — Is considered by some authorities as a form of glaucoma. The consideration of serous inflammations of the uveal tract is a subject of great disagreement among the various authorities. We have referred to each disease separately because each division of the uvea, the iris, ciliary body, and chor- oid are certainly susceptible to separate involvement by other pathological processes, and we cannot conceive why there may not be a serous inflammation of either structure alone. As a rule, however, we usually find a serous inflammation involving the choroid, ciliary body and iris at the same time, and while it may commence in one structure it probably rapidly extends to the others and perhaps should more properly be termed a serous uveitis. As the cornea is also usually affected in serous uveitis, it 330 DISEASES OF THE CHOROID. may be that the disease described as descemetitis is merely a manifestation of the similar process in the cornea through a direct extension by continuity of tissue. Pathology. — There is at first a general or localized hyperaemia, especially affecting the veins of the choroid. Following the hypersemia there is either a serous or sero-fibrinous exudation, which is found extending inward either into the pigment layer of the retina, between the retina and vitreous, or into the vitreous body itself. The increased secretion of a serous fluid within the eye may, when the channels of excretion have become altered or obliterated, result in glaucomatous symptoms. Symptoms. — There may be slight ciHary injection and the dotted appearance of the cornea, as in serous iritis. The aqueous and vitreous humors are slightly hazy, causing a general indis- tinct and hazy appearance of the fundus. Fine floating opacities may be discovered in the vitreous and vision is impaired in pro- portion to the opacity of the media. The tension should always be examined, as it is very liable to become increased and glau- comatous symptoms set in. Serous choroiditis seems often to be associated with syphilis, rheumatism or gout, and generally oc- curs as a complication of serous iritis. The treatment is the same as with other inflammations of the choroid, but the use of remedies, especially Gels, and Bry., is very essential. Choroiditis Disseminata Simplex. — Simple disseminated choroiditis is of the plastic form of inflammation. Pathology. — Plastic choroiditis never attacks the whole choroid, but takes place in small patches, which may coalesce and grow larger. The hyperaemia in this form is followed by a fibro- cellular exudation into the stroma of the choroid, and we find numerous small nodules composed of a fibrinous substance and round cells. There is also a lymphoid infiltration along the ves- sels, which makes them appear as yellowish-white striae. The retina and pigment layer at this stage are normal, or only slightly elevated by the underlying infiltration. Absorption may take place at this stage, leaving the stroma of the choroid normal. If the process goes on, there is a proliferation of the pigment layer over the nodules, the exudation presses more and more upon the CHOROIDITIS DISSEMINATA SIMPLEX. 33! retina, the layer of rods and cones become involved and the tissue of the retina is affected. The proliferation of pigment extends into the external granular la3^er, and, when the exudation ex- tends deeply into the retina, the radial fibres of the retina run into the exudation and become united with the fibrillated struc- ture of the nodule. In the later stages the cell elements gradu- all}^ disappear and the fibres retract, leaving a depressed retinal scar. The cells covering the exudation lose their pigment and may be totall}' destroyed. Their pigment, having thus been freed, is taken up b\' the cells at the peripher}^ of the patch of exudation, and then we have the characteristic white atrophic spot surrounded by a dark pigmented border. Symptoms. — The subjective symptoms of this disease are not at all prominent or characteristic. They will simplj^ complain that their eyes feel a little weak and that the vision does not seem quite as clear as formerly. Very frequently we find, upon oph- thalmoscopic examination, extensive choroidal changes with little or no loss of the visual acuit3^ Randolph-'^ reports two cases of very pronounced disseminate choroiditis with preservation of normal acuteness of vision. Often there is some night-blindness in those cases of marked choroidal changes, even when the vision is good. Slight scotomata are frequently complained of, especially in the later stages, and upon testing the field of vision we are apt to find it somewhat contracted. All the subjective symptoms are apt to be more marked during the stage of exudation than in the atrophic stages of the disease. The extent of the visual dis- turbances and the other symptoms depend, in a great measure, upon the location of the disease — if near the periphery, the effect is of course much less than when occurring at or near the macula. As the disease advances toward the macula the patient may complain that objects looked at appear distorted (jnetamorphopsia) . This is due to the exudation causing a change in the relative position of the percipient elements of the retina. Again, all objects may appear diminished in size (^micropsia) or unnaturally enlarged {^macropsia) . In micropsia there is, owing to a fresh exudation, a separation of the retinal elements at the point of such an exudation, and the image of any object falling on such a point affects a smaller number of retinal elements than normal and the *Archiv. Ophthal., vol. xviii., 4, 1889. 332 DISEASES OF THE CHOROID. object appears smaller. In macropsia, on the other hand, there is a greater approximation of the retinal elements, due to the con- traction of an old exudation or some other atrophic change, and objects appear enlarged. Hyperaemia of the disc and haziness of the vitreous may sometimes be present when the disease has reached the neighborhood of the optic disc; or, on the other hand, if the disease extends far forward, it may result in some affection of the ciliary body or iris. The most characteristic indications of choroiditis are, however, only to be determined by an ophthalmoscopic examination In the early stages, if occurring in dark persons, it is difficult or impossi- ble, owing to the greater amount of normal pigment, to recognize the first changes. If, however, the patient is a blonde, there is first seen a slight injection of the choroid in spots. Following this, in the stage of exudation, there may be seen numerous yel- lowish-red nodules, of a more or less circular shape, varying in size, scattered about through the equator of the eye. When the disease is acute, there may be slight haziness of the retina around the optic nerve, and possibly slight haziness of the vitreous. After a longer or shorter period the color of these plaques of ex- udation changes to a yellow and later to a white, or a bluish-white appearance, and, owing to the pigment proliferation around their borders, become surrounded by bla^k masses of pigment. (See Chromo-Iyithograph, Plate II., Fig, 4). The stage of the disease is determined by the appearances of these patches, which are, in the atrophic stages, white in color — due to the showing through of the sclera and to the cicatricial tissue itself, they have irregular margins, more or less surrounded by pigment, and choroidal vessels may be seen here and there passing through the white spot. In the stage of exudation the choroidal vessels are entirely hidden and the color of the patches are of a yellowish red, with no pigment. In atrophy there is a depression or sinking of the patch, while in exudation there is an elevation. Frequently there may be even in the same eye all stages of the disease. Choroiditis Areolaris. — This is only a variety of the dis- seminate form just described, in which the nodules have more of an areolar structure and with great, proliferation of the pigment over the nodule. The patches in areolar choroiditis are usually CHOROIDITIS CIRCUMSCRIPTA. 333 larger, of a round or oval shape, and their location is especially around the optic nerve and the macula. The recent patches ap- pear as very dark masses of pigment. As they grow older they gradually lose their dark color and finally appear white, sur- rounded by a black ring. In this form the pigment spots and exudation bear a certain relation to each other; the pigment spots are first noticed, and, as it progresses, the centre of the patch be- comes lighter, of a yellowish-white appearance, and gradually goes on to a clear white spot surrounded by pigment. The choroid between the patches remains perfectly healthy, and, although the location of the disease is all around the macula, it is usually last affected; but, w^hen it is involved, it often becomes affected sud- denly. This form is especially found in young persons and will exist for a long time with good vision — the macula rarel}^ being involved before middle life. Choroiditis Circumscripta, or Choroido-retinitis Centralis, is simply another form of disseminate choroiditis occurring in and near the macula. There is in this usually the development of a single nodule, but ver}^ rarely there may be two or three, consist- ing of a connective tissue frame- work, with cells and- agglomera- tions of pigment. It arises in the choroid, but extends into the layers of the retina, which are raised at the point of the nodule, but are perfectly normal and healthy around it, thus proving the affection of the retina to be due merely to pressure and not to in- flammation of its own tissue. It goes on to atrophy with shrink- ing of the cicatrix, which draws the retina back along with it. (Fig. 75-) The disease is always uniform in that scattered nodules are never found, and, while there may be more than one nodule, they are always closely arranged around the macula. An ophthalmo- scopic examination shows at first a reddish- yellow, or later a bright yellow^ round or oval spot at the macula. It is in the earlier stages elevated, well defined and may be vascular, while in the later stages it becomes whiter as it goes over into atrophy and then a depression occurs. This form of choroiditis affects vision by causing a very pronounced scotoma, which is persistent and especially anno34ng in the earlier stages; metamorphopsia is also usually complained of. 334 DISEASES OF THE CHOROID. Choroiditis Syphilitica, or Choroido-retinitis Syphilitica, is still another form of plastic choroiditis, the pathological changes in which are the same in the late stages as already described under choroiditis disseminata and choroiditis circumscripta (Fig. 75). In the first stage the disease attacks the epithelial layers, the retina and the vitreous. This form of choroidal affection, if not in- variably, is, in a large majority of cases, a manifestation of syph- ilis, and generally appears in the late secondary or early tertiary stage of syphilis. It seems to be most apt to occur in cases where syphilis has been acquired late in life, is most frequently found affecting both eyes and is sometimes preceded by an attack of iritis. Symptoms. — The characteristic symptoms of this affection are the fine, dust-like opacities of the vitreous, seen upon an examin- ation by the direct method, with a weak illumination (after caus- ing the eye to move rapidly upward and downward), to rise like dust before the wind. The opacities in some cases may form flakes or filaments, which, however, are seen to float up and down in a medium full of the characteristic dust. In certain cases these coarser opacities may increase greatly in size, but the peculiar dust appearance is always present and remains throughout the whole course of the disease. Another peculiarity of this dust-like haziness of the vitreous is that it varies considerably in amount from time to time during the course of the affection, and, owing to this, the vision will improve or diminish often within a few hours. When the vitreous dust is not sufficiently dense to obscure a view of the fundus, we will often see a hypersemic condition of the disc, an indistinctness of its outlines and a slight haziness of the retina. Hemeralopia, or night-blindness, is almost universally present among patients suffering from double specific choroiditis, and, in all cases where but one eye is affected, the size of objects seen with the diseased eye, when compared with the healthy, appear small (micropsia). Another characteristic sign is the subjective perception of luminosities (phosphenes), generally seen as spark- ling scotoma and are always seen upon entering a bright light. The vision is always very much reduced in this form of choroiditis. Course. — This form of choroiditis may run an acute course, re- covering with nearly perfect vision and leaving no trace behind. CHOROIDO-RETIXITIS. Fig. 75- 335 Choroido-retinitis. B, choroid; C, retina; 3, choroidal nodule, to which the retina is attached by its radial fibres, cicatricial contraction well advanced. DD, points showing a reunion of the choroid and retina. 336 DISEASES OF THE CHOROID. More frequently, however, there remains some impairment of vision due to the persistence of vitreous opacities, which may be very dense, or to the changes in the choroid, similar to those in the disseminate form, which may develop gradually in the later stages of the disease. Causes. — Choroiditis of all forms, in a very large proportion of cases, is due to syphilis, and in those cases not resulting from that disease there seems to be a decided hereditary trait. Scrofula, chlorosis, anaemia and similar general disorders of nutrition may cause choroiditis. Other cases are connected with, or extend from, a progressive posterior staphyloma. The disseminate and central forms of choroiditis may occur spontaneously, so far as any direct cause can be determined, while the areolar form seems to occur frequently in tutors, governesses and others of whom it may be said their occupation requires what may be called an intelligent use of the eyes. Gould* reports cases of central choroido-retinitis, which he attributes to ametropia, believing that chronic uncor- rected ametropia may result in permanent lesion in the region of the macula, with pigmentary changes, which he thinks may re- sult from straining of the retina in an effort to secure a clear image. Treatment. ^ — Under this heading we shall consider the treat- ment of the several forms of choroiditis already described. Rest in a darkened room for a long period has been recom- mended for inflammation of the choroid. This, together with bandaging of the eye, will answer in some cases of acute serous inflammation, but its tendency to impair the general health usually renders it unsafe, especially in chronic cases and in the disseminate form of inflammation, in which it is far wiser to al- low moderate exercise in the open air, with the eyes protected from the bright light by smoked or blue glasses. Complete rest of the eyes from all work should always be required. Atropine may be useful in some cases, as it paralyzes the tensor choroidea, thus preventing any movement of the inflamed tissue upon change of light. In the serous variety, if the intra-ocular tension be- comes increased,^ frequent paracentesis may be performed, or if this does not suffice an iridectomy must be made. Abstinence from all stimulants and proper hygienic measures are necessary. ^Archiv. Ophthal., vol. xix., i, 1890. TREATMENT OF CHOROIDITIS. 337 AururQ. — Choroiditis, with or without retinal complication, especially if there is exudation into the choroid and retina or into the vitreous, causing haziness of the vitreous. We may have sen- sitiveness to light and touch, ciliary injection and some pressive pain in the eye from above downward or from wdthout inward, aggravated on touch, or pain in the bones around the eye. A general feeling of malaise and depression of spirits is often present. Kali iod. — It is the remedy for syphilitic choroido-retinitis char- acterized by great haziness and exudation into the vitreous, which may vary from day to day; also for syphilitic disseminate choroid- itis, with little or no haziness of vitreous. Much benefit has been derived from its use in simple disseminate choroiditis even when the atrophic changes in the choroid are far advanced or when the whole uveal tract has. become involved. Mercurius. — The various preparations are used, according to special indications, though the corrosivus or solubis is more often needed. Mercury is of great value in choroiditis, especially dis- seminate, and when the iris is also ijivolved (irido-choroiditis). The syphilitic dyscrasia would particularly point to its use, though it is indicated in non- syphilitic cases. The pains are usually in- tense both in and around the eye, varying to a great extent in char- acter. The nocturyial aggravatio7i of all the symptoms is of im- portance in the selection of this remedy, as well as the general condition of the patient. Phosphorus. — Both serous and disseminate choroiditis have been benefited, especially when accompanied by photopsies ajid diromopsies of various shapes and colors (^red predominating^ . We find in the proving of Phosphorus, that it has produced hypercsmia of the choroid, and experience shows that it is often adapted to this condition. When sexual excesses seem to be the cause of the trouble this remedy is indicated. The optic nerve and even retina ma}^ show decided hyperaemia. Black spots pass before the vision. There may be some dread of light The eyes seem better in the twilight. Particularly suitable to lean, slender persons, and espe- cially if complicated with cough, etc. Bryonia. — Serous choroiditis, or inflammation of the uveal tract, following rheumatic iritis. From serous infiltration into the vitre- ous the haziness is often so great as to seriously interfere with our view of the fundus. The vessels of the fundus are congested; the 22 338 DISEASES OF THE CHOROID. pupils may be somewhat dilated and the tension increased. The eyeball feels sore to touch and 7notio7i, while darting pains through the eye into the head are usually present. Gelsemiuin. — It may be of service in the plastic forms of choroiditis, but its grand sphere of action is in serous inflamma- tion of the uveal tract, especially if anterior to the equator, with great haziness of the humors The impairment of vision will be great; may be slow and gradual or subject to sudden changes. The haziness of the vitreous is usually fine; the tension may be increased and pupil dilated. The iris may be involved, with tendency to posterior synechiae. The pain is dull, aching, press- ing, in and over the eyes; may extend to occiput and be relieved by hot applications. Eyeball sore to touch. Heaviness of the lids. Headache, general depression, loss of muscular tone, fever and thirstlessness. Belladonna. — An important remedy in hypercemia or acute in- flammatory conditions of the choroid, particularly of the dissemi- nate variety and accompanied by congestive headaches. The optic disc is of a deep red color and the retinal vessels enlarged, especially the veins. The pupil is slightly dilated, ciliary injec- tion usually marked and the eyes sensitive to light, with full feel- ing as if pressed out of the head. Disturbances of the vision are often present, as halo around the light and various flashes of light and sparks. The headache and constitutional symptoms decide our choice. Kali mur. — The benefit derived from its use in the absorption of exudations has been demonstrated in exudative choroiditis. Nux vom. — In disseminate choroiditis occurring in persons ad- dicted to the use of stimulants, also when atrophic changes are even far advanced, Nux often seems to materially improve the degree of vision. The eyes are especially weak and sensitive to light in the viorjiing. Gastric derangements and other constitu- tional symptoms are of great importance in selecting this drug. Prunus spin. — Inflammation of the choroid, either with or without iritic or retinal complication. Haziness of the vitreous and other common symptoms of the disease are present, but the characteristic indication will be found in the/>a^>^, which is usually severe, as if the eyeball were being pressed asutider, or else sharp, shooting and cutting through the eye a?id corresponding side of the head^ or crushi7ig in character » CHOROIDITIS SUPPURATIVA. 339 Pulsatilla. — Hyperaemia of the choroid or sub-acute cases of choroiditis occurring in women of a mild, tearful, yielding disposi- tion and when accompanied by amenorrhoea; also in tea drinkers who are subject to neuralgic headaches. Eye symptoms not char- acteristic. Sulphur. — Chronic cases of choroiditis, especially if occurring in a strumous subject. Sharp darting pains are usually present. Often assists in clearing the vitreous and completing a cure after other remedies have been used with advantage. The hemeralopia found in some cases may be relieved. Veratrum vir. — Choroiditis, especially in women with much vaso- motor disturbance. Aching pains in the eyes, becoming sharp in the evening. Photopsies. Painful menstruation and aggravation of eye symptoms at that time. In addition to the above, the following remedies have been em- ployed with favorable results: Aeon., Arsen., Duboisin, Hepar, Jaborandi, Psor., Ruta, Sil. Choroiditis Suppurativa (^Choroiditis Metastatica. Panophth- almitis, Traumatic Purulent Choroiditis) . — The characteristic feature of purulent choroditis is an infiltration and new formation of cells in the parenchyma of the choroid, and, as the disease ad- vances, the whole structure of the choroid and uveal tract be- comes filled with round cells, and the retina and vitreous are infiltrated with pus cells. The purulent inflammation may extend outward and thus may finally result in a purulent infiltration of all the membranes of the eye (panophthalmitis). Schbbl* describes the pathological anatomy in twent3^-seven cases of panophthalmitis, and concludes that, from whatever cause it occurs, it commences as a fulminating purulent retinitis or choroi- ditis, or both together, and from this rapidly extends to the other coats. Symptoms and Course. — The lids are oedematously swollen, red and puffy, the conjunctiva chemosed, and, from the inflam- mation of the capsule of Tenon, there is exophthalmos, with limita- tions in the movement of the eye. The cornea is hazy, the aqueous cloudy and hypopyon rapidly forms. There are posterior synechise, ■^ Archiv. Ophthal. vol. xx., i, [891. 340 DISEASES OF THE CHOROID. the anterior chamber shallow and the tension is liable to be in- creased. The white reflex from the fundus is present and indi- cates the formation of pus within the eye. In this form of choroiditis the pain in and around the eye is usually very severe and the eye is sensitive to touch. Tension of the eye is dimin- ished. The rapid onset and course is apt to be accompanied with high fever, vomiting and other general manifestations. Destruc- tion of vision takes place early and the suppurative process quickly results in perforation and atrophy of the eyeball. Causes. — It most frequently develops after some injury of the eyeball, where a foreign body has become lodged within the eye; or may occur from a slight perforation or incision in which possi- bly some infectious matter has been conveyed into the eye. Thus it may be set up by operations — after the removal of cataracts or any opening of the bulbus, in cases of purulent or infectious con- ditions of the eye, as in dacryocystitis, perforating ulcers, etc. It is most often found in old people and the prognosis is always unfavorable. As a metastatic choroiditis it may occur in two w^ays. First, where it is found in connection with pyaemia, puerperal fever, ty- phoid, variola, malignant pustule, phlegmonous er^^sipelas, sup- purative endocarditis, acute rheumatism, etc., the immediate cause in these cases is an embolus affecting the choroidal vessels, and this -embolus undoubtedly conveys the infecting micro-organism. The choroiditis, when resulting in this way, is usually confined to but one eye, although it sometimes has been found occurring in both eyes. This form is also apt to be very rapid and acute in its de- structive course. The purulent infiltration occurs first between the retina and choroid and rapidly extends, involving the whole eyeball. The second form of metastatic infection is that found following meningitis or cerebro-spinal meningitis, and in these cases it is due to the communication between the sub-arachnoid cavity of the brain and the intervaginal space of the optic nerve, forming a direct channel for the transmission of the inflammatory products to the eye. One or both eyes may be affected, although more frequently hut one. In this variety the course is not usually as acute or as purulent as in the preceding form. Thrombosis of the cerebral sinuses, associated with a thrombosis of the ophthalmic veins, may also give rise to a suppurative choroiditis. CHOROIDITIS SUPPURATIVA. 34I Diagnosis. — Rarely we may find a very sluggish form of sup- purative choroiditis with no inflammatory signs which looks so much like a glioma of the retina that it is almost impossible to differentiate between them. In both, the cornea, aqueous and lens are clear, anterior chamber shallow, pupil dilated, iris and lens pushed forward, with a light colored (whitish or yellow) re- flex from the pupil. The chief diagnostic sign may be the tension which early will be normal in both, but soon becomes increased in glioma, and decreased in choroiditis (or pseudo-glioma as it is also called). In choroiditis we may have a history of previous illness. The course of the disease would of course ultimately determine the diagnosis, as choroiditis leads to atrophy of the eyeball and glioma to perforation. We should never delay too long, as early enuclea- tion offers the only chance in glioma, and as choroiditis leads to blindness nothing is lost from an enucleation in that case. Prognosis. — In all forms of suppurative choroiditis, from what- ever cause it ma}^ arise, the prognosis is absolutely unfavorable, and when due to meningitis, pyaemia, etc., life itself is of course in danger. Treatment. — Our first endeavor should be to save the eye if possible, and with this end in view any exciting cause must be re- moved. If it is due to a swollen, cataractous lens, this must be ex- tracted; if to an orbital abscess, this must be opened; or if a foreign body is found to be the cause, as is frequently the case, we must try to remove it, unless it is too deep within the eye, when it is far better to enucleate. In cases of metastatic origin little can be done, as the general illness will usually require our main attention. Enucleation should not be performed while the inflammatory process is very pronounced, as experience has shown that it is ad- visable to wait before we undertake the operation until the severity of the symptoms has subsided; but if a foreign body is present within the ball, enucleation of the eye is strongly recommended after the inflammation has been subdued, for there is always danger of sympathetic irritation of the other e3'e. Enucleation during panophthalmitis has been practiced and recommended by some. RoUand^ has enucleated in eighty cases without a death. He, however, does not enucleate when phos- phenes indicate that the lymph sheaths of the optic nerve have be- *Rec. d'ophth., 1888, No. 7. 342 DISEASES OP THE CHOROID. come affected or cerebral symptoms have manifested themselves. Andrews* reported twelve enucleations with no unfavorable symptoms. He also gives the statistics of thirty fatal cases, but believes the danger can be diminished by strict antiseptic precau- tions and care. For the disease itself, in the first stage, cold or ice compresses may be used with advantage, but if the pain becomes very severe in and around the eye, especially if suppuration has commenced, more benefit will be gained from warm applications, either dry or moist. Atropine may be of advantage, early, in palliating the pain. If the pain is very severe and the tension increased, paracentesis or an iridectomy will be found of service. If, however, suppura- tion has so far advanced so as to destroy the eye and the pain is intense, it is best to make a deep free incision of the eyeball at once and employ hot fomentations. A nourishing diet, even stimulants, becomes necessary to sustain the patient's strength after suppuration has taken place. Rhus tox. — The most commonly indicated remedy in panoph- thalmitis, whether it be of traumatic origin or not. It is useful in nearly every stage of the disease, though is particularly adapted to the first. The lids are oedematously swollen, spasmodically closed, and upon ope*ning them a profuse gush of tears pours out. The conjunctiva is cedematous, forming a wall around the cornea, which may be slightly hazy. The iris may be swollen, pupil con- tracted and aqueous cloudy, while the pain in and around the eye is often severe, especially at ?iight and upon any change in the weather. Aconite. — First stage, accompanied by high fever and much thirst. Eyelids red, swollen, hot and dry, with much pain in the eye. Hepar. — After suppuratio?i has begim. Eye very sensitive to touch a?id the pains severe and throbbifig, a7neliorated by warm ap- plications. Phytolacca. — Panophthalmitis, especially if traumatic. Lids very hard, red and swollen; chemosis and pus in the interior of the eye. Pains quite severe. Apis. — Lids cedematous, chemosis, stinging pains through the *N. Y. Med. Jour., Dec. 29, 1888. ( SCLEROTICO-CHOROIDITIS ANTERIOR. 343 eye. Drowsiness and absence of thirst usually accompany the local indications. Arsenic. — If the patient is very restless and thirsty, with oedema of the lids and conjunctiva, and severe burning pain. Arsenicum cases are similar to Rhus, though the former does not compare with the latter in degree of usefulness. Asafoet., Bell., Merc, Sil., Sulph. and other remedies may in certain cases and stages be useful. Sclerotico-Ohoroiditis Anterior. — In this form of choroiditis there is a participation of the sclera in the inflammatory process. The disease is generally circumscribed to a portion of the sclera and choroid in the vicinity of the iris, although it may entirely surround the cornea. It is usually chronic in its nature, the most acute cases often lasting for months, w^hile others w411 run for 3^ears. The appearance resembles very closely that described under episcleritis, although the pain is apt to be more severe and the inflammation and swelling of the conjunctival tissues is more general. The inflammation ma}^ extend to the iris, causing synechiae; or to the cornea, causing what has been called a sclero- tising keratitis. In the chronic form, staph 3^1oma frequently results from a weakening of the sclera, due to the inflammation; it becomes thinned, presenting then a bluish or grayish-blue color. The staphyloma may be of varying size or shape, and occur either at the sclero-corneal margin or as far back as behind the ciliar}^ region. This gradual bulging is a very slow^ process, extending often over a period of years and is usuall}^ unaccompanied by much pain. It seems to occur more frequently in women than in men and is most liable to occur before adult life. The prognosis is alwa3's unfavorable, especially in the more chronic cases, as treatment seems to be of little value. See Scleritis. Sclerotico-Ohoroiditis Posterior {Sclerectasia Posterior, StaphyloTna Posterior^ . Pathology. — The pathological changes present in posterior staph3doma are those of an atrophic choroiditis, with a gradual thinning and atrophy of the sclera. It may have small points of 344 DISEASES OF THE CHOROID. exudation, especially near the macula, which have a tendency to coalesce and go on gradually to atrophy. Pigment proliferations are usually present around the edges of the crescent, especially when the condition is progressive. There may also be found fluidity and opacities in the vitreous and changes in the retina. The vitreous may be detached either at the lens or the posterior pole. Symptoms. — The disease is always found existing in myopic eyes, the eyeball is apt to appear prominent and its movements may be somewhat impaired. Patients will sometimes complain of a feeling of tension in the eyes and there may be some pain in or around the eye, and a tired, strained aching of the eyes when using them. In the progressive stage metamorphopsia is a most frequent symptom, and often times complaint is made of black spots floating before the vision (muscse volitantes), of cloudy vision and subjective light sensations. An ophthalmoscopic ex- amination will show the presence of a white crescent around the optic nerve, usually at its outer side (See Chromo-Iyithograph, Plate II., Fig. 3); the size and shape of the crescent may vary greatly from a small, narrow rim atone side to a spot several times the diameter of the optic nerve. The optic nerve will have a pinkish appearance, from contrast with the whiteness of the staphyloma, due to the sclerotic shining through the atrophied choroid. The retina is detached somewhat from the choroid and the retinal vessels may be seen pass ng across the staphyloma. Vision becomes affected by enlargeme -t of the blind spot and there is usually some amblyopia, which may be due to the reflection of light from the white surface and to the conges- tion of the retina. If the disease becomes progressive, the myopia increases, the vision is more and more impaired, the black spots before the eye increase and the optic nerve and retina become more irritable. The edges of the crescent show signs of inflammation, appear more irregular and congested; there is slight proliferation of pig- ment in small spots surrounding the borders of the staphyloma, which increases more and more as the disease advan:es, and ex- tending especially toward the macula. These spots of pigment gradually coalesce and the centres undergo a gradual change in color until they form one large, white, atrophic spot with a nar- SCLKROTICO-CHOROIDITIS POSTERIOR. 345 row border of pigment surrounding it, similar to the changes found in disseminated choroiditis. Causes. — Posterior staphyloma is considered to be mechanical in its origin. The predisposing cause being congenital and heredi- tary, the insertion of the optic nerve being obliquely, and to the inner side of the posterior pole of the eye, would render the outer side where the staphyloma occurs weaker, and any abnor- mality in this direction would increase the weakness at that point. The exciting causes are first an insufficienc}^ of the internal recti, causing a dragging upon the eye from prolonged efforts of con- vergence, and results in an elongation from an increased pressure upon the eyeball. The use of the accommodation in myopic eyes is another factor in the causation of posterior staphyloma. In myopia the longitudinal fibres of the ciliary muscle are especially developed, and in the effort of accommodation there is a drawing forward of the choroid through the fibres of the tensor choroidea, which results in an increased vascularity of the choroid at its at- tachment around the optic nerve. In this way there is created a low form of choroiditis at that point which causes a softening and bulging of the tissue. The sclera is more vascular around the optic nerve, and any congestion there would serve to soften its tissue. An increased vascularity would tend to increase the tension, but, owing to the weakness of the sclera, it bulges instead. Bend- ing the head forward, as is so frequently seen in myopic children, seems to increase the vascularity and so increases the staphy- lom. Myopia is especially liable to increase from ten to twenty years of age, becatise at this time the sclera is more pliable and the child is using the eyes more. Complications. — As a result of posterior staphyloma, we fre- quently find opacities of the vitreous and pigmentation of the retina from the traction upon it. The majority of cases of detachment of the retina are dependent upon the posterior staphyloma. Posterior polar cataract is also apt to result from disturbances of nutrition. Prognosis. — The prognosis should alwaj^s be guarded, espe- cially if the patient is obliged to use the ej^es. Treatment. — As myopia always accompanies this disorder of the fundus, the proper selection of glasses should receive our first attention, the greatest care being taken that they are not too strong. 346 DISEASES OF THE CHOROID. We should next warn the patient against the overuse of the eyes for near objects, and also to always avoid stooping or bending forward when using the eyes at near work, as this tends to increase the venous congestion, thus serving to accelerate the progress of the disease. It is injurious to read in the recumbent position. These patients should, therefore, sit upright, with head erect, when reading, and with the back to the light, so that the page will be illuminated and the eyes not subjected to its bright glare. The work or book should not be brought nearer as the eye becomes fatigued, but be laid aside until the eyes are thor- oughly rested. If the patient complains of dazzling from the bright light, as is often the case, either blue or smoked glasses may be allowed. In aggravated cases they should be required to abstain from all near work. An effort should also be made to overcome the insuflSciency of the internal recti by exercising with prisms as described under exophoria, as by increasing the power of convergence we remove somewhat the strain upon the accom- modation. The constant and continued use of Ab'-opine for a long time has been found advantageous in some instances. Belladonna. — Sclero-choroiditis posterior, with flushed face and throbbing co7igestive headaches. The eye appears hypersemic externally as well as internally. The optic 7ierve and whole fundus are seen congested. Opacities may be present in the vitreous; photopsies and chromopsies are sometimes observed. The eyes quite sensitive to light. Duboisia. — Vessels of the optic disc and retina much enlarged and tortuous. Disc congested and outlines indistinct. Sharp pain in the upper part of the eyeball. Phosphorus. — Fundus hyperaemic. Muscae volitantes and flashes of light before the vision. Everything looks red. Prunus spin. — Staphyloma posterior, accompanied hy paijts iyi ball, as if pressed asmider, or sharp a7id shooti?ig in and around the eye. Vitreous hazy and vessels of the fundus injected. Spigelia. — When accompanied by sharp stabbing pains through the eye and around it, often commencing at one point and then seeming to radiate in every direction. Thuja. — An important remedy in all inflammatory conditions of the sclera, ^s^o^oidiWy \n strumous or syphilitic subjects. The globe SENILE CHANGES OF THE CHOROID. 347 may be quite sensitive to touch and the photophobia is usually marked. Carboveg., Croc, Jaborandi., Lyco., Kaliiod,, Merc, Physos., Ruta and Sulph. are also remedies to be borne in mind. Compare remedies for Choroiditis. Senile Changes of the Choroid. — A rare form of colloid degeneration is sometimes met with in old people. There arises at the periphery from the lamina elastica, small, yellowish-white nodules which press forward into the retina, pushing aside the pigment layer. These nodules are irregularl}^ scattered through the periphery and ma}^ be irregularly surrounded by pigment. The}' gradually extend toward the posterior pole of the e5^e. They resemble somewhat the spots of disseminate choroiditis, and are practically of little importance, as the vision is but ver}" slightly, if any, disturbed. x\nother form described by Berry (Joe. cit.) as se?iile central choroiditis shows in the early stages a reddish-yellow, irregularlj^- oval shaped patch which later assumes more of an atrophic appear- ance, the edges become more irregular and bordered by pigment. The patch generally appears in both e3^es and varies in size. The condition causes metamorphopsia and a central scotoma, so that central vision is very greatly impaired. There is no tendenc}^ for the condition to extend to other parts of the fundus and hence vision is never entirely destroyed. Albinism, — General absence of pigment in the tissues is a con- genital defect which may affect the entire uveal tract, and, when it does, the iris is of a very, pale blue, the pupil is small and there is a constant effort to avoid the light. Nystagmus is usually present, the lens may be ill- developed and there is always ambly- opia. A pinkish glare is seen from the pupil, and with the ophthalmoscope the choroidal vessels are brilliantly outlined. Albinos always bring objects very close to the e^^es to compensate for their amblj^opia and to abate the nystagmus by strong con- vergence. Slight relief is obtained by the use of dark glasses to moderate the light. Tumors of the Choroid. — Tubercidosis of the choroid occurs in the disseminated form or as a single nodule. The miliary form 348 DISEASES OF THE CHOROID. appears as small, round, elevated spots of a whitish or pale yellow color, which may within a few days grow larger and increase in number. Sometimes twenty or thirty may be counted in the eye. Both eyes may be involved, and they are especially found around the optic nerve. Pathologically they are the same as miliary tubercles elsewhere. With the addition that the giant cells con- tain pigment. The choroid between the nodules is hypersemic and infiltrated with round cells. Their presence forms one of the symptoms of general miliary tuberculosis, especially when the meninges are affected. Solitary tubercle of the choroid appears as a rather large light - colored tumor which causes detachment of the retina and blind- ness. They are found to consist of a great number of smaller miliary nodules that have coalesced. Their occurrence in young people and the discovery of other foci of tuberculosis are the diagnostic signs between the solitary tubercle and sarcoma of the choroid. As the eye is aways lost and life endangered the prog- nosis is unfavorable. The treatment is enucleation. Sarcojna. — Nearly all varieties of sarcoma may be found oc- curring in the choroid, although the pigmented or mel mo -sar- coma are by far the most frequent. Sarcomas usually commence at either the ciliary region or around the posterior pole of the eye. When located anteriorly the iris is apt to be bulged forward and upon dilatation of the pupil a greyish-brown or black mass may be seen and a scotoma is present. If in the macular region there is in the early stage loss in visual acuity and the ophthalmoscope shows a detachment of the retina of a nodular form and abrupt sides. The diagnosis of a tumor behind the detachment may present some difficulties. If a tumor is present, the color appears darker than in a simple detachment and the tension is increased ; while, in simple detachment, the tension is diminished, the detached part of the retina has a wavy appearance on movement of the eye, generally occurs at the posterior pole of the eye and usually settles to the bottom. Glaucomatous symptoms in a detachment of the retina generally indicate the presence of a tumor. The origin of the growth in some cases may be traced to an injury of the eye, although more often it is a primary condi- tion with no traceable cause. Knapp* divides the symptoms and * A Treatise on Intra-ocular Tumors. SARCOMA OF THE CHOROID. 349 progress of choroidal sarcoma into four stages: First, the origin and commencing growth without sj^mptoms of pain or irritation of the eye, the only subjective symptom being a disturbance of vision. The first stage varies from six months to four years. Second, the appearance of inflammatory symptoms in the eyeball. The most cliaracteristic symptom of this stage is the severe pain due to the increased tension. In this second, or glaucomatous stage, blindness rapidly comes on and the diagnosis is now often impossible. This stage usually lasts about one year. Third, the stage of perforation, when the external appearance of the grow^th, if it breaks anteriorly, is that of dark, hard nodules. If the per- foration occurs at the posterior pole we soon get an exophthalmos and restricted movement of the eye. There is at first relief of pain, but as the progress is now rapid pain returns, haemorrhage and an abundant secretion sets in and there is simply a mass of tumor and death is apt to occur from exhaustion. The fourth and last stage is that of metastasis to other organs, usually the liver or lungs, with the inevitable death of the patient. Sarcomas occurring at the posterior pole of the eye, while rare, have been found, and GriSith* reports a case seen by himself and gives the records of six other cases. Sarcoma appears especially in old age, is very rarely seen under fort}-, and rareh' affects but one eye. The prognosis is fatal if left alone and is unfavorable even in the early stage. There is but little danger of recurrence in the orbit after enucleation in the first stage, but Fuchs says the danger of metastasis is not essentially influenced by the time at which the operation is performed. The pigmented variety is more malig- nant and more liable to return, especiall}' w^hen it has reached the glaucomatous stage prior to removal. About two-thirds of all sarcomas return after removal. Microscopical examination ma}^ show the tumor to be any one of the following varieties: Melano- sarcoma, leuco-sarcoma, fibro-sarcoma, m5^o-sarcoma, chondro- sarcoma, osteo-sarcoma, cysto-sarcoma, glio-sarcoma, or sarcoma- cavernosum. The treatment should alw^a3's be an early enuclea- tion and care should be taken to sever the optic nerve as far back as possible. In the third stage the orbit must be thoroughly cleaned out. Ossification of the Choroid. — True bone may, in the course ■^Archiv. Ophthal., vol. xvii., 2, 1888. 350 DISEASES OF THE CHOROID. of time, be formed in the choroid. It is usually found in the inner layers of atrophied" balls and more especially in ej^es that have been lost by irido- choroiditis. The plate of bone generally assumes a more or less spherical shape, although some spiculae or growths may be found upon it. The diagnosis is made by feeling a hard body which ends at the ciliary region, as ossification never takes place in the ciliary body. The principal danger seems to be that of exciting sympathetic irritation and the treatment should be enucleation. Haemorrhages in the Choroid are the result of some diseased condition of the blood-vessels. The exciting cause may be from injuries, operations, coughing, etc. The haemorrhage ma}^ be slight or extensive and it may extend forward between the choroid and retina, producing detachment of the retina, or more frequently it will extend outward between the choroid and sclera and may cause a separation of the choroid from the sclera. The diagnosis between haemorrhage in the choroid and haemorrhage in the retina is uncertain, when occurring in the outer layers of the retina; but when in the inner, or nerve-fibre layer of the retina, the haemor- rhage has a striated or flame-shaped appearance, while that in the outer layer of the retina or in the choroid is not striated. Haem- orrhage into the retina usually corresponds to the retinal vessels — that is, it usually occurs along the course of the vessels and is apt to cover the vessels slightly. If there are no retinal vessels near the haemorrhage, it is more likely to be in the choroid. If the haemorrhage is in the retina, its color is more of a bright red and its outlines are well defined; while if in the choroid it appears of a darker red and the outlines are ill-defined. Choroidal haem- orrhages interfere somewhat with the vision by causing scotoma. On absorption of a haemorrhage there is left behind an atrophic spot surrounded by pigment. Treatment. — Haemorrhage is the most common symptom that demands our attention in the treatment of a rupture of the chor- oid, though we may have haemorrhages arising spontaneously or from inflammatory changes, etc. The remedies chiefly called for will be Am., Bell., China, Crotal., Ham., Lack., Merc. corr. , or Phosph. For special indications refer to Retinitis Hcsinorrhagica. DETACHMENT OF THE CHOROID. 35 1 If there is h5^per8emia or inflammation of the choroid present, our treatment will be guided by the rules laid down under chor- oiditis. Detachment of the Choroid from the sclera maj^ occur from an injury, from an effusion of blood or serum, or from a tumor. Its diagnosis is always diflBcult and uncertain. The ophthalmo- scopic examination gives an appearance similar to that of a tumor — a dark mass, like that seen in sarcoma, but more often at the lower part of the eyeball. In detachment the tension is decreased, while in tumor of the choroid it is increased. Groenouw * reports two cases of detachment of the choroid, after cataract extraction, with spontaneous recovery. As these simulate choroidal tumor, he cautions against enucleation until after watching the case for two weeks at least, as the apparent tumor may disappear spon- taneously Eyes have been enucleated for choroidal tumor which have proven to have been a detachment of the choroid. The ten- sion is, however, diminished and it differs from retinal detachment by having none of the wavy appearance on moving the eye, and it has a dark red or black appearance instead of the bluish-green color of a detached retina. Rupture of the Choroid. — This condition is of comparatively frequent occurrence. It is usually found after a blow on the eye, and we ma}' find associated with it, from the same injur^^ a rupture of the retina, a separation of the iris, or a dislocation of the lens, but often the rupture of the choroid occurs alone. It is generally accompanied by a haemorrhage that often conceals the rupture at first. The location of the rupture is almost always at the posterior pole of the eye, and is more frequenth* seen between the optic nerve and the macula. Rupture occurs at this point, because the choroid is here more closely attached to the sclera and does not so easily give to the impact of the blow. It is gen- erally vertical and in the shape of a curved line, the concavitv being directed toward the optic nerve; it is most frequently a single line, with occasionally one or more bifurcations, although two distinct ruptures ma^^ occur. The ophthalmoscopic appearances var3\ In the early stage it *Archiv. Ophthal. , vol. xviii., 3, 1889. 352 DISEASES OF THE CHOROID. may be completely obscured by the haemorrhage. Later it is seen as a yellowish-red line, and, as the blood becomes absorbed and the swelling and haziness of the retina pass off, it gradually assumes a more and more white appearance, until it finally looks like a clear white line, possibly bordered by a little pigment. The pigment layer of the retina is always ruptured, and usually the layer of rods and cones is also involved. The loss of vision depends upon the amount of destruction in the retina and its nearness to the macula. It causes a scotoma, more or less large, according to the size of the rupture. Prognosis. — Should be guarded, because, in the atrophic stage, the vision may decrease after it has first improved. When the retina is involved we never find the retinal vessels passing over the ruptured choroid as they may in an uncomplicated case. Ooloboma of the Choroid. — This is a congenital anomaly, often hereditary, due to an arrest of development in foetal life and is usually associated with acoloboma of the iris, but may be found alone and may be present in one or both eyes. Other evidences of arrested development, such as harelip and cleft palate, are sometimes met with, together with the ocular defect. The usual location of a coloboma of the choroid is downward or downward and inward, and may extend from, the iris through the ciliary body and choroid to the optic nerve, which may also be involved. Coloboma may vary greatly in shape in different cases. It is, however, generally more pointed or narrow at the optic nerve, be- coming wider toward the equator. The appearance with the ophthalmoscope is that of a white, glistening patch, with the retinal vessels seen coursing over it and occasionally masses of pigment may be found here and there upon it; the edges of the coloboma appear distinct, clear cut and often pigmented. In all cases the retina is either imperfectly developed or absent, and, in consequence, a scotoma corresponding to the coloboma is usually present. The sclera may also be to some extent affected; that is, it is thinned and may be staphylomatous. In place of the choroid over the region of the coloboma there is to be found a thin con- nective tissue membrane which corresponds to both the choroid and retina, as the vessels of both are found in it. Cases of so-called coloboma, in which the defect is confined to the region of the COLOBOMA OF THE CHOROID. 353 macula alone, have been rarely reported, but these may possibly have been the result of degenerative changes following some in- flammatory condition in intra-uterine life. Johnson^ gives a thorough description of extra papillary colobomata, illustrated by drawings and chromo-lithographs. He believes that coloboma may occur in any part of the fundus and are more frequent than generally diagnosed. They differ from atrophic changes due to disease in that their margins are always sharply defined, they are always surrounded by healthy tissue, the pigment is in front and never behind the retinal vessels, the appearance of the coloboma always remains the same, the floor of the coloboma being of a daz- zling whiteness, or sometimes covered by a laj^er of connective tissue looking like mother-of-pearl. *Archiv. Ophthal., vol. xix., i, 1890. 23 354 DISEASES OF THE RETINA. CHAPTER XVIII. Diseases of the Retina. Anatomy. — The retina is the delicate membrane lying be- tween the choroid and the vitreous and extending from the optic nerve to the ciliary processes, where it terminates in a finely in- dented border called the or a serrata. Microscopically the retina is divided into ten layers which are, from within outward: i. The internal limiting membrane; t. The nerve-fibre layer; 3. The layer of ganglion cells; 4. The internal molecular layer; 5. The internal granular layer; 6. The external molecular layer; 7. The external granular layer; 8. The external limiting membrane; 9. The layer of rods and cones; 10. The pigment layer. The internal limiting membrane is a very thin, imperfect mem- brane, serving to separate the nerve-fibre layer from the vitreous. The fibres of Miiller terminate in this layer. The nerve-fibre layer consists of the axis cylinders of the optic nerve-fibres, which run in a radiating direction to the ora serrata, where they terminate. At the macula lutea these fibres are bent into arches and are so arranged that a larger number of them reach the yellow spot than could if they approached it in a radiat- ing direction. The layer of ganglion cells forms, excepting in the region of the macula, several layers of multipolar cells, having both a nucleus and a nucleolus. A nerve-fibre enters each of these cells and one or more prolongations extend outward into the inner molecular layer. These ganglionic cells are arranged more closel}^ to each other near the optic nerve than at the ora serrata. The internal molecular layer consists of the fine fibres from the layer of ganglion cells, irregularly arranged, with an amorphous molecular substance. The inter7ial gra?nilar layer is composed of two kinds of cells with nuclei. The larger of these are nerve cells, similar to those in ANATOMY. 355 the la3'er of ganglion cells, and having two offshoots, one passing into the inner granular layer to anastomose with the offshoots from the ganglionic cells and the other passing outward into the ex- ternal molecular laj^er, where, it is claimed b\' some, they anasto- mose with fibres from the layer of rods and cones. The smaller Fig. 76. Diagram showing minute anatomical structure of retina. cells of this layer are connected with the fibres of Miiller. The exter7ial molecular layer is ver}' thin and is made up of the 356 DISEASES OF THE RETINA. fibres just mentioned, together with a molecular substance simi- lar to that of the internal molecular layer. The external granular layer, like the internal, is composed of both nerve and connective tissue elements. The former consists of bi-polar cells, from which offshoots pass outward to the la3^er of rods and cones and inward to the internal granular laj^er. The external limiting membrane is the expansion formed by the terminal extremities of the fibres of Miiller. The layer of rods and cones is the most important part of the retina. The rods, commencing as fine fibres in the outer mole- cular layer, pass through the outer granular layer and, just be- neath the external limiting membrane, begin to increase in size, forming the rod granule, and some distance after passing through this membrane thej^ taper down into cylindrical shaped rods, which extend outward to the pigment layer. The cones also commence as a cone-shaped swelling in the outer molecular layer, where they are in direct communication with the fibres from the internal %ranular layer. The cone-fibre becomes thinner until, just underneath the external limiting membrane, it again swells rapidly and there forms the cone itself, which contains a large oval nucleus and nucleolus. The cones are shorter and thicker than the rods and are of a bottle-shaped appearance. The rods and cones are arranged perpendicularly to the pla.ne of the retina and may be divided into an inner and outer part. The inner segment is thicker than the outer and appears granulated; the outer part is broken up into fine, highly refracting lamellae, ap- pearing like superposed circular discs or a pile of coins. The pigment layer consists of a single layer of hexagonal nucleated cells, the inner surface of which is loaded with pigment granules. 'X\i^ fibres of Miiller form the connective tissue framework of the retina which traverses its various layers from the internal to the external limiting membranes and spreads out in these membranes. The macula lutea or yellow spot is about 1.25 mm. in diameter and is the most sensitive portion of the whole retina. It lies to the outer side of the antero-posterior axis of the eyeball. The shape of the macula has been almost universallj^ described in text- books as oval; the error of this has been pointed out by Johnson*, ^ Archiv. Ophthal., vol. xxi., i, 1892. ANATOMY. 357 who claims that: " The macula is invariably circular, and prob- ably corresponds to the extreme limit of the macula region," and that it is best seen with a very weak illumination and by the direct method; that by this method of examination the macula ring can be seen in its entire circumference in nearlj^ every person under thirty-five 3^ears of age and frequently over that age. He con- cludes that the mistake of all authors who have seen the macula as oval is that they have examined by the indirect method. The color of the macula has also been variously described, usually as of a somewhat \'ellowish appearance, from which it w^as called the yellow spot, but Johnson {loc. cit ), by means of sixteen colored drawings, shows that " in normal eyes of Europeans the inner portion of the macula appears of a more intense or brighter red than the fundus generally, the color deepening as it approaches the fovea centralis, where it is almost always masked by the bright foveal reflex, varying in shape and intensity." Anatomically the macula differs from other parts of the retina in that there are no rods, and the cones are longer and narrow^er than in other parts of the fundus. At the centre all the other layers of the retina are thinner, forming a depression called the fovea centralis, but toward the margin the retinal layers, espe- cialh' the layer of ganglionic cells, are for the most part thicker than elsewhere. The vasadar supply of the retina is derived from the arteria cen- tralis retinae which divides on the optic disc into an upper and lower branch. These branches then turn outward, forming a large ellipse around the macular region, none of its capillaries extend- ing into the fovea; other branches are given off to supply the inner and other parts of the retina. Each artery is generalh^ ac- companied by a vein. The appearance of the healthy retina is that of perfect trans- parency. The retinal vessels are easily distinguished from those of the choroid b}- being more clear and well-defined and by their taking a more radiating course and branching dichotomousl3\ Pulsation of the retinal veins and still more rarely of the arteries may occasionally be seen in normal eyes; both may be produced by pressure of the finger upon the globe during an ophthalmo- scopic examination. Usually, however, pulsation of the retinal vessels is indicative of some pathological change. 358 DISEASES OF THE RETINA. Hypersemia Retinae. — It is always difficult to state in any given case whether the congestion exceeds that which is physio- logical or not, and in making the diagnosis the relative sizes of the arteries and veins should be considered. Normally the retinal arteries are about three-quarters the size of the corresponding vein. Hypersemia may be either active or passive. Active hy- percsinia {arterial 01^ ir?'itation) usually results from some strain- ing of the eyes, such as a prolonged use of the eyes at fine work or by poor light. It is very often associated with or caused b}^ some refractive error and is, of course, present in the first stage of retin- itis, or may be present with inflammation of the cornea, iris, etc. The relative size of the vessels in active hyperaemia is usually well maintained and the diagnosis rests upon the congestion of the optic disc, which becomes more pinkish, with less contrast between it and the surrounding fundus. It manifests itself to the patient by fatigue on using the eyes, sensitiveness to light, pain and pressure within the eye. Passive hypercEmia {venous or stasis) results from some circulatory interference which ma}^ take place in the eye, as in glaucoma, or external to the eye, as in pressure upon the optic nerve. In this form the relative normal propor- tions between the arteries and veins becomes lost and we find the veins tortuous and increased in size, while the arteries may either remain normal or become diminished. In hypersemia the only symptoms complained of by the patient will be some dimness of vision; or of flashes of light before the eyes. Treatment. — H3^persemia frequently depends upon some re- fractive error, which should be corrected by suitable glasses. Rest of the eyes is of great importance, and hence the patient should be instructed to abstain from all use of the eyes. The remedies most frequently found of service are Dubois., Bell., Phos., Conium, Puis, or Bry. The special indications will be found under Retinitis. Retinitis Simplex. — {Retinitis Serosa, Retinitis Diffusa, CEdema of the Retina.) Pathology. — There is a hypersemia of the retinal vessels fol- lowed by an infiltration of serous fluid into all the layers of the retina. The membrane, especially in the neighborhood of the disc, becomes somewhat swollen and thickened. RETINITIS SIMPLEX. 359 Symptoms. — Patients will complain of a diminution of vision, as though looking through a mist, and the field of vision may be somewhat impaired. The ophthalmoscope will show a hyperaemia of the retina and optic papilla, together with a diffuse grayish or bluish appearance of the retina, especially in the vicinity of the optic disc, the outlines of which are slighth^ blurred and indis- tinct. The vessels may be slightly covered, as with a veil, or ap- pear perfectly distinct. Causes. — This form of inflammation may precede or extend into other types of retinitis. It has also been attributed to exposure to cold, heit or strong light, and as a result of overuse of the e3^es b}'- poor light especially when there is some refractive error, and in many cases it is impossible to assign a distinct canse. Prognosis. — If the disease leads to no more serious form of in- flammation, recovery, with perfect restoration of vision, is the rule. Neuro-retinitis is a more common diagnosis, as the optic nerve and retina are usuall}^ inflamed at the same time. Treatment. — Restis the most important aid in all cases whether inflammatory or only hyperaemic, and the more complete it is, es- pecially in neuritis or retinitis, the better for the patients. They should be instructed to abstain from all use of the eyes, particu- larly by artificial light. Some authors, Stellwag and others, rec- ommend the confinement of the patient in a darkened room and the emplo3^ment of a bandage. Such severe measures are, how- ever, not required except in extreme cases. It is better to allow moderate exercise in the open air, taking care that the e3^es are properl}^ protected from the irritating influence of bright light b}^ the use of either blue or smoked glasses. Proper hygienic rules, according to the nature of the case, de- mand our most careful attention. Belladonna. — One of the most frequently indicated remedies for both hyperaemia and inflammation of the optic nerve and retina. The retmal vessels will be found enlarged a7id lorhions, particularl}' the veins, while a blue or bluish- gray film may seem to overspread the fundus (oedema). Extravasations of blood may be numerous or few in number. The optic disc is swollen and its outlines ill- defined. The vision is, of course, deteriorated. The pains are usually of an aching^ dull character, though may be throbbing and severe, accompanied b}" throbbing^ congestive headaches with visibly 360 DISEASES OF THE RETINA. beating carotids and flushed face. Phosphenes of every shape and hue, especially red, may be observed by the patient. Decided sensitiveness to light. The eyes feel worse in the afternoon and evening, when all the symptoms are aggravated. Duboisia. — Of great value in the treatment of both hypersemia and inflammation of the optic nerve and retina. Retinal vessels large and tortuous, especiall}^ the veins. Optic papilla swollen and outlines ill-defined (engorged papilla). Haemorrhages in the retina, aching in the eyes and pain through the upper part of the eyeball just beneath the brow, which may be very severe. Chronic hypersemia of the conjunctiva. Phosphorus. — Hyperaemia or inflammation of the optic nerve and retina, especially with extravasations of blood. Degeneration of the coats of the blood-vessels. The eye may be sensitive to light and vision improved in twilight. Vision impaired, muscae voli- tantes, photopsies and chromopsies are present, halo around the light. The eyeballs may be sore on motion and pain may extend from eyes to top of head. Pulsatilla. — HypercBmia and i7ifiammation of the optic nerve and retina accompanied by more or less severe pains in the head always relieved i7i the ope7i air. Sensation as if a veil were before the eyes, or the vision may be nearly lost. All the ophthalmo- scopic appearances of engorged papilla or simple hyperaemia may be present; if dependent upon menstrual difficulties or associated with acne of the face or disorders of the stomach. Bryonia. — Serous reti litis or hyperaemia, with a bluish haze before the vision and severe sharp pain through the eye and over it. Eyes feel full and sore on motion or to touch. Great heat in the head, aggravated by stooping. Mercurius. — Retinitis with marked nocturnal aggravation and sensitivejiess of the eyes to the glare of the fire. Congested condi- tions of the fundus found in those who work at a forge or over fires. Degeneration of the blood-vessels, with haemorrhages into the retina. Concomitant symptoms will assist us in the selection. Cactus. — Retinal congestions, especially if heart trouble is present. Conium. — Fundus congested, with much photophobia; ciliary muscle weak. Nux VOm. — Retinitis occurring with gastric disturbances, RETINITIS ALBUMINURICA. 36 1 especially in drunkards. The eye indications vary, but are usually aggravated in the morning. Veratrum viride. — E^igorged disc, with severe pain at menses and general vaso-motor disturbances. In addition to the above, the following remedies may be of benefit in rare cases or as intercurrents: Aeon., Ars., Aurum, Chin, sulph., Gels., Kali, iod., Kalimur., Lach., Spig. and Sulph. Dazzling of the Retina. — Under this heading we shall class all those cases accompanied b}^ a dazzling sensation, due to ex- posure to the bright glare of the sun, upon snow or water, to the electric light, etc. These conditions ma^^ produce a diffuse retin- itis or neuro-retinitis, or, again, such exposure may be followed by amblyopia, with no ophthalmoscopic signs. Widmark * con- siders the trouble as produced by direct irritation of the part af- fected and that this is caused almost exclusively by the ultra- violet rays which exert a similar influence upon the skin. The patients complain of a dazzling, a central scotoma and slight im- pairment of the vision. Objects appear in a mist and the air seems to flicker. Cases of retinitis have also been reported as the result of a single intense flash of light. The treatment of these cases consists in the prevention of all use of the eyes and in pro- tection from the light. Retinitis Albuminurica.— {Renal Retinitis, Papillo retijiitis. Retinitis of BrighV s Disease). Pathology. — The pathological changes in albuminuric retinitis are numerous and variable in the different stages of the disease. There is at first a slight granular exudation into the retina, with a fatty degeneration of the walls of the vessels. Following this there is a h3^perplasia of the connective tissue of the retina with subsequent fatty degeneration. The nerve-fibres become remark- ably swollen; these swellings are club-shaped and highly refracting and the whole layer is much thickened. Later these fibres under- go fatt}^ degeneration and atrophy. The ganglion cells may undergo a similar degeneration or remain unaltered. The gran- ular layers become infiltrated and thickened and pass into a fatty degeneration. Haemorrhages, which result from the degen- " Revue generale d'ophthalmologie, Paris, Aug., 1890. 362 DISEASES OF THE RETINA. erated walls of the retinal vessels, may occur at any place, but are found most numerous in the nerve-fibre layer, and serve to in- crease the destruction of the retinal elements. There may be a slight proliferation of pigment, but this layer is but little affected. There are usually found pathological changes in the choroid, nerve, and other parts of the eye. According to Weeks,* we may divide this disease into two classes of cases — those occurring in all forms of acute disease of the kidneys, such as pregnancy, scarlet fever, etc., in which the kidney disease precedes the changes in the retina, and, in the other class, he places those dependent upon a general diseased condition of the vessels in which the eye symp- toms precede those of the kidney. In the first form, which is by far the most frequent, oedema and white patches appear first, to be followed by haemorrhages; while in the second class a slight haemorrhage near the macula and a few bright dots are the first evidence, followed later ])y the oedema and white patches. Symptoms. — The only subjective symptoms noticed by the patient is that of impairment of vision, which may vary from a slight cloudiness to complete blindness. The field of vision and also the color vision remains good. Frequentl}^ the disease is diagnosed by the ophthalmoscope before the patient is aware that there is any kidney lesion whatever. With the ophthalmoscope there is seen swelling and hyperaemia of the disc; the retinal arteries are somewhat diminished and the veins increased in size; there is a diffuse haziness of the retina, together with haemor- rhage and the formation of white patches. In a well-marked case there is in the macula or its immediate vicinity numerous fine white spots, which are, in the early stages, small and separate, but later on, or in a truly typical case, form a star-shaped figure, at the centre of which lies the fovea centralis. These specks are due to the infiltration with fat of. Miiller's fibres.^ Other of these spots and somewhat larger in size, due to the fatty degeneration of the two granular layers, are usually seen around the papilla, and in this locality they will often coalesce into a broad zone around the optic nerve entrance, giving it the appearance usually designated as surrounded by a snow bank. These peculiar white spots of the retina are due to a fatty degeneration of the nerve-fibre and granular layers,, and, when ^Archiv. Ophthal., vol. xvii., 3, 1888. RETINITIS- ALBUMINURICA. 363 seen, may be considered almost pathognomonic of albuminuria, particularly so when assuming the star- shaped arrangement at the macula. The white patches occur mosth' in the deeper layers of the retina, as proven b}^ the fact that the retinal vessels ma}' usuall}' be seen passing over them, but may be partially or completel}^ covered by the patch at some places. Haemorrhages are almost universall}^ found in albuminuric retinitis, but, unlike the white patches just described, are not es- pecially pathognomonic of this disease. They may occur in great numbers and of various sizes and shapes, from large, dark red ex- travasations to small, round or linear-shaped spots scattered throughout the fundus. Haemorrhages occurring in the nerve- fibre la5^er are striated in appearance. The extent of the haemor- rhages is considered to be somewhat indicative of the severity of the disease. Course.^ — When due to pregnancy, diphtheria, or scarlet fever, is comparatively short, but when dependent upon the contracted kidney it is very chronic. Albuminuric retinitis ma}^ either gradually or suddenly pass into a neuro-retinitis resembling very closel}^ the choked disc from cerebral causes. The ophthalmo- scope picture of retinitis albuminurica ( See Chromo-Lithograph, Plate II, Fig. 6) maj^ remain unaltered for a long time, the haemorrhages and white patches slowly disappearing, while new ones at the same time may make their appearance. The white plaques at the macula are alwaj^s the last to disappear, and, may never, according to some authorities. As the secondary changes go on the optic disc becomes discolored and atrophied, the retinal vessels become contracted and pigment changes in the retina result. Causes. — Renal retinitis may occur with any form of kidnej' disease, but is especially found wath the contracted kidney. It is also quite frequenth^ seen associated with the albuminuria of pregnancy, and more rarely with post scarlatinal nephritis. A few cases have also been reported associated with functional albumin- uria. Both e^'es are as a rule involved, although it may occur in but one. Diagnosis. — The ophthalmoscopic appearances are alwa3^s quite characteristic of this disease, and the presence of albumin in the 364 DISEASES OF THE RETINA. urine would at once confirm the diagnosis. Diabetic and leukse- mic retinitis both present appearances of the fundus very similar to those found in this disease, and an examination of the urine will be necessary to clear up the diagnosis. A neuro-retinitis re- sulting from intra-cranial disease, especially if it be complicated by albuminuria, would present great difficulty in the differential diagnosis and a very careful study of the general symptoms would be required. The white spots in choroidal affections would differ from this by the presence of more or less pigment and by the dif- ferent location and shape of the white patches. Opaque optic nerve-fibres resemble somewhat closely the snow-bank appearance around the papilla, but in opaque nerve-fibres the white patches extend out from the disc in a fan-shaped manner, it is unaccom- panied by any change in the macula or oedema of the retina and the vision is but little or none affected. Prognosis. — In albuminuric retinitis the prognosis must neces- sarily cover two points; first, as to vision, and second, as to the life of the patient. The prognosis as to vision should always be unfavorable, excepting in the slighter cases and particularly those occurring in pregnancy. The appearance of albuminuric retinitis in all cases, excepting when associated with pregnancy, is always a most unfavorable symptom as regards the life of the patient. It is extremely rare for recovery to take place in cases of kidney dis- ease after the retina has become involved, and in the majority of cases a fatal termination will ensue inside of two years. In the retinitis albuminurica of pregnancy the prognosis depends chiefly upon the period of gestation, and secondly upon the extent of the disease. Some cases of very extensive haemorrhages, with marked patches of infiltration of the retina and almost complete loss of vision, when only occurring in the list weeks of pregnancy, may recover, after confinement at full term, with almost complete restoration of vision. On the other hand, slight changes in the earlier months of pregnancy, which have a tendency to increase in spite of treatment, may prove very serious both to vision and the life of the patient as well, if allowed to go on to full term. The longer the disease exists the greater are the degenerative changes which may take place, and it is on this account that the appearance of the disease in the last weeks of pregnancy proves far less serious than when occurring early. Induction of prema- RETINITIS ALBUMINURICA. 365 ture delivery in these cases becomes then a question of grave im- portance. The presence of albuminuric retinitis, when of a high degree and accompanied by loss of sight, denoting advanced de- generation of the kidneys, together with the fact that the ursemic condition of the blood, threatens the life of both mother and foetus, to us argues in favor of interference. Howe draws the conclusion that ' ' The induction of labor is warrantable when the retinitis appears in the earl}^ stage of pregnancy and persists in spite of proper treatment, but is not warrantable in the last few weeks, in spite of the greater ease with which it is accomplished, unless the inflammation is unusually severe." Complications. — Detachment of the retina and haemorrhage into the vitreous are the most frequently seen complications, al- though other conditions, such as glaucoma, extravasations into the choroid and embolisrh have been recorded as occurring with this disease. Treatment. — The principal treatment should be directed to the kidneys, the seat of the primary disease, and such hygienic and dietetic measures adopted as are recommended for Bright' s disease. Benefit has sometimes been derived from keeping the patient quiet in bed and upon a low or skim-milk diet. The use of stimulants should be avoided. Mercurius corr. — Has been more extensively used in albumiri- uric retiyiitis than any other remedy. The fatty degeneration, ex- travasation of blood from the weakened vessels and all the patho- logical changes in the eye as well as in the kidney point to Mer- cury as the remedy, even though no characteristic subjective symptoms are present. The results are especially favorable when pregnancy appears to be the exciting cause of the difiiculty. Apis. — If associated with oedematous swelling of the lids and general dropsical condition. Patient very drowsy, with little thirst and scanty urine. Arsenicum. — If the patient is restless, especially at night after midnight, with great thirst for small quantities. Urine scanty and albuminous. Gelsemium. — Retinitis albuminurica occurring during preg- nancy. White patches and extravasation of blood in the retina. Dimness of vision appears suddenly. Serous infiltration into the vitreous, making it hazy, may be observed. The patient is thirst- less, and albumen is found in the urine. 366 DISKASKS OF THE RETINA. Kalmia. — Nephritic retinitis accompanied by much pain in the back, as if it would break. Hepar, Kali iod., Plumb, and Phosph. have either been used or are highly recommended for this condition of the eye. In fact, any remedy applicable to the disease of the kidney will often prove of service in the eye complication. As haemorrhages are usually found in the retina in this form of inflammation, compare the remedies recommended for Retinitis Hcsmorrhagica. Retinitis Diabetica (^Retinitis Glycosurica). — The appearance and general features of this form of retinitis are practically the same as already desciibed under albuminuric retinitis, with the exception that in diabetic retinitis there is, as a rule, less exuda- tion or white patches and usually more haemorrhages. Opacities in the vitreous, probably due to haemorrhage, are frequently found. The white spots are apt to be smaller in size and not grouped at the macula or around the disc in the manner so charac- teristic of albuminuric retinitis, although cases have been reported in which the appearance was absolutely identical. Retinitis oc- curring with diabetes is quite rare and usually makes its appear- ance only after the diabetes has existed for a long while. It is more frequently found existing in both eyes, although it may occur in one eye alone. The pathological change's are the same as those occurring in albuminuric retinitis. As this form of retinitis is especially characterized by haemor- rhages into the retina, compare the remedies recommended for Retinitis Hcsmorrhagica and Albiiminicrica. In addition to which, Secale is suggested, though the chief attention must be directed to the diabetes. Retinitis Leukaemica {^Splenic Retiititis). — This 'is an ex- tremely rare form of retinal inflammation, which, in its earlier stages, resembles a simple retinitis, but later it develops a charac- teristic appearance, the essential features of which are the peculiar color of the fundus and of the blood in the retinal vessels. The fundus becomes of a peculiar orange hue, due to an alteration in the elements of the blood of the choroidal vessels, and presumably the same changes in the blood exists in all the vessels of the body. RETINITIS H.^MORRHAGICA. 367 Loring "^ says this orange tint is b}^ no means constant and that he has more frequently seen the color as a pale graj'ish-pink, and in some cases there is no deviation from the normal color of the fundus. The retinal veins are of a bluish-pink, while the arteries have the same orange color; the veins are enormously distended; he arteries are less distended, so that the normal proportionate relation between the vessels seems exaggerated. The optic disc ma3^ be somewhat paler than normal, and its outlines slightly ill- defined. Haemorrhages are especialh^ prone to occur in this tdisease, and are generally found in the anterior half of the retina. These haemorrhages ma}^ disappear rapidly and fresh ones appear in different parts of the fundus. The diagnosis should depend upon a microscopical examination of the blood, which shows a decreased proportion of red blood-corpuscles and an increased pro- portion of w^hite. The treatment should of course be directed to the general disease, as the retinal complication may be looked upon as merely a symptom of the disease. Retinitis Haemorrhagica {^HcEmorrhages into the Retina, Retinitis Apoplectica) . — Under this heading we class all haemor- rhages into the retina, whether accompanied b}^ inflammation or not, excepting those occurring in the characteristic or distinct forms of retinitis elsewhere described. Haemorrhage into the retina is common to nearly all forms of retinal inflammation and perhaps should be considered a symptom rather than a disease, but they are certainly met with in cases independent of local in- flammatory changes. When unaccompanied by inflammation, haemorrhages may occur in any la3'er of the retina, and ma}^ extend into the vitreous or backward, causing detachment of the retina. They are especiall}^ apt to occur along the course of some of the larger vessels, and the macular region seems to be a favorite site. The immediate cause of the haemorrhage seems to be usually the result of a disease of the walls of the vessels, allowing of dia- pedesis, rather than from rupture, although rupture no doubt does occur in man}^ cases, especiall}^ when following traumatism or after operations. The location of the haemorrhage, as to the la3^ers of the retina * Text-Book of Ophthalmoscopy, Part II., p. 154. 368 DISEASES OF THE RETINA. involved, can usually be determined by the appearance of the ex- travasation (See Chromo-Lithograph, Plate III., Fig. i.) If occurring in the nerve-fibre layer, as is more often the case, because it is in this layer that the larger retinal vessels course, the haemorrhage assumes a flame-like appearance, elongated and sharply defined borders, with radiating extremities. This pecu- liar shape of the extravasation is due to the direction of the nerve- fibres between which the blood settles. If occurring deeper in the retina, the haemorrhage is more irregular or circular in shape, although this appearance may be seen in an extensive haemor- rhage in the nerve-fibre layer by causing a rupture or pushing aside of the nerve-fibres. Symptoms. — The subjective symptoms of retinal haemorrhages, when unaccompanied by inflammation, are, when in the posterior pole, a positive scotoma, together with sometimes a colored vision; that is, in some rare cases the patient will complain of a reddish mist before the eyes after a fresh haemorrhage. If the haemor- rhage has occurred at the periphery, there will be found a defect in the field of vision corresponding to the extravasation. Meta morphopsia or distortion of objects seen by the portion of the retina affected may also be present. If signs of inflammation are added to haemorrhages in the retina, we will then have a swollen appearance of the disc, its outlines are clouded and indistinct, the retina is hazy, its veins engorged and tortuous and the arteries are small. When the signs of retinitis are present, they may be secondary and due to the irritation caused by the blood clots, which may lead to fatty degeneration, to hypertrophy of the nerve-fibres, and, rarely, to attacks of acute glaucoma. In the so-called Retinitis Apopledica, the fundus is spattered with small haemorrhages, with here and there larger, irregular patches of blood. These haemorrhages are usually along the side of the vessels, and many of the smaller ones appear as short lines running parallel to the vessels. This form of retinitis always comes on suddenly and chiefly among elderly people. The vessels are affected with atheroma or syphilitic degeneration, and cardiac or chronic renal disease are usually present. The occur- rence of apoplexy of the retina is always indicative of serious cerebral haemorrhage. Causes. — Haemorrhage into the retina may occur from numer- RETINITIS H.^MORRHAGICA. 369 ous causes; in the majority of cases it is due to arterio-sclerosis or some heart disease, especially if but on one side; from disturbances in the circulation we find it frequently in cardiac lesions, such as hypertrophy or valvular stenosis, in embolism or thrombosis of the central vessels of the retina and in menstrual disturbances. It may also be caused by general conditions or diseases resulting in changes in the composition of the blood or in the walls of the vessels, as found in septicaemia or pyaemia; in diseases of the kidney, spleen or liver; in pernicious anaemia, haemophilia, purpura and scurvy; in jaundice, diabetes, gout, etc. It also often results from trau- matism and from sudden reduction of the intra-ocular tension, as in iridectomy for glaucoma. Many other causes have been as- signed in reports of individual cases of retinal haemorrhage. Lang* records a haemorrhage at the macula of three times the diameter of the disc in size, occurring after an action of the bowels in a healthy boy, twenty years of age, subject to constipation. Four months later the haemorrhage had disappeared and vision w^as perfect. Prognosis. — This depends upon the cause, together with the size and location of the haemorrhage. Many cases recover with partial or complete restoration of vision when occurring in young, robust individuals and when not the result of some organic lesion elsewhere. As a rule, however, the prognosis is unfavorable, not only so far as the ocular condition is concerned, but to life as well, for, as we have seen, retinal haemorrhage is frequently the fore- runner of cerebral extravasation, or occurs mereh^ as a s^^mptom of some serious disease of other organs. Complications. — Secondary changes in the retina and optic nerve frequently follow. Glaucoma, either acute or haemorrhagic, detachment of the retina and vitreous opacities, not infrequentl}^ result from haemorrhage into the retina. Treatment. — Rest for the eyes must be enforced. All undue mental or ph3^sical exertion and the use of stimulants must be strictly prohibited. Change of scene and quiet and cheerful sur- roundings, with suspension of business cares or literary labor, are often important. If dependent upon general disturbances, these will require our attention. ■^Trans. Ophth. Soc. Unit. Kingd., vol, viii., p. 155. 24 370 DISEASES OF THE RETINA. Lachesis. — From its use, haemorrhages into the retina have been seen to speedily disappear and the accompanying inflamma- tion rapidly diminished. It is very commonly called for when no characteristic symptoms are present with the exception of the pathological changes. The retina, and perhaps optic nerve, are inflamed and congested, while throughout the swollen retina may be observed extravasations of blood of various ages and sizes. General indications determine its selection. Orotalus. — In the snake poisons we possess our chief agents for hastening the absorption of extravasations of blood into the retina. CrotaJus has been used with great advantage, especially if the haemorrhage is unaccompanied by inflammation. Belladonna. — Apoplexy of the retina, especially when arising from or accompanied by congestive headaches. Suppressed men- struation may be the cause of the difficulty. The retina and optic nerve will be found inflamed and congested. Mercurius corr. — Of great benefit in haemorrhages into the retina dependent upon pronounced degenerative changes in the coats of the blood-vessels, with or without inflammation. It not only hastens their absorption, but serves to restore tone to the vessels themselves. Phosphorus. — In a haemorrhagic diathesis when the concomi- tant indications point to its selection. Arnica. — Retinal haemorrhages of traumatic origin. Duboisia and Pulsatilla may also render valuable service. Retinitis Syphilitica. — Retinitis due to syphilitic infection may be either hereditary or acquired. In the acquired form it generally occurs with the secondary lesions and rarely with the tertiary. Symptoms. —One eye may, at first, be alone affected, though usually the second will become involved later. It is often asso- ciated with choroiditis, as already described under choroiditis syphilitica, and may be found associated with an inflammation of the optic nerve, forming a neuro-retinitis. It may be either diffused or circumscribed, usually the former, when it appears as a grayish opacity, especially around the optic disc and extending in lines along the vessels, as white striations in places partly cov- ering the vessels. There may be slight congestion of the disc> RETINITIS SYPHILITICA. 37 I and quite rarely, slight haemorrhages. The vitreous is especially apt to be involved {^chorio - retinitis) , and we find a diffuse, dust-like opacit}', with now and then some thin floating shreds. Syphilitic retinitis often passes into a chorio-retinitis, when we may have the following appearances, as described by Hirschberg,* based upon an examination of about three hundred cases: Opaci- ties in the vitreous, usually like a cloud of fine dust, some hazi- ness and congestion of the retina with numerous small white spots throughout the fundus which are free from pigment, sharply out- lined, and with no tendency to coalesce. Patients complain of a persistent dazzling and night-blindness, with scotomas and possi- bly blindness following. Xearh' all parts of the e3^e, cornea, iris, lens and vitreous, may become involved and undergo changes. Course and Prognosis. — Syphilitic retinitis will often come on quite rapidl}^ and run an exceedingl}^ chronic course. The prognosis should always be guarded, for, even under the most active treatment and the most favoral general conditions, the im- provement may be but slight and relapses are apt to occur. In spite of all treatment it may result in atrophic changes in the retina, choroid or optic nerve. Treatment. — The general indications mentioned under other varieties of retinitis are, of course, applicable in this form of retnal intlammation. Mercurius. — Especialh- the remedy for this form of inflamma- tion of the retina. The solubis or corrosivus have been more commonly employed, though the other preparations are also use- ful when special indications point to their use. The retina will be found hazy, congested and often complicated with an inflam- matory condition of the choroid or neighboring tissues. The eye is particularly sensitive to artificial light. Nocturnal aggravation of all the symptoms is always present. More or less pain is ex- perienced both in and around the eye, especially during the even- ing and after going to bed. Kali iod. — For syphilitic retinitis this should be one of the first remedies thought of, especially if there is choroidal complication, though the chief indications for its use will be furnished b}- the general condition of the patient. ■■^Berliner klin. Wochenschr., No. 46, 188S, and Centralbl. f. Augenhk., vol. xii., p". 369. 372 DISEASES OF THE RETINA. Aurum.-— Especially after over-dosing with iodide of potassium or mercury, and if accompanied b}^ detachment of the retina. Eye sensitive to touch, with pain in and around, seeming to be deep in the bones. A general syphilitic dyscrasia is perceptible in the constitutional symptoms which govern our selection of Aurum. Asafoetida. — When accompanied by severe boring, burnhig pains above the brows, especially at night; also, if there is pain in the balls from within outward, ameliorated by pressure (reverse of Aurum). Other anti-syphilitic remedies may be useful, given according to general indications, or we may find a remedy recommended for the other forms of retinitis, serviceable in this variety when par- ticular indications are present. Retinitis Punctata hJ^%^Q.&n^(yCe7itr at Punctate Retinitis'). — This is a circumscribed form of retinitis to which Mooren gave the name of punctata albescens. Its essential features consist of numerous small white glistening dots and striae, closely packed together, giving a stippled appear- ance to that part of the fundus involved. In one case under my observation, a few years ago, the entire fundus was filled with these small white dots, and yet the patient had nearly perfect cen- tral vision. The usual location of this disease is in the posterior pole of the •eye in the vicinity of the macula lutea. In this form of retinitis there is usually but slight if any in- flammatory symptoms — merely an increased tortuosity of the retinal veins and possibly a few small haemorrhages. No especial cause has been assigned for this form of retinitis, which usually occurs in those of middle age. Burnett * reports one case under his own observation and gives an abstract of five other, recorded ■cases, from which he concludes that the prognosis is, as a rule, good — some cases going on to complete recovery, while none seem to lead to destruction of the vision. Retinitis Proliferans. — A development of connective tissue in the retina may occur at any part of the fundus and appears as a shred-like or membranous formation. These masses are of a *Archiv. Ophthal., vol. xii., i, p. 22. RETINITIS PIGMENTOSA. 373 bluish- white appearance and often extend into the vitreous, hid- ing the optic disc and covering the fundus to quite an extent. They sometimes seem to follow the course of some of the larger vessels, which are in parts covered by the formation and again are seen passing over it. The formation of these patches may have resulted from a previous retinitis or neuritis, although Loring {Joe. cit.) has seen cases which he believed were either congenital or acquired in very early life. Leber* attributes the cause of these formations to repeated haemorrhages, which gradually be- come organized. Retinitis Pigmentosa {Sclerosis of the Retina, Pigjnent De- generation of the Retina). — The name retinitis pigmentosa is ac- cording to Frost t a misnomer, because the disease is much more of a degenerative change than it is an inflammatory condition. Pathology. — This consists of a hypertrophy of the connective tissue throughout the retina, with atrophy of the nervous element (especially the layer of rods and cones) and the migration of pig- ment. There is also a new formation of pigment cells which are very rich in pigment, and at some points an atrophy of the pig- ment occurs. There is a considerable thickening of the walls of the vessels, with a corresponding diminution in their calibre. The changes commence first in the outer layers of the retina, and later the granular layers are affected, then the layer of rods and cones is destroyed and the entire retina becomes changed and sometimes adherent to the choroid in spots. There is a colloid thickening of the vitreous membrane of the choroid, which ex- tends into the retina and becomes covered with pigment. The disease begins at the periphery of the fundus and gradually ex- tends toward the posterior pole. Symptoms. — Central vision is but slightly affected in the earlier stages of the degeneration, and only becomes materially dimin- ished when the process has involved the region of the macula lutea. The field of vision becomes concentrically contracted, ex- tending as the disease advances until often there is such extreme narrowing of the field that the patient is only able to read by fixing a single word at a time. He may read fine print, yet be *Graefe and Saemisch, vol. v., p. 666. fBrit. Med. Journ., Dec. 14, 1889. 374 DISEASES OF THE RETINA. unable to cross the street alone, owing to the contraction in his field of vision. In extreme cases the contraction progresses to complete blindness. Hemeralopia or night blindness is usually one of the earliest symptoms and often the first to attract the pa- tients' attention — they notice that on approach of dusk their movements become uncertain and that they are apt to stumble over objects. Ophthalmoscopic examination presents a striking and character- istic appearance. (See Chromo-Iyithograph, Plate II., Fig 5.) The entire periphery of the fundus will generally show beauti- fully arranged masses of pigment, which assume the shape and ap- pearance of bone corpuscles, the processes from which extending off to unite with each other form a network which encircles the periphery of the fundus. The pigmentation will often extend farther toward the macula, on the temporal than on the nasal side and is frequently seen extending farther backward along the course of the vessels. The retinal vessels, both arteries and veins, become greatly contracted. The optic disc becomes of a greyish- yellow appearance, at the same time the vessels are gradually narrowing, owing to the loss of capillary circulation. Course. — This condition, commencing either congenitally or in early childhood, may remain stationary at some period, but usually advances steadily, with increasing contraction of the field, until finally, a little after middle life, vision has become nearly de- stroyed. Both eyes are almost invariably affected. Causes. It is undoubtedly of hereditary origin in nearly all cases and consanguinity seems to be an important factor, as inter- marriage, one or two generations remote, can generally be found. Congenital deaf -mutism, epilepsy and idiocy are frequently seen in cases of retinitis pigmentosa. This disease is more frequently found in men than in women. The prognosis is unfavorable. Diagnosis. — Retinitis pigmentosa may be confounded" with dis- seminated choroiditis, but in the latter the shape and arrangement of the pigment is decidedly different, the patches are more or less circular, are isolated and present signs of exudation with atrophy, and we find corresponding white patches with irregularly pig- mented borders. In retinitis there are no spots of choroidal atro- phy, the pigment is stellate and is more apt to be along the vessels or covering them in spots. DETACHMENT OF THE RETINA. 375 Complications. — Nystagmus is frequenth^ present and more especially so in those cases that have become far advanced in very early life. Posterior polar cataract may also be found in the later stages and very rarely vitreous opacities. Treatment. — Over use of the eyes and exposure to bright light must be avoided. Much attention must be given to the gen- eral health for a long period. Lyco., Nux vom. and Phos. are suggested as remedies. Detachment of the Retina. — {Aviotio Retina-, Ablatio Re- iina). Pathology. — In simple or idiopathic cases the fluid behind the detachment is found to be albuminous in character and contains blood and lymph corpuscles, fat cells, pigment, epithelium, etc. The vitreous is usually liquid and the retinal changes consist in a destruction of the rods and cones; fibrous tissue ma^^ be formed in the retina and atrophy of the nerve elements ensues. When de- tachment occurs as a result of morbid conditions of other struc- tures, such as cyclitis and choroiditis, there is, of course, the added pathological changes of those diseases. Symptoms. — There is more or less loss of vision, which ma}- come on suddenly. This is usually the first symptom to attract the patient's attention to the eyes, although sometimes black spots floating before the eyes, or flashes and rays of light, have been noticed as preceding a detachment. Vision is not wholly lost, unless the region of the macula is involved in the detachment. There is a limitation in the field of vision which appears to the patient as a dark cloud. This restriction in the field often escapes observation in fresh detachments, unless the examination be made carefuU}^ and with a weak lis?ht, because the retina being nour- ished by its own vessels still retains its function to a certain ex- tent. When the detachment is due to a tumor, the defect in the field of vision is more sharpl}^ defined than when the result of an exudation and the central vision may remain unaffected. If the detachment be of the lower part of the retina, the upper portion of the field of vision is lost, and, if above, the lower, and so on. Patients complain of a distortion of objects (metamorphopsia), of black spots floating before the vision — due to opacities of the vitreous — and of various light sensations and phosphenes. Night blindness may or may not be present 376 DISEASES OF THE RETINA. The objective appearances with the ophthahnoscope are best seen by an examination by the direct method and there is theu noticed, in place of the normal red reflex from the fundus, a green or bluish-gray (See Chromo-Lithograph, Plate III., Fig. 2) mem- brane which is thrown up into folds and extending forward into the vitreous. The detached retina as a rule is seen to oscillate on movement of the eye and the vessels on the surface of the detached part appear darker and often smaller than normal. xMovements of the detached retina are seen when the underlying substance is fluid and the amount of motion depends upon the consistency of the vitreous and is not seen when there is a solid substance, as a tumor, beneath. At the borders of the detachment, which are usually sharply defined from the normal fundus, the retinal vessels. pass out of focus and a change of focus is always necessary on passing from a normal to a detached portion of the retina. The retinal vessels, as they rise over the separated portion, lose their light streak and appear dark and tortuous as they course up and down over the furrows of the detachment. There ma}^ often be seen a rupture at some portion of the detached retina. The size and position of these rents vary in diffc rent cases. Diminished tension is found in all cases that have existed for some time and when not due to a tumor. The detachment may occur in any part of the fundus, though usually above, and extends gradually to the lower part from a sinking of the fluid, the -upper portion of the retina sometimes becoming again re-attached. Detach- ments may be complete or only partial, and when the latter, may appear as a small line or furrow or may be more or less circular in shape. Course. — Detachment often develops within a few hours, but it may gradually take place during one or two weeks. Kver}^ de- tachment has a tendency to extend and become total. Idiopathic detachment is frequently found in both eyes, but rarely occurs in both eyes simultaneously, the second eye being involved often only after many years. Causes. — Separation of the retina is most frequently found in myopic eyes, and is more apt to occur in very high degrees of myopia. It seems to occur more frequently in men than in women and in about one-half of the cases in those upward of fifty years of age. It results from traumatism, haemorrhages, intra- DETACHMENT OF THE RETINA. 377 ocular tumors, cysticerci and from diseased conditions of the eye^ such as retinitis, cyclitis, irido-cycHtis, etc. The mechanism of a detachment has been the subject of ex- tended investigation, and the researches of Leber and Nordenson would indicate that it is due to a shrinking of the anterior portion of the vitreous, which, by dragging upon the retina, causes a rupture and that the fluid of the vitreous passes in behind the retina through the rupture and fills up the space left by the mem- brane. The diffusion theory supported by Rsehlmann-^ is that, owing to some chemical change in the vitreous, the diffusing " vitreous salts " cause an albuminous fluid to collect behind the retina, this diffusion of fluid behind the retina going on it is pushed more and more inward until it finally gives away. The primary cause, therefore, seems to be due to some change in the vitreous which may perhaps be due to some senile change or to some disease of the choroid or ciliary body whereby the nutrition of the vitreous has become altered. Diagnosis. — In the majority of cases the ophthalmoscopic ap- pearances present such a perfect picture that no trouble is found in recognizing a detachment. The only difficult3^ occurs in small or transparent detachments, and these will usually be revealed by a careful examination with the aid of a mydriatic. The most im- portant point in the diagnosis is to determine whether it is due to an intra-ocular tumor, and the most valuable sign rests on the tension, which is plus in tumor and minus in simple detachment. Prognosis. — This, as a rule, is unfavorable, for the detach- ment, when of any size, will usually extend and become total, no matter what care or treatment is followed. A detachment of the upper part of the fundus will usually extend to the lower, from a sinking of the sub-retinal fluid. Cataract frequently occurs in cases of detached retina. Spontaneous re-attachment may take place after a longer or shorter interval, and, when it occurs early, the vision may be greatly restored and no ophthalmoscopic signs be seen that any detachment has taken place. Treatment. — If the patient comes under treatment a short time after the detachment has occurred, or even in six months afterward, he should be confined to his bed for from four to six weeks at least, chiefly upon his back, with the eyes bandaged. *Archiv. fiir Ophthal., xxvii, Part I, p. i. 378 DISEASES OF THE RETINA. This is of great importance in aiding recovery. If it is impossible to confine the patient to his room, he must be warned to avoid all use of the eyes and to keep as qniet as possible. If he must be out in the light the eyes should be protected by darkly colored glasses. In many cases, the constant use of Atropine is of advantage, as it prevents accommodation and thus keeps the eye and tissue more quiet. Operations to allow the escape of the fluids have been reported with some success. Sutphen * reports three cases of detachment of the retina treated by puncture, with one success and two failures. Bull f reports five cases treated by Schoeller's method of injecting tincture of iodine into the vitreous in front of the de- tached retina to tear the shrinking or contracting bands in the vitreous and to produce an adhesive retinitis. In all of these cases the results were unfavorable. Yet successes have been reported by the authors of both these methods. GelsemiurQ. — One of the most prominent remedies for serous infiltration beneath the retiiia dependent upon injury, or myopia. Especially indicated if accompanied by choroiditis, with haziness of the vitreous and some pain. A bluish haze, or wavering is often observed. Aurum. — Has been used successfully in amotio retinae. The symptom under Aurum which suggests its use is as follows: *' Upper half of vision as if covered by a black hody; lower half visible." The choroid, or retina, is usually inflamed, and opaci- ties are seen in the vitreous, giving rise to the '' blacks " com- plained of by the patient. Apis. — Fluid beneath the retina. Passive pain in the lower part of the ball, with flushed face and head. Stinging pains through the eye. CEdematous swelling of the lids. Arnica. — Traumatic detachment of the retina. Digitalis. — Adapted to the general pathological condition and has this common symptom of detachment of the retina: "As if the upper half of the vision were covered by a dark cloud even- ings on walking." Benefit has been seen from its use. Ars. , Bry., Hep., Kali iod., Merc and Rhus may also be thought of for this condition. * Trans. Atner. Ophthal. Soc, 1888. t Trans. Amer. Ophthal. Soc, 1891. ISCHEMIA RETINA. 379 Ischaemia Retinae {Ayicsmia of the Retina). — Thi^ term has been applied to a peculiar condition of the retinal circulation which has been seen or recorded a few times. It consists in a great reduction in the size of the retinal vessels, especially the arteries, which appear as very fine threads, and in one case recorded by Knapp"^ could not be found at all in one eye. This was a case of sudden blindness during whooping cough, the optic nerves were white and the vessels were all very fine and thread-like, while no arteries could be discerned in the right eye. No other lesions were present. Vision improved and there was an increase in the size of the vessels after paracentesis was made. The reduction in the size of the arteries, as a rule, is the only ophthalmoscopic appearance present, although the optic disc maj^ be pale and its outlines indistinct. There is usually total blind- ness, and the attack may come on suddenh^ or gradually and last from a single moment to several weeks. The trouble has been supposed to be due to reduced heart's action, and, by von Graefe, attributed to some obstructive cause within the optic sheath. Treatment. — When the anaemic condition of the retina is complete (vision entirely lost), paracentesis or iridectomy, to di- minish the intra-ocular tension, becomes necessary. Inhalation of Nitrite of Amyl will be of service. We sometimes observe a partial anaemia of the optic nerve and retina associated with and depend- elit upon general anaemia. These cases should be treated by the administration of those remedies indicated by the general condi- tion of the patient, as Calc, China, Ferrum, Phos., Puis., etc. Agaricus has cured cases accompanied by a tendency toward chorea. Embolus of the Arteria Centralis Retinae. — An embolus may become lodged in the central artery of the retina, or in anj^ of its branches. It is only rarely that the circulation becomes completeh^ stopped. As the retina has an independent circulation of its own with no provision for collateral circulation in case of ob- struction, its nutrition ceases at any stoppage of the central artery. Symptoms. — There is nearly always sudden loss of sight, with- out pain or external symptoms. Occasionally there is slight gid- *Archiv. Ophthal., vol, iv., p. 448, 1875. 380 DISEASES OF THE RETINA. diness and headache, flashes of light and some uncertainty of vision preceding the sudden onset of blindness. The field of vision, in complete obstruction, is lost in all directions, as there may be even no perception of light in these cases. If one of the branches is involved there may be simply a loss of the field of vision in one direction. The pupil may be somewhat dilated and will not respond to light. The tension may be either increased, decreased or normal. The optic nerve becomes paler and of a grayish-white appear- ance from a diminished amount of blood in its capillaries. The retinal vessels appear thin and contracted, the arteries can only be traced for a short distance into the retina, while the veins present a contraction as they pass from the disc, but become fuller again toward the periphery of the fundus. Minute haemorrhages in the vicinit}^ of the macula or disc are sometimes found. There is a whitish opacity of the retina, especially in the region of the macula and around the disc. This opacity may come on within a few hours or it may be delayed a week and after a time it begins to disappear. The opacity of the retina probably occurs in the inner layers, which receive their blood supply from the retinal arteries. In connection with the appearance of the opacity around the macula there is seen a cherry red spot corresponding to the position of the fovea centralis. This bright red spot is due to the red color of the choroid shining through the thinned retina and is less likely to form when the stoppage is in some of the retinal branches. After some weeks the o^tic disc undergoes atrophy, the retinal opacity subsides, the arteries show a white streak and may become converted into white threads; if haemorrhages have occurred they undergo degenerate changes. The diagnosis depends upon sudden blindness in one eye, the ophthalmoscopic picture already described, and the discovery of an endocarditis, valvular disease, or some other source of an embolus. When the embolus becomes lodged in one of the branches it may sometimes be seen with the ophthalmoscope, but as a rule the diagnosis is made on account of a swelling in the artery at some point with an obliteration of the vessel beyond. The visual disturbance is limited to a scotoma of the portion of the field involved. THROMBOSIS OF THE VENA CENTRALIS. 38 1 Thrombosis of the Vena CentraUs will present appear- ances very similar to those of an embolus of the artery, but with more inflammatory symptoms, simulating to some extent retinitis hsemorrhagica. In complete stoppage of the vein the optic disc will be nearly obliterated by haemorrhage, there will be numerous haemorrhages throughout the retina and especially along the course of the vessels, and, together with these, j^ellowish patches of exudation. The veins will be enlarged and tortuous and the arteries small and straight, and there ma}^ be a diffuse opacity of the retina. Thrombus usually occurs in old people with ather- omata, and orbital cellulitis from erysipelas is frequently a cause. In partial plugging of the vein there will be less opacity of the retina and fewer haemorrhages, the veins wall be enlarged and the arteries contracted. Vision is wholly or partially destroyed, and there may be recurrences of the haemorrhage. Interesting cases of thrombosis of the central vessels were reported by Loring * which he had previousl}^ reported to the i\merican Ophthalmo- logical Society as cases of embolism. Later Angelucci gave the following differential diagnostic points: *' Embolism. — Normal course of vessels, arteries narrow^ed, veins gradually increasing in calibre toward the periphery, no venous pulsation, absence of retinal haemorrhages. " Thrombosis. — Tortuosity of vessels, arteries of normal calibre or nearly so, veins gorged with blood and here and there inter- rupted, venous pulsation and retinal haemorrhages." Causes. — Valvular disease of the heart, especially when com- plicated b}^ an acute endocarditis, is the most frequent cause of em- bolism. It occurs also in diseases of the kidney and in aneurisms. While a thrombus generally results from a phlebitis and also in cardiac diseases. Embolism may occur at any age and usually affects but one eye. Prognosis. — This is ahvaj^s unfavorable, as embolism of the central artery, when complete, almost invariably leads to blindness. In some cases there will at first apparentl}^ be some improvement, but even in these cases optic nerve atroph}^ is apt to follow^ When, however, a branch, instead of the main trunk, is involved, the prognosis is, of course, more favorable. ^Amer. Jour. Med. Sci., April, 1874, 382 DISEASES OF THE RETINA. Treatment. — But little if anything of value can be done for this condition. Operations to reduce the intra-ocular tension, in hopes of restoring the circulation, such as sclerotomy and para- centesis, have been practiced. Inhalations of the Nitrite of Amyl have been credited with curing some cases of embolism. Vision may, in exceptional cases, return without an}^ treatment, though it is better to give those remedies which seem to be con- stitutionally required. By reference to Opuim a case will be found described in which a cure was effected. Whether or not this was due to the Opium administered is a question. Hyperaesthesia Retinae. — Over-sensitiveness of the retina to light may be a symptom of inflammation, but it also results from close application of the eyes at fine work. It may also be found in neurotic or hysterical subjects and may or may not be associated with refractive errors. Symptoms. — -There is a dread of light, which may be so intense that the subjects will shield their eyes from all light, and it often results in a blepharospasm. There is frequently lachrymation and more or less neuralgic pains around the eyes and head. The vision is not at all affected, but we find many of the asthenopic symptoms so often present in refractive errors,^ such as fatigue upon using the eyes, with some blurring of near objects. Upon ophthalmoscopic examination we may find slight congestion of the disc and retina. In the higher degrees of irritation the outlines of the disc become ill-defined. lyoring believes that atrophy of the optic nerve may be excited by a chronic condition of irritation. Treatment. — If dependent upon any anomaly of refraction, the proper glass must first be prescribed. In rare, severe cases it may be necessary to confine- the patient in complete darkness for a week or more and then gradually ac- custom him to the light. Though usually it is better to advise exer- cise 171 the open air, having the eyes protected by smoked or blue glasses, or a shade. Especial attention must be paid to the gen- eral health of the patient. Belladonna. — Hypercssthesia of the retina, particularly if de- pendent upon some anomaly of refraction or reflex irritation. Eyes very sensitive to light; cannot bear it, as it produces severe i COMMOTIO RETlNy^. 383 aching and pain in the eye and even headache. Flashes of light and sparks observed before the vision. The ej^e symptoms as well as the headache are usually aggravated in the afternoon and evening. Coniuni- — Over-sensitiveness of the retina to light, especially if accompanied with asthenopic symptoms, so that one cannot read long without the letters running together; with pain deep in the eye. Excessive photopsies, but fundus normal in appearance. Photophobia. Everything looks white. Natrum mur. — Hypersesthesia of the retina, especially from reflex irritation in chlorotic females; there is great photophobia, with muscular asthenopia; some conjunctival injection; eyes feel stiff and ache on moving them or on readiiig; letters run together on attempting to read; sticking, throbbing headache in the temples. Nux vomica. — When t\\& photophobia is excessive in the morn- ing and better as the day advances. Ignatia. — H3^persesthesia of the retina in nervous, hj^sterical patients. Great dread of light and severe pain around the eye. Lactic acid. — Hyperaesthesia of the retina, with steady aching pain in and behind the eyeball. Macrotin. — Angell considers Macrotin more widely service- able than any one remedy. The ciliary neuralgia is usually marked. Merc. sol. — Eyes more sensitive to artificial light, and in the evening. A large number of remedies which produce marked photophobia may be indicated by the general symptoms and cachexia of the patient, as Aeon., Antimon. tart., Ars. , China, Gels., Hep., Hyos. , Puis., Rhus., Sep., Sulph., etc. Commotio Retinae. — This term is applied to sudden loss of vision from blows or concussion of the ej^eball. An injury from a blow upon the eye may result in an almost complete loss of vision without any immediate evidence of damage having been done; although, after a time, there may be signs of atrophy of the nerve. In more moderate injuries, such as from the cork of a bottle, there may be slight ciliary injection, some contraction and sluggishness of the iris and a grayish haziness of the retina. 384 DISEASES OF THE RETINA. especially in the region of the macula. This opacity of the retina is of considerable size and is due to an acute oedema of the retina, which comes on within a few hours and disappears after two or three days. There may be a decrease in the size of the arteries and an enlargement of the veins. Vision may be more or less affected and is not perfectly regained until long after the opacity of the retina has disappeared. Glioma Retinae {Fungus Hcsmatodes of the Eye, Encephaloid of the Retina). — Gliomata are the only tumors arising from the retina, and they take their origin from the connective tissue or neuroglia of the retina. Pathology. — It consists of small cells with large nucleus, and minute processes similar to those of the granular layers of the retina, numerous blood-vessels and a small amount of connective tissue. A glioma most often originates from the inner granular layer, although it may have its starting point in any of the layers of the retina; it may extend either outward or inward from its place of origin and its especial path of extension is along the optic nerve. Its histological features are similar to small, round-celled sarcoma and is often called a glio-sarcoma. Symptoms and Course. — The condition generally first noticed is a bright reflex from the interior of the eye. There is no pain or redness and the anterior part of the eye is normal. When seen early there is noticed, with the ophthalmoscope, a white or yellowish-red tumor, with either a nodulated or smooth surface, and usually blood-vessels are seen coursing over its surface. The retina is generally detached and the lens and vitreous are clear. As ' the tumor increases the iris and lens become pushed forward and the anterior chamber shallow. The growth continues to increase, causing distension of the eye; pain sets in, the coats .of the eye give way and the tumor appears externally. It becomes ulcerated, bleeds easily and exudes a bloody, foetid discharge. Its growth is rapid and soon involves the orbit and temporal regions and pre- sents a huge vascular mass. The choroid and optic nerve become involved — first the medullary portion of the nerve and then the sheath. This causes a thickening of the nerve, and, in this way, extension to the brain. Metastasis may take place to other parts of the body, the patient becomes cachectic and death from exhaus- tion or brain-disease is the final result. GLIOMA RETINA. 385 Causes. — Glioma of the retina is either congenital or occurs in infants. It usually appears under the age of ten, and but one case, that of Mervill,* in a man aged twenty-one, is on record where it occurred after the sixteenth year. Usually but one eye is in- volved, although both may be implicated simultaneousl}^ or in succession. Diagnosis. — Purulent choroiditis so closely simulates glioma as to be spoken of sometimes as pseudo-glioma. The differential diagnosis depends on the histor}^ and local appearances. In choroiditis there is the history of previous illness, meningitis or cerebro-spinal meningitis, and often an inflammation of the ej^e will have been noticed. These two symptoms are the essential diagnostic points, although in choroiditis the mass is apt to be more yellowish in appearance and the tension minus; w^hile in glioma the tension is rarel}^ low and may be increased even before glaucomatous symptoms become evident. Prognosis. — In glioma the prognosis is always bad, although numerous cases are recorded where the eye has been removed early with no recurrence of the growth, but it is altogether hopeless, if left to its own course. The most common method of death is by an extension along the optic nerve to the brain. If a relapse oc- curs after enucleation a fatal issue is most certain. Noyes {^loc. cit.) says: " A single case is given in which the patient survived after removal of secondary tumor." To this may be added a case re- ported by Dr. Geo. S. Norton,* where the secondar}^ growth ap- peared about two and one-half months after the enucleation, with the previous symptoms of constitutional disturbance. This was removed and the fluid extract of Red Clover blossoms (^Ceanotlucs Americana) administered. This patient was last seen by the writer ten years later, at which time she was in perfect health and with no signs of any return of the growth. Treatment. — This should always be by operation, and, if the enucleation is made in the very early stage, there is a fair chance of eradicating the disease, w^hich is at this time purely local. In enucleation for glioma it is always best to remove as long a portion of the optic nerve as possible. If the operation is made in the glaucomatous or later stages of the disease, all the contents of the * Trans. American Ophthal. Soc, vol. 2, p. 364. 25 386 DISEASES OF THE RETINA. orbit should be removed. After the growth has perforated the eyeball and becomes of a fungus appearance, operation can only be considered for relief of the pain, as it is then too late to offer any hope of preserving the life. The use of Red Clover blossoms to prevent the recurrence of glioma, after operation, seems from the case reported by Frenchf and Norton {loc. cit. ) to be worthy of a trial in all cases of this malignant disease. So far as we have been able to find, no other medication has ever proved of any value. "^ Journ. Ophthal., Otol. and Laryngol., vol. 2, April, 1890. t Trans. Amer. Inst. Horn., 1884. 1 ANATOMY. 387 CHAPTER XIX. Diseases of the Optic Nerve. Anatomy. — The optic nerve extends from its terminal expan- sion, the retina, which receives visual impressions, to the brain centres, where perception takes place. It maj^ be divided for its anatomical considerations into three separate regions — cranial, orbital and intra-ocular portions. Each optic tract arises by two roots, of which the exterrial is made up of fibres arising from the corpus geniculatum externum, from the thalamus opticus and from the anterior corpus quadrigem- inum. From these ganglia radiating fibres extend to the gray matter of the occipital lobe. The hiner root of the optic tract re- ceives fibres from the corpus geniculatum internum and from both the posterior and anterior corpus quadrigeminum. Another bundle of fibres comes direct from the cortex of the occipital lobe. Other fibres have been traced as coming through the crus cerebri and along the pons varolii from the posterior columns of the cord. Still other fibres of this internal root come from the corpus denta- tum of the cerebellum. The optic tract formed by the union of these two roots passes forward along the inferior surface of the thalamus opticus, crosses the crus cerebri and unites upon the olivary process of the sphenoid bone with the optic tract from the opposite side to form the optic chiasm or commissure. In addition to the fibres of the optic tracts, the chiasm has fibres which appear to come from the corpus subthalamicum and serve to connect corresponding parts on opposite sides of the brain. They are known as the commissural fibres of Meynert and of Gudden, and have no direct visual function (Fig. 77). In the optic commissure the fibres of each optic tract undergo partial decussation, the fibres of the right optic tract supplying the right half of each retina and the left optic tract supplies the left half of 388 DISEASES OF THE OPTIC NERVE. each retina. The dividing hne in the eye is on the vertical meri- dian through the macula, while at the fovea there is an interming- ling of the fibres from both sides. The orbital portion of the optic Fig. 77. Scheme of the central visual apparatus. R, retina, shaded where it is innervated by the left, clear where innervated by the right hemisphere; No, nervus opticus; Ch, chiasma; Tro, tractus opticus; CM, Meynert's commis- sure; CG, Gudden's commissure; /, lateral tract root; m, median tract root, Tho, thalamus opticus; Cgl, corpus geniculatum laterale; Qa, nates; Bqa, brachia anteriora; Rd, direct cortical tract root; Ss, sagittal medullary layer of occipital lobe; Co, cortex (chiefly of the cuneus); Lin, median tract (Schleife). nerve commences where it passes through the optic foramen from its orgin in the optic commissure. From the chiasm to the fora- AXATOMY. 389 men the nerve is about 10 mm. long, and from the foramen to the eyeball it is about 28 mm. long and 4 mm. in diameter. At the optic foramen the nerve becomes invested with a sheath from the dura mater, in addition to the pial sheath in which it has been inclosed in the skull. Between the dural and pial sheaths of the optic nerve is a space which is imperfectly divided by trabeculse of connective tissue and containing lymph. This space is directly continuous with the arachnoid cavity of the brain. Another lymph space lies beneath the pial sheath, but this is normally only microscopical. The arteria and vena centralis retinae pierce the nerve about 15 mm. behind the eyeball. The central artery does not supply the nerve as a whole, but gives off very minute branches just behind the lamina cribrosa to supply it and the optic papilla. The pial sheath is a fibro-vascular structure, very closely ad- herent to the nerve and gives off connective tissue bands which form a network of trabecular tissue between the fibres of the nerve. It receives its blood supply from branches of the oph- thalmic artery, and, by its continuity with the pia mater, forms a communication between the intra-cranial and orbital arteries. The pial sheath terminates by becoming blended with the inner layers of the sclera. The dural sheath forms a fibrous covering to the nerve and terminates by blending with the outer layers of the sclera. The ocular portion of the optic nerve is that part where it pene- trates the globe. On passing into the ej^eball the sheaths are left behind, as described above, and with them the connective tissue septa separating the fibres turn aside and blend with the sclera. The nerve-fibres, having lost their medullary coat, are continued as naked axis cylinders, and terminate as the optic papilla. The Lamina Cribrosa is made up of fibrous tissue interwoven with the connective tissue sheaths and septa from the optic nerve at the level of the sclerotic opening. This structure is more or less visable with the ophthalmoscope and represents the limit of an ophthalmoscopic view. The optic nerve fibres, in order to gain entrance to the globe, must pierce both the sclera and choroid, which they do through a circular opening. The edge of this opening may be in close contact with the nerve or a small space may be left through which the sclera may be seen. Krause esti- 390 DISEASES OF THE OPTIC NERVE. mates the number of fibres within the optic nerve as high as 400,000. The Ophthalmoscopic Appearance of the Healthy Papilla is that of a circular area, whitish in color, due to the lamina cribrosa, which shines through the transparent nerve-fibres — the white substance of the sheaths having terminated at this point. It generally has a pinkish tint, due to the presence of capillaries, the degree of this coloration varying in" different individuals. A little to the inner side of the disc the central artery of the retina is seen to emerge, which usually divides after passing the lamina cribrosa, although it may sometimes have divided before coming into view. The two chief divisions thus formed pass, one upward and the other downward, to the retina. The central vein is somewhat darker in color and larger in size than the artery and accompan- ies it. There are frequently small lines of pigment bordering the disc at some point. The Physiological Cup is an excavation at about the centre of the disc of a varying extent, but it never reaches to the edge of the disc, as does the cup of glaucoma. It is usually funnel-shaped and more distinctly white in appearance than is the rest of the disc. (See Chromo-Lithograph, Plate II, Fig. 2.) This is due to an ex- posure of the central part of the lamina cribrosa from the diverg- ence of the nerve-fibres as they turn or bend to pass over into the retina. The Sclerotic Ring is a whitish ring found at the edge of the disc and is caused by the opening in the choroid being somewhat larger than that in the sclera, and thus permitting the sclera to be seen through the transparent nerve-fibres. It is generally more visible at the outer edge of the disc, owing to a greater thinness of the nerve-fibres at that point. The average diameter of the disc is about 1.6 mm., its apparent size varying with the refraction of the eye. Opaque Nerve Fibres. — This is a rather frequent congenital anomaly which generally affects but one eye, though it is some- times seen in both. The condition is due to the continuance of the opaque medullary sheath of some of the fibres of the nerve for a short distance after passing through the lamina cribrosa of the sclera. Opaque fibres are most often seen extending either COLOBOMA OF THE SHEATH. 39 1 above or below (See Chromo-Lithograph , Plate III, Fig. lo) and appear as a white patch, which runs a variable distance, sometimes ending abruptly, but generally as a striated, fan-shaped margin. The diagnosis of the condition is not difficult; and yet it is some- times confused with atrophy of the choroid or with the white mound around the disc seen in retinitis albuminurica. In opaque nerve-fibres the white or yellowish patch is, except in extremely rare instances, continuous with and concealing the margins of the disc. The retinal vessels may be wholly concealed or will appear here and there. The striation and flame-like shape of the opaque fibres are also characteristic diagnostic points. The surrounding parts of the fundus are normal and vision is usually only affected by an enlargement of the blind spot. Coloboma of the Sheath. — This is another very rare anomaly which depends upon an imperfect closure of the foetal fissure and is very frequently mistaken for a retraction of the choroid found in myopia. It is often accompanied b}- a fissure or defect in the choroid; but, unlike choroidal changes, it has no pigment border. There is an apparent elongation downward and backward of the nerve which has a concave look. The nerve runs into the ex- posed sclera or sheath. The usual location of the coloboma is at the lower part of the disc, though in three cases that came under my observation and reported in the Journal of Ophthalmology , Otology and Lajyngology, vol. ii., p. 2, 1890, the coloboma was in each instance at the upper part of the disc. Hyperaemia of the Disc. — Simple congestion of the disc is evidenced by an increased redness, it assuming a general dull red hue which shades off into the surrounding fundus so that the out- lines of the disc become blurred and indistinct. In addition to the appearance of the disc, as seen with the ophthalmoscope, there may be some photophobia, fatigue on using the eyes or slight pains around the eye. Hyperaemia of the disc occurs in all inflammations of the retina and choroid, and may be caused by refractive errors, especially in hypermetropic and astigmatic eyes. It is also common in those exposed for a long period to the glare of a bright light. Cerebral hyperaemia, fracture of the skull, or morbid process at the base of the skull may result in hyperaemia of the optic nerve. 392 DISEASES OF THE OPTIC NERVE. As the normal redness of the disc may vary, being greater in plethoric persons and in those using alcohol to excess, it is always somewhat difficult to say when an abnormal congestion is present. The treatment must be directed to the cause, as it is more fre- quently symptomatic than idiopathic. The remedies especially to be considered are Bell., Duboisia, Phos. and Pulsat. Haemorrhage of the Optic Nerve. — When the extravasa- tion occurs in the papilla it is readily seen. It is found to occur where the vessels have become degenerated, as in albuminuria, diabetes, etc. It may also occur iu embolism or thrombus of the central vessels, and is perhaps most frequently seen in some form of neuritis or neuro-retinitis. In these cases the vision may be but little affected, unless the fibres going to the macula are in- volved, when the damage to sight is serious. Haemorrhage into the sheath of the nerve behind the eye is more rare and generally results from injury, as fracture of the base of the skull or of the orbit. The ophthalmoscopic signs are not at all indicative of the condition, as they may simply consist in a slight hyperaemia and haziness of the retina, or there may be all the characteristic signs of embolism of the central artery.. The vision is as a rule destroyed from atrophy. Neuritis Optica (^Papillitis, Choked Disc.) — Inflammation of the optic nerve has been divided clinically into several forms, viz.: Papillitis or choked disc, ?ieuritis descendejis or neuro-retinitis, and neuritis retro-bulbaris. As all but the last variety present ophthalmoscopic signs and are very similar in appearances, as well as causes and pathological changes, they will be described under the general heading of neuritis optica, while to the last form, neuritis retro-bulbaris, we shall devote a separate space. Pathology. — The changes in the nerve head consist, first, of a venous hypersemia and oedema, followed by a hypertrophy of the nerve-fibers, lymphoid infiltration and an incn ase of the con- nective tissue, especially that of the neuroglia of the nerve and that surrounding the central vessels. There are also inflamma- tory changes in the trunk of the nerve and its sheaths. Tubercles have been found in the sheaths of the nerve in cases due to tuber- NEURITIS OPTICA. 393 cular meningitis, and in suppurative meningitis pus cells are found, not only in the spaces between the sheaths but also in the connective tissue of the nerve itself. In s^^philitic neuritis there is thickening from h3'pertroph3' and cell infiltration of the inter- stitial connective tissue and pial sheath. Later on the pressure from the increased size of the nerve results in an atrophy of the nerve-fibres. The atrophic changes of the nerve in choked disc are described at length by Ulrich.^ In some cases where there is less thickening of the connective tissue, gra3^ atrophy ensues, in which the nerve-fibres are preserved, but become smaller through loss of their medullary sheath. Symptoms. — There are no external signs of neurit's, excepting in some cases a dilatation of the pupils, and, when present, is gen- erally in those cases where central vision has been lost for some time, and in complete blindness the pupil is not only dilated, but is often immobile. Pain is only present in those cases due to some orbital affection, when there ma}' be some tenderness on pre- sure. The vision in neuritis is sometimes perfecth' normal, and yet the ophthalmoscopic picture of inflammation of the optic nerve be quite characteristic. This fact illustrates the importance of an ophthalmoscopic examination in all cases, even though central vision be perfect. Usually there is, however, more or less impairment of vision even to mere perception of light, which may have come on quite rapidh^ or more often gradually. In some cases of an oedematous papillitis the vision will remain normal for several weeks and then commence to gradually fail, while in other cases it w^ill be impaired from the first and steadily become worse. The field of vision may be varioush^ affected, sometimes re- maining normal; again it may become concentrically contracted, or it maybe irregularly contracted in different sections. Hemian- opsia, absence of half of the visual field, may be present and be either horizontal or vertical, and indicates the origin of the neu- ritis to be intra- cranial. There may be a central scotoma, due to an enlargement of the normal blind spot from swelling, or there ma3^ be an abnormal scotoma, due to involvement of the axial fibres. Color sense may or ma}- not be lost, and, when it fails, generally does so in the usual order of green first, then red and blue last. The loss of color perception is generally proportionate *Archiv Dphthal., vol. xviii., i, zSSg. 394 DISKASES OF THE OPTIC NERVE. with the loss of central vision and affords an indication as to the course of the disease. If the vision and color sense fail gradually and proportionally, atrophy may be expected to follow, and, in cases where recovery takes place, the visual field and color per- ception return proportionately. The Ophthalmoscopic Appeara?ices vary greatly, but in every case there is hypersemia, haziness and swelling, or wooliness, of the disc, with increase in the size of the central vein. In severe cases the swelling of the disc is excessive, the cental vein enormously distended and the artery contracted. Flame-shaped haemorrhages on or near the disc are often present and sometimes white spots of exudation are found in the retina. The media and remaining portions of the fundus are normal. In Papillitis, or Choked Disc, we find in its simplest form a serous infiltration, causing an excessive swelling, with redness of the disc and engorgement of the retinal veins. To this may be added other inflammatory changes, resulting in a grayish exudation into the disc and surrounding retina, with sometimes haemorrhages. When both eyes are affected one is usually more so than the other and one nerve is apt to be affected before the other. The swelling in a marked case of choked disc, due to serous infiltration, forms an almost globular, bright red mass of marked prominence, pro- jecting into the vitreous several mm., whose outlines shade off into the surrounding retina. The retina may or may not be in- filtrated, its arteries are small, but the veins are engorged. These cases are very similar to those of neuritis descendens and are most frequently found affecting both eyes, as is the rule in almost all cases of papillitis, when of intra-cranial origin. Monocular papil- litis, due to cerebral tumor, usually affects the eye to the opposite side of the tumor, but in all cases of neuritis affecting but one eye the cause is generally below the optic chiasm. Fick says choked disc is due less to inflammatory round cell infiltration than to the dilatation of the vessels, the saturation with serum, and the thick- ening of the non-meduUated nerve-fibres. Yet actual inflamma- tion is never quite lacking, and an infiltration with round cells and hypertrophy of interstitial tissue occurs sooner or later. In IVeuritis Descendens, or Neuro-retijiitis the ophthalmoscopic ap- pearances, while somewhat similar to those of papillitis, are not so well marked. There is less swelling of the disc, its outlines are NEURITIS OPTICA. 395 indistinct, the arteries small and the veins enlarged. (See Chromo- Lithograph, Plate III, Fig. 3. ) The disc is opaque and of a deep red color and there is apt to be an infiltration along the retinal vessels. There are often more extensive changes in both the nerve and retina; they become swollen and infiltrated, haemor- rhages occur and white patches appear in the retina in the vicinity of the macula and disc. These patches in the neighborhood of the macula often assuming the stellate appearance seen in retinitis albumin urica. Course. — The duration of optic neuritis will vary greatly in different cases In some the disease will reach its height in two or three weeks, remain stationar}^ for perhaps a similar period and then subside, the nerve returning to its normal condition. These cases are often dependent upon a meningitis which runs its course before the neuritis may be said to have reached its height. Other and more severe cases may develop rapidly, but the subsidence of the neuritis \\i\\ be ver}^ slow — taking wrecks or months — and the symptoms are replaced by those of atrophy. A case of choked disc has been reported by Matthewson * in which the appearance of the nerve remained unchanged for three years Causes. — It is impossible to differentiate the various forms of neuritis from the cause, for, while papillitis often iadicates a cerebral or intra-cranial disease, still a neuro-retinitis may originate from similar conditions. If the neuritis is monolateral the cause is probably of local origin, depending upon some disease in the orbital region, as caries, periostitis, tumors and cellulitis, or of some disease of the surrounding structures, such as the frontal sinus or the antrum of Highmore. If bilateral, it is in the major- ity of instances due to some diseased condition of the brain, of which tumors (syphiloma, tubercle, glioma, and abscess) are by far the most frequent cause. Neuritis resulting from tumor of the brain is usually the most intense kind (choked disc) and does not seem to depend upon their size or location, although tumors involving the cerebellum are considered the most apt to cause this lesion, w^hile those of the convexity of the brain are least liable to cause optic neuritis. Next to cerebral tumors, tubercular meningitis is the most frequent cause. In addition to these local and cerebral causes we may find neuritis appearing in constitutional disturb- * Trans. Fifth Internat. Ophthal. Congress, p. 613, 1876. 39^ DISEASES OF THE OPTIC NERVE. ances of various kinds among which may be mentioned syphilis. Horstmann"!^ gives the description, together with the field of vision, in eight cases of specific optic neuritis. It may also be found in severe febrile diseases, such as typhus, variola, etc., from toxic agents, such as lead, albuminuria, etc ; in anaemia, espe- cially when occurring in youth; in females with menstrual dis- turbances; from simple exposure to cold and rheumatism. It occurs in all ages and may be congenital. Several cases of optic neuritis have been found accompanying acute myelitis which was located in the lower and middle portions of the cord. The course of the extension in these cases has not been demonstrated, but in all probability takes place along the fibres of the optic tract which have been traced to the posterior columns of the cord. The method by which an intra-cranial disease causes neuritis optica has been the subject of much research and controversy. We believe the weight of opinion to-day has abandonded the earlier theories and accepts now what might be called two methods of ex tension, the mechanical and the inflammatory. In the me- chanical it is due to hydrops of the sheath resulting from increased pressure within the skull, forcing the cerebro-spinal fluid forward between the sheaths of the optic nerve, causing, through compres- sion on the nerve, an oedema and neuritis. In the inflammatory theory, which seems to be supplanting the mechanical, there is found evidence of inflammation in the nerve and its membranes, and even in the nerve head and retina itself. The assumption is that germs or some chemically acting material is carried from the brain to the papilla, by the lymph current where its destructive influence is developed. Prognosis. — This depends chiefly upon the cause and severity of the disease. In all cases of neuritis optica the prognosis should always be guarded, as more or less loss of vision is apt to result from atrophy of the optic nerve. If due to some grave cerebral or general disease, it is of course unfavorable; but, if there is no incurable disease causing the optic nerve lesion, then the eye trouble may be relieved. The progress of the neuritis is indicated as already mentioned by the progress of the visual and color sense. In neuritis from meningitis, or cerebro-spinal meningitis, useful *Archiv. Ophthal., vol. xviii., 2, 1889. 1 I NEURITIS RKTRO-BULBARIS. 397 vision may sometimes be recovered, especially if the primary disease is rapidly controlled or when the optic nerve has become involved only in the later stages of the disease; but, as a rule, however, more or less atrophy ensues. When the neuritis is due to orbital affections, syphilis, anaemia or menstrual disturbances, the prognosis is somew^hat more favorable, as restoration of vision may be more or less complete. Treatment. — As neuritis usually is associated with other and more serious diseases, the treatment will, as a rule, be directed to the general condition or cause of the neuritis. If resulting from some orbital condition, as cellulitis, tumors, etc., treatment as laid down under those headings would be indicated. In some cases of syphilitic neuritis the use of potassium iodide in large doses has given most flattering results. For remedies and their indications, what has been said under Retinitis applies to neuritis as well, but a careful study of the materia medica may show the true remedy to be one the least thought of. Neuritis Retro-bulbaris. — {Axial Neuritis, Orbital Optic Neuritis, Central Amblyopia, Toxic Amblyopia^. — This consists of an inflammation of the optic nerve between the eyeball and the chiasm and partakes of the nature of both a neuritis and an atrophy. Pathology — The pathological changes in retro-bulbar neuritis have been the subject of extended investigation, and Samelsohn* was the first to describe in detail the anatomical changes in this disease. Since then his results have been corroborated b}^ a num- ber of others, among whom may be mentioned the cases of Vossius and Uthoff, reported at a later date in the same archives. More recent papers, to which liberal reference has been made in the prep- aration of this subject, are those of Knappt and De Schweinitz.;|: The disease is one of interstitial inflammation followed by atrophy of the axial fibres of the optic nerve, with connective tissue pro- liferation, which may start at different points. According to De Schweinitz there is an increase of nuclei, hypertrophy of the con- nective tissue and wasting of the nerve-fibres of a limited portion ^Graefe's Archiv., 1882, No. i. fArchiv. Ophthal., vol. xx., i, 1891, X The Toxic Amblyopias, 1896. 398 dise:asks of thk optic nkrvk. of the optic nerve known as the papillo-macular bundle; in fact, that there is an interstitial sclerosing inflammation comparable, according to Samelshon, to the same pathological process that alcohol produces in the liver. The papillo-macular bundle, ac- cording to Bunge consist of those fibres in the optic nerve which supply the retina, between the macula lutea and the papilla, and lie in the temporal portion of the nerve-tip in a wedge shaped segment. They occupy about one-third of the surface of the papilla with the apex of the triangle toward the vessels. These fibres gradually approach the axis of the nerve and reach it at the optic canal. In front of the chiasm they occupy the upper and inner portion, but in the optic tract they sink again to the central portion and remain there until they arrive at the brain. This same condition is the lesion in central amblyopia from alco- holism and other similar affections. A certain number of healthy nerve-fibres may be seen in the atrophic parts, which explains why sight may be preserved in isolated spots of the field in persons practically blind from retro-bulbar neuritis and also why they do not become perfectly blind in the amblyopia from alcohol. Symptoms. — Knapp divides the disease into acute and chronic types and details the following symptoms as found in acute retro- bulbar neuritis: More or less severe headache; pain in the orbit aggravated by movements of the eye and by pressure upon it; im- pairment of sight which advances rapidly and may cause blindness within a day or two; central scotoma, for both color and form, which may be partial or complete, the periphery of the field remaining normal; diminished color-perception; moderate con- gestion and serous effusion of the optic papilla and surrounding retina, which may be followed by ischaemia, or this may be pres- ent from the beginning, and the termination of the condition, as shown by the ophthalmoscope, in either a return to the normal wnth recovery of vision, or a partial atrophy of the disc — always in the temporal half — with a central scotoma remaining, or a gen- eral atrophy with total blindness. Causes. — Exposure and over- work, acute infectious diseases, such as measles, rheumatism, diphtheria, etc.; poisoning from alcohol, nicotine, lead, opium, etc., and suppression of menses. Prognosis is always uncertain, as many cases will either partially or completely recover, while others will result in perma- NEURITIS RETRO-BULBARIS. 399 nent blindness, with sometimes the preservation of several islets of sight in the visual field, as already referred to. In the chro7iic type, or what may, perhaps, be more properly termed toxic reU^o-bulbar neuritis, we find the following symptoms are present: Symptoms. — There is a gradual loss of vision almost always af- fecting both eyes, the subjects frequently complaining of a fog before the eyes and that they see better at dusk, or day blindness; there is no pain, either spontaneous or upon pressure; central .scotoma, stretching between the fixing point and the blind spot, at first for colors and then absolute; ring scotoma are sometimes noticed; the color-perception is lost for both red and green; and exceptionall}^ for blue (green appears as a dirty white and red as a brownish color); the range of accommodation is diminished; the peripheral boundaries of the visual field are normal, and although direct vision is destroyed, complete blindness is not to be appre- hended; the ophthalmoscopic appearances in the earlier stages of the disease ma}^ show a slight congestion or a nearly normal con- dition of the papilla, in the later stages an atrophy of the temporal half or sometimes the lower and outer quadrant of the disc or a general atrophy of the nerve. Causes. — In a large majority of cases it is due to an abuse of alcohol, tobacco, or m.ore frequently of both, and hence is found almost exclusively in males, and in them not generally until middle life. When due to alcohol it is more apt to be found in those who seldom or never drink to intoxication, but who indulge in frequent drinks daily. Noyes {loc. cit.) found, out of 204 cases, that 132 w^ere due to these causes. The remaining cases in the table cited by Noyes were due to diabetes, lead, bisulphide of carbon, syphilis, multiple sclerosis, cold, menstrual disturb- ances, pregnancy, loss of blood from abortion, anomaly of heart, periostitis orbitae, and in 32 cases the cause was unknown. Many other drugs, such as iodoform, the coal tar products, arsenic, quinine, salicylic acid, etc., are also causes of toxic amblyopia. That tobacco alone can cause a retro-bulbar neutritis has been denied by some, but sufficient cases have been reported to make it certain in our opinion that it may. Prognosis. — In the early stage, before atrophy of the optic nerve has occurred, the prognosis may be considered favorable, as 400 DISEASES OF THE OPTIC NERVE. more or less complete recovery may be expected if the patients will give up their use of tobacco and alcohol. In some cases the sight will return to normal, even though triangular atrophy of the disc remains. Treatment. — When due to alcohol or tobacco, total abstinence from all spirituous liquors and to da ceo must be strictly enforced; after which our attention should be turned to those remedies which will restore the whole system to its natural tone. The hypodermic injection of strychnine has proven of value in some cases that would not yield to other remedies. Nux vom. has been, and probably always will be, the most im- portant and most commonly indicated remedy in this trouble. The results following its use are often marvelous. There are no marked eye symptoms in this disease, and therefore nothing to guide us to this drug with the exception of the cause. Arsenic seems especially adapted to loss of vision dependent upon the use of tobacco, and has proven clinically to be of the first value in retro-bulbar neuritis. Terebinth. — Amblyopia potatorum, with dull aching pain in the back and dark-colored urine. Atrophy of the Optic Nerve. — This disease may occur in any part of the nerve from the eye to its origin, and, when present, may extend in either direction. Atrophy may be sub-divided into non-inflammatory and inflammatory types. Non-infla7nmatory (simple, primary or genuine) atrophy is that form where the wasting away of the nerve substance has not been preceded by visible signs of inflammation, although Loring be- lieved that all cases, if seen early enough and examined with sufficient care, would have shown evidences of inflammation. Inflammatory atrophy is that form occurring as the. result of a neuritis or a retinitis. This variety is also sometimes spoken of as a neuritic or retinitic atrophy. Pathology. — Atrophy consists of changes in all the nerve ele- ments; there is a degeneration of the nerve-fibres, and interspersed between the fibres are found fat globules, granular cells and amyloid corpuscles; there is an increase of the connective tissue ; the walls of the blood-vessels become thickened and their calibre reduced; the nerve-fibres are reduced to an indifferent structure; ATROPHY OF THE OPTIC NERVE. 4OI the whole nerve becomes smaller and appears to be changed into a cord of connective tis.-ue. The medullary substance is first affected. In gray atrophy, in addition to these changes, the nerve assumes a gray, translucent and jelly-like appearance and a gela- tinous substance may be found around the vessels. Symptoms. — The loss of central vision varies all the way from a slight depreciation to blindness, and, if both eyes are affected, it is apt to be more advanced in one than the other. The contrac- tion of the field of vision is always a well-marked defect, but is not indicative of the cause of the atrophy; it usually commences as a concentric, peripheric narrowing. The limitation may begin in any direction and as a rule advances concentricall}^, but is usually well advanced before central vision begins to decline; Tience, if there is any paleness of the nerve or suspected atrophy, ' the field of vision should be carefulh^ examined. Occasionally we find an irregular contraction of the field, which will cause a peri- pheral scotoma corresponding to the defect and it may occur either with or without concentric narrowing. Central scotoma which points to a lesion of the macular fibres is rarely in the earlier stages, yet it may occur. Hemianopsia, or complete loss of one- half of the visual field, may also be found. In this the same side of each eye is usualh^ affected, although it has been seen in simple atrophy affecting the inner half of each retina, and in this respect simulating the limitation due to cerebral disease. There is always a defect in the color vision in all kinds of atrophy. Green is usually first affected and is confounded with the gray or yellow colors; following the loss of the green will be that of the red, blue, yellow and white in the order named, al- though exception all}'' red may be lost first. Contraction of the color-field is usually much greater than that for form. Dilatation of the pupil is often present in complete atrophy, and frequently will show no contraction when light is thrown into the eye, but may do so in the act of convergence. When atrophy is present in but one eye, and the pupil makes no contraction from the stimu- lus of light thrown into that eye, if the light be thrown into the unaffected eye instant contraction will take place in the diseased eye. The ophthalmoscopic appearances in atrophy of the optic nerve are always distinctive and characteristic. (See Chromo-Lithograph 26 402 DISKASKS OF THE OPTIC NERVK. Fig. 5, Plate III.) The first change is the reduction in the amount of the circulation, which first affects the capillaries at the outer part of the disc because they are less numerous in this loca- tion. Diminution in the amount of the vascularity in the temporal part of the disc results in a slight paleness, in contrast with which the vessels from the nasal side appear more distinct, and on ac- count of this it may be mistaken for a congestion. The paleness then commences on the nasal side and finally extends over the entire surface of the disc. The diminution or disappearance of the capillaries often constitutes all the changes that occur in the vessels, as in some cases the larger vessels will remain normal for years (in inflammatory atrophy vessels are also contracted). The alteration in the color of the optic disc admits of consider- able variations, from a slight gray to a white hue, and sometimes it assumes a greenish or bluish cast. Its outlines are distinct and clear cut, especially so in advanced cases. Much care and con- sideration is always required to distinguish a slight pathological paleness of the nerve from that which is normal or physiological, as the whiteness of the disc may vary decidedly in health. The paleness of the optic disc in atrophy is due to the want of capillary vessels and to the over-development of connective tissue. Owing to the shrinking or wasting away of the substance of the nerve in atrophy, the size of the disc appears, and is in reality, smaller than normal. The surface of the disc is flattened or concave, and the extent of the concavity will vary, depending somewhat upon the degree of the normal physiological cup; while the depth of the excavation depends upon the degree of nerve-fibre degenera- tion that has taken place. At the bottom of the excavation in atrophy the lamina cribrosa is usually distinctly seen and has a mottled-gray appearance. Inflammatory atrophy differs from the non-inflammatory, in that the papilla shows connective tissue changes due to organization of the exudate. The neuritic atrophy gives a grayish-white color to the disc, margins ill-defined, veins enlarged and tortuous. Later the disc becomes a bluish -white, smaller in size, clear cut. the vessels contracted, and we do not see the lamina cribrosa as in the inflammatory type. In retinitic atrophy the disc is of a grayish-red color and clouded, margins indistinct and vessels greatly dimin- ished in calibre. ATROPHY OF THE OPTIC NERVE. 403 The surrounding fundus, in atrophy following papillitis or reti- nitis, will frequentl}' show spots of degeneration and masses of pigment here and there, indicating previous inflammatory changes and haemorrhages. In simple gray or white atrophy these spots are not seen. Course. — In optic nerve atrophy the course depends some- w^hat upon the cause, but is always slow, lasting for months and in man}- cases taking 3'ears to run its course to complete blindness. Non-inflammator}' atrophy generalh' occurs in middle life and men seem to be more subject to it than women. The atrophy of children is as a rule neuritic. Causes. — Graj^ degeneration occurs in sclerosis and paralysis of the insane, but generall}^ as a result of some disease of the spinal cord, especially tabes dorsalis by far the most frequent cause of non-inflammatory atrophy. This atrophj^ usually comes on in the early stage of tabes and with the Argyll-Robertson pupil and the absence of patellar reflex, which are also often early symptoms, affords valuable aid in the diagnosis of this disease. As to the general causes, Noyes ijoc. cit.) gives the following table of the causes of atrophy in 183 cases cited by Uhthoff: Whole 1 Number. | ^^"- Women. Spinal cord Brain Simple progressive 59 1 55 41 I 23 22 1 16 17 i 13 8 3 7 6 4 1 4 ' 4 2 2 3 1 2 3 2 2 2 I I I I 1 4 18 6 4 5 5 I 4 I I ; I After neuritis optica Sudden embolism of arteries Disease and accident in orbit Dementia paralytica Loss of blood . . ... Alcoholism Lead poisoning . . . Hereditary ... Iniury Epilepsy Nephritis . . Railway spine Congenital, ' with hydrophthalmia . . 183 ; 132 51 In addition to this table, which only includes causes outside of the eye, could be added man}^ other causes, such as syphilis, 404 DISEASES OF THE OPTIC NERVE. diabetes, menstrual disturbances, colds, malaria, etc., while, from within the eye, inflammatory atrophy ma}" follow from an in- flammation of the nerve, retina, choroid, etc. Examination of Uhthoff's table shows a preponderance of cases resulting from lesions of the brain and spinal cord, and this fact has been fre- quently noticed by other observers, and, hence, examination of the eye is always important in suspected lesions of these structures. Diagnosis. — In w^ell-marked cases of optic nerve atrophy, the diagnosis presents no difficulties, but in the earlier stages, or where there is but slight paleness of the nerve, it often requires a careful consideration of all the symptoms detailed, with especial attention paid to the field and color perception. As this disease, in the great majority of cases, is due to some disease of the brain or spinal cord it is often necessary to consult the neurologist for a thorough examination of these structures. The differential diagnosis between optic nerve atrophy and glaucoma will be con- sidered under the latter disease. Prognosis. — In all forms of atrophy of the nerve the prognosis should always be guarded, for, as a rule, it is unfavorable. In some cases, where the originating cause has been controlled, or but transient, as in meningitis — especially when occurring in young subjects — more or less complete recovery has taken place. Other cases will be met with in which there is a remarkable preservation of the sight, as judged from the appearance of the disc and the circulation. In estimating the prognosis, the field of vision should be carefully watched, as it is considered to be more unfavorable where there is a regular concentric limitation than in the irregu- larly notched field. Treatment. — In true atrophy of the optic nerve very little can be done to restore vision, though we are often able to check its progress by the selection of appropriate remedies as indicated by general symptoms. The general health requires most careful attention. The diet should be nutritious and light, while tobacco and all liquors must be prohibited. Mental and physical fatigue must not be allowed. The hypodermic injection of Strychnia has proved efficacious in some instances, though its internal administration is usually more satisfactory. Favorable results have been reported from the use of galvan- TUMORS OF THE OPTIC NERVE. 405 ism, and it seems as though, when properly and persistently used, it should be of value in checking the progress of the disease at least. Nux vom. — Has been followed by more favorable results in this condition than any other remedy. Argent, nitr., Arsen., Verat. vir. and others have been used with advantage. Injury of the Optic Nerve. — This may result from a fracture of the orbital wall, or of the base of the skull, or from the pene- tration into the orbit of a foreign body, and it results in an atrophy of the nerve. Tumors of the Optic Nerve. — Very few cases of tumors of the optic nerve are on record, and those reported have been of the fibroma, sarcoma, glioma and myxoma type. vSymptoms. — There is simply a very slow, gradually increasing exophthalmos, wdth defective vision. The growths are usually ver}' slow and painless, and the movements of the ej^e are gener- ally unaffected. There is seen upon ophthalmoscopic examination symptoms of papillitis, the veins are engorged, the papilla oede- matous and congested, and later there wall be a shrinking of the vessels and white atrophy of the nerve. Treatment. — Removal of the tumor is, of course, the only remedy. This should be done, if possible, without removal of the eyeball; but in most instances enucleation has been necessary. The nerve should be severed as far back as possible, so as to include the whole tumor. As removal of a tumor of the optic nerve without enucleation of the e^^eball has onl}^ been successfully made in a very few in- stances, the following successful operation made by Dr. Geo. S. Norton, and reported by the writer in the Archives of Ophthal- mology, July, 1892, is worthy of record and is reported as taken from his case records: " Miss J , age 30, was first seen on September 25, 1890, and gave the following histor}^: The right e3^e began to protrude ten or twelve 3'ears ago, and has steadily increased ever since. For five j^ears she had much sharp pain in the e3^e, extending to the back of the head and down to the stomach. Examination 4o6 DISK ASKS OF THK OPTIC NKRVK. shows O. D. V. = yI-o, O. S. v. = |f, a protrusion of the right eye directly outward of twenty-two centimetres, which varies at different times, being greater on some days than others and greater during menstruation, and she says that the vision seems to be better when the eye is small. The ophthalmoscope showed the retinal vessels contracted and optic nerve atrophic. The move- ments of the eye were as good as could be expected from the amount of the protrusion. Is very nervous and would not allow of deep pressure to determine the nature of the growth. *' October 7th. — Eyeball protrudes directly forward so that the posterior portion of the globe is just even with the outer border of the orbit. No pulsation could be detected. Patient very nervous, had a fainting spell with retching just before being put on the table for operation, but recovered after taking some whisky. Ether was given and well borne throughout the opera- tion until after the tumor was removed, when the pulse became so much weakened that a hypodermic of brandy was given. Pal- pation, after she was under ether, showed a soft, elastic tumor behind the eyeball and connected with it. Aspirating needle inserted at the outer canthus drew out a drop or two of serum. An incision was then made between the superior and internal recti muscles of sufiicient size to permit of the finger being passed down to the tumor. Using the finger as a guide, the tissues around the tumor were severed, back to the optic foramen. The nerve was then divided at the optic foramen and afterward severed close to the eyeball. Tumor at once appeared at the opening and w^as removed. By rotating the eye the cut end of the nerve could be seen, and it appeared clear and white. The socket was washed out with a i to 4,000 solution of the bichloride of mercury, the eyeball replaced and covered with the lid. There was but moderate haemorrhage throughout, yet some infiltration of blood underneath the conjunctiva and into the lids was noticed, so that protrusion appeared about the same as before the operation; a compress bandage was applied, the ice-bag used locally and Aconite given. " Oct. 2 1 St. — The day after the operation the temperature was 99}4, pulse 102. The ice was used for three or four days. Patient has had no pain at any time. The eyeball protruded greatly for three or four days, caused by the infiltration of blood TUMORS OF OPTIC NERVE. 407 into the orbit and the Uds, extending even to the other eye. There was quite extensive chemosis below, so thac the conjunctiva protruded greath^ appearing between the lids. Upper lid greatly swollen, but covered the eyeball. This swelling graduall}" sub- sided, so that about the sixth or seventh day the lid retracted, leaving the eyeball exposed and the cornea haz3\ The eyelid was drawn over the eyeball and held in place by adhesive strips, which were kept on for four or five days. To-day there is considerable haziness of the cornea, but it has diminished greatly. The eye has sunken back into the orbit nearl}^ as much as the other e^^e. Eye is, however, nearly immovable, especially outward and in- ward, and stands somewhat outward. The conjunctiva still pro- trudes between the lids, but is diminishing, and with but slight discharge. No pain or unpleasant sensations. *' Nov. 20th. — Still some swelling at the inner canthus, mod- erate discharge, cornea a little hazy below, but clearing. Much better movements of the eye. "Dec. loth. — Optic disc very white, but from its centre are seen tw^o small vessels running upward for about the distance of the diameter of the optic disc. There are also seen slight choroidal changes. Much less redness of the eye and movements much better. " May 3, 1892 — Eighteen months after the operation there is little, if any, perceptible protrusion of one eye more than the other. The movements of the eye are a trifle limited in all direc- tions, but the eye stands perfectly straight. An oblique illumina- tion of the cornea shows a very slight opacity. The pupil is slightly dilated, but not as much as one year ago. In fact, the general external appearance of the eye is not noticeably different from the other, and the eye operated upon could only be told by a close examination. The ophthalmoscope shows the optic papilla to be of an extremely white, glistening appearance, with a faint line showing the position of the central vessels; at the upper part of the papilla there appears a leash of small vessels. There are some choroidal changes a short distance from the disc. The fundus appears normal and in the lower part of the field there is seen two good sized retinal vessels. ' ' 408 AMBLYOPIA AND AMAUROSIS. CHAPTER XX. Amblyopia and Amaurosis. Under this heading are classed all those conditions where there is either partial or complete loss of vision without any perceptible ocular lesions. The term Amblyopia is applied to those cases where there is but partial loss of vision, and Amaurosis where the loss of vision is complete. Formerly many cases of loss of vision from excessive use of alcohol and tobacco were classed under the heading of amblyopia, but in the advance of ophthalmological knowledge they have been found to be cases of inflammation of the optic nerve behind the eyeball and are now classed as cases of retro-bulbar neuritis. Hemianopsia, while also considered under this heading, perhaps should not be, because, while there is no perceptible lesion of the eye, the cause is known as due to some cerebral disease. Amblyopia ex Anopsia. — Weak-sightedness from disuse results when a child with hitherto healthy eyes commences to squint, for in an effort to overcome the annoyance of seeing double he learns to suppress by a mental act the image seen by the squinting eye. As a result of this suppression when followed for months and years, there takes place a permanent change in the nervous function of the eye, which is manifested b}^ more or less loss of vision, a^iiblyopia ex anopsia. This condition is often associ- ated with high degree of hypermetropia and astigmatism and will usually not excite attention until the child has entered into school life, and is probably due to the fact that, owing to the refractive error, distinct images have never been focused upon the retina. If, however, the condition is not detected until adult life, no im- provement is to be expected. Other cases of amblyopia ex anopsia are due to non-use of the visual function, owing to congenital opacities of the cornea or TRAUMATIC AMBLYOPIA. 409 lens, from persistent pupillary membrane, or in cases of strabismus in early infancy. There is usuall}^ but one eye affected in these cases, and, when the vision is defective in both eyes, nystagmus is often present. Often by bandaging the good eye and thus com- pelling the squinting eye to perform the function of vision, even for half an hour each da}^, the development of amblyopia may be prevented. An existing amblyopia can sometimes be benefited by this procedure; but as it has to be followed out for a ver\^ long time it is apt to be neglected. Naumo\v* in an analysis of 47 cases of death of new-born infants, has found in 12 cases retinal oedema, retinal haemorrhages into the macula, choroidal haemor- rhages and the beginning of choked disc. The changes were found especially in those who suffered difficult and instrumental deliver}^ and he believes that congenital amblyopia has its origin in these changes, which are caused by stasis in the vessels of the head. Traumatic Amblyopia may occur from an}- severe injury to the head, from concussion of the spine or from a direct blow upon the eye. In some of these cases there may be a fracture of the skull or a haemorrhage along some part of the nerve, which is apt to produce a neuritis; and, having then inflammatory signs in the eye, should not come under the classification of amblyopia. The prognosis of these cases, while often favorable, should, as a rule, be guarded and dependent somewhat upon the severit}' of the injury. Amblyopia from Lightning. — Cases of loss of vision from a stroke of lightning are usually accompanied b}^ such lesions as burning of the skin, hair or cornea; ptosis is often present and cataract is apt to follow. In some cases there may be a neuro- retinitis, or, later atrophy of the nerve. These cases often have a greater loss of vision than can be accounted for b}^ the recogniz- able changes in the eye, and hence can onlj^ be considered in part an ambl3'opia. Amblyopia from Loss of Blood. — Loss of sight may take place after severe haemorrhage and may be accompanied by changes 41 AMBI^YOPIA AND AMAUROSIS. in the retina or nerve, yet in some cases may present no visible lesions. It has been seen after severe haemorrhages from various organs, lungs, stomach, uterus, bladder, etc. Both eyes are usually affected in the large majority of cases and in nearly one-half the loss of sight is permanent. Temporary blindness may occur from loss of blood, and is due to the lack of blood supply to the visual centres or to the retina, and in these cases more or less complete recovery may be expected. Hysterical Amblyopia. — Hysterical blindness is more fre- quently found in young girls and women. It is usually temporary and unaccompanied by other hysterical symptoms. The loss of vision is usually complete, and but one eye is generally affected. These patients will often be made to see by placing a perfectly plane glass in the form of spectacles before the eyes and the result is due to suggestion. There is usually a concentric contraction of the field of vision, hemianopsia and color blindness may result from hysteria, and we have seen other functional disturbances, such as ptosis, blepharospasm and strabismus in hysterical subjects. Pretended Amblyopia {Mali?igering). — The pretense of blindness is not infrequently met with, and, as a rule, these sub- jects only claim more or less complete blindness in one eye. Simulated blindness may be practiced for various reasons, the most frequent, perhaps, being in order to secure damages after some trivial injury, to excite sympathy, to secure pensions, etc. We have seen blindness claimed from the mere lodgment of a cinder in the cornea, which had been removed, leaving no trace of its location behind. An exaggeration of an existing defect of the vision is often claimed. In all cases where the amaurosis is claimed to exist in both eyes, its detection becomes extremely difficult and may often only be proven by careful watching of the subject without his knowledge. The action of the pupils may give some clue; if dilated and immovable, the use of a mydriatic nny be suspected, for in dilatation of the pupil in true blindness there may be some contraction for the stimulus of a bright light or upon convergence and there is apt, also, to be a shade more of dilatation when the eyes are in a shadow. By bringing an object suddenly before the HEMERALOPIA. 411 eyes iu assumed blindness there may be the natural closure of the lids to prevent injury to the eye. Where the loss of sight is claimed to be in but one eye, there are several tests that may ex- pose the deception. The test by causing diplopia is perhaps the simplest. In this a prism of eight or ten degrees is placed before the sound eye with its base up or down, and if the person on look- ing at a lighted candle fifteen or twenty feet away acknowledges the double images, binocular vision is at once proven. The crossed diplopia test is made by holding a prism of ten degrees base outward before the pretended blind eye, and if it really sees the eye will rotate inward for the sake of single vision. Another test is made by using a strong convex glass before one eye and a plane glass before the other to read the Snellen test type at twenty feet, and, by a reversible frame, make the person use unconsciously his bad eye. Again by paralyzing the accommo- dation of the good eye, or by placing a strong concave lens in front of this eye, and, if the patient can read, we know it is done with the affected eye. The stereoscope, Snelling's colored type and various other methods are also useful in discovering an assumed blindness of one eye. In all these tests caution should be taken that the patient does not suspect that you are trying to detect his dissembling. Rather let him infer that you are seeking to find the cause of his amaurosis. Hemeralopia (^Nyctalopia, Night-bUnd^iess) . — This condition is found quite frequently without any recognizable lesions of the eye and must be considered as distinct from the night-blindness occurring as a symptom of retinitis pigmentosa and other lesions of the fundus. Hemeralopia is a functional complaint due to ex- posure to strong, brilliant lights, and is more prone to affect those whose systems have become greatly debilitated from the want of proper food. It prevails sometimes as endemic in certain coun- tries, as in Russia, during their protracted fasts; it is frequently found in sailors, from exposure to tropical suns, and is often by them called "moon-blindness;" in soldiers, after prolonged marches; in travelers in the arctic zone and in those who work before furnaces. Hemeralopia is sometimes congenital and then remains unchanged during life. 412 AMBIvYOPIA AND AMAUROSIS. Persons suffering from night-blindness are found to have good vision during daylight, but, upon the approach of dusk, or when going into a moderately darkened room, the vision becomes greatly impaired. The field of vision is normal and the fundus shows no lesion. The cause of the difficulty is probably a torpor of the retina, and, under favorable conditions, improvement may be ex- pected. Treatment. — As the general health is usually more or less im- paired in hemeralopia, a generous diet must be ordered. Rest and protection of the eyes from bright light are first required; in severe cases it may be necessary to confine the patient to a dark room with a gradual return to ordinary daylight. Lycopodiura is the remedy most commonly needed in this dis- order. Many cases have yielded promptly to its use. Other remedies, as China, Hyos. and Ranunculus bulb, may be required. Snow-blindness. — The dazzling of the snow may produce a contraction of the visual field, scotoma and night-blindness from torpor of the retina. (See retinitis nyctalopica. ) In other cases it will cause intense photophobia, pain, blepharospasm and re- sult in an acute conjunctivitis, or sometimes an ulceration of the cornea. Color Blindness. — Inability to discriminate colors is usually congenital, but may occur in diseases of the retina, optic nerve, brain or spinal cord, and consists of some impairment of the function of the retina. When not the result of disease, the sub- jects' s vision may be in every other respect perfect. He will simply be unable to detect certain colors, as red, green or blue, when partial, and, when complete, all colors will be indistinguish- able, simply black and white being recognized. Red is the color for which blindness is most frequently present, while the var3dng shades of green are next most frequently lost. Numerous theories have been advanced to explain the phenomena of color-blindness, of these the Young- Helmholtz and the Hering are the more generally accepted. The You7ig-Helmholtz theory originally suggested by Thomas Young, in 1807, who considered that there were three sets of COLOR BLINDNESS.. 413 color-perceiving elements in the retina, corresponding to the funda- mental colors, red, green and violet, and that all other colors are mixtures of these sensations. This assumption was modified by Helmholtz, who suggests that all colors excite the red, green, and violet elements at the same time but in varying degrees of intensity. According to this theory red-blindness is due to absence or paralysis of the organs peceiving red, and that therefore the red- blind have but two fundamental colors — green and violet. The red colors then exciting only the organs for green and violet, and the latter but very slightly appear to the red-blind as a green of feeble intensity, while the light shades of red do not excite the organs for green, in the red-blind, sufficiently to even create the sensation of green but appear to them as black. The sensation of green excited by red rays in those who are red- blind is of a less degree of brilliancy than the green colors appear to them, because red does not stimulate the fibres for the perception of green to the same extent as does green. In this way the red-blind is generally able to distinguish red from green, not b}^ the difference in color but by the difference in brilliancy. By experience he learns to recognize reds from greens and may go through life without being aware of any defect. As the man with red-blindness onl}^ distinguishes between red and green of equal brilliancy by the fact that the red appears darker, we can by decreasing the brilliancy of the green find a shade which will excite exactly the same sensation as does the red, and he is then unable to tell the two colors apart. Such colors are known as confusion colors and are used to detect color- blindness. In green-blindness the case is of course reversed, the elements perceiving green being either absent or paralyzed, the green- blind having only the red elements excited by green it appears to them as red. Bering' s theory is based upon an analysis of the sensations re- ceived when looking at a color. All colors excepting four primary colors — red, green, blue and yellow — excite in us a mixed sensa- tion. These primary colors form two pairs, red and green and yellow and blue, each color being antagonistic to its mate. They are also known as complementary colors, because when mixed in proper proportions they neutralize each other and produce the 414 AMBIvYOPlA AND AMAUROSIS. sensation of white. These pure colors excite in us a simple, un- mixed sensation, but other colors excite a mixed sensation, as, for example, orange gives an impression of both yellow and red. Ac- cording to Hering's theory, both white and colored light cause chemical changes in the retina or its visual substances, which he says are of three kinds, the white-black, the red-green, and the blue-yellow. He believes color-blindness to be due to the absence of one or both of the colored visual substances. In red-green blindness there is absence of the red-green visual substances and this variety is quite common. The blue-yellow blindness is very rarely found, if both the colored visual substances are absent there is total color blindness, this form is extremely rare, and, in fact, its existence is denied by some. To the red-green blind both red and green appear white or gray. This variety of color-blindness is found in about four per cent, of males, and in about one-fourth of one per cent, in females. Color-blindness causes no trouble excepting to those in certain callings, as painters, railroad and nautical service, etc. Heredity seems to play an important role in the occurrence of color-blindness. There are upward of fort}^ different tests that have been sug- gested for color-blindness, but the best is that made by Holmgren's wools, which consists in having the observer select from a heap of wools of various shades those that correspond to the one given him as a test object. There are three tests to be made. The first will detect all those who have any defect of color-vision, and the others show the nature of the defect. In the first test, a skein of light pure green, rather freely mixed with white, is used and the patient required to select all the corresponding shades of green. If he selects any of the confusion colors, viz. : grays, drabs, yellows, rose and salmon, or hesitates and Ghows doubt as to whether he should choose one, then he should be subjected to the second test. For the second test a bright shade of purple (rose) is taken as a test; the confusion colors are blues, violets, grays and greens. If the patient be red-bliiid he will choose the blue and violet, because purple being composed of red and violet or blue, is to the red -blind identical with the two latter colors; while if he h^ green-blijid, he will choose agray and bright green. For the third test a bright red skein is selected, the con- HEMIANOPSIA. 415 fusion colors for this being the dark and light shades of green, and brown or olive. The red-blind chooses a green and dark brown; while the green-blind selects a green or lighter brown. In acquired color-blindness there is impairment of the visual acuity. There may be constriction of the field both for white and colors, or in some cases a normal peripheral field with a central color-scotoma. Acquired color-blindness is usually dependent upon some disturbance of the conducting nerve-fibres, as in neuritic atroph)" or toxic amblyopia. In neuritis the vision may be but slightly impaired and the field for white but slightly contracted, and still we may find color-disturbance, from a slight limitation for a single color to total color-blindness. In atrophy of the optic nerve, together with the decrease in the vision and concentric contraction of the field for white, we have failure of the color- sense first for red and green and last of all for blue. In toxic amblyopia, especially when due to alcohol and tobacco, there is in the earlier stages a relative scotoma for red and green. There may be peripheral defects for the same colors, and in rare cases a small central scotoma for blue. In toxic amblyopias the relative scotoma, z. e., for colors, in the later stages as the disease pro- gresses becomes an absolute scotoma, blind to light of any kind. Hemianopsia (yHemiopia, Hemianopid) . — Obscuration of one- half of the visual field almost always involves both eyes. The division is almost universally vertical, although cases have been reported in which the upper or lower half of the field has been lost. Vertical hefuianopsia may be of three varieties. The most fre- quent form is that of homonymons he^nianopsia, in which the cor- responding half of the field of each eye is wanting. Thus the right half of the field, from the patient's point of view, is lost, and is due to a loss of function in the left half of each retina and is called right homonymous lateral hemianopsia, and is vice versa when the left half of the field of each eye is wanting. Temporal hemianopsia (or heteronymous lateral hemianopsia) is where the external or temporal half of the field of each eye is blind. The form of hemianopsia is due to loss of conducting power in the nasal halves of the retina and results from pressure or disease at the angles of the commissure or the inner strands ol 41 6 AMBIvYOPIA AND AMAUROSIS. the Optic nerve just before reaching the chiasm. This form comes on less suddenly than the homonymous. Nasal heteronymous hemianopsia is where both nasal fields are wanting and is the most rare form of vertical hemianopsia. In the two last forms of heteronymous hemianopsia the dividing line is apt to be irregular, while in homonymous cases the line of division is usually distinct and vertical. Horizontal hemianopsia may occur in diseases of the eye or pos- sibly from some lesion causing pressure upon the lower or upper part of the optic nerve or chiasm, or downward upon one optic tract. Monocular hemianopsia may occur from a lesion of one optic nerve in front of the chiasm and, as a rule, has an irregular bound- ary line. Hemiachromatopsia is where the color sense in corresponding halves of each eye becomes lost. This is an extremel}^ rare con- dition and but very few uncomplicated cases are on record. The lesion is probably in the cortex. In a defect of the light sense where there is a corresponding defect in the form and color sense it is called absolute hemianopsia. In cases where there is defect for form, with an equal defect for colors, the light sense remaining intact, it is called relative hemian- opsia. Wilbrand * concludes that the centre for form lies between the centres for color and light sense and that the centre for color occupies the most central position in the brain. When the hemianopsia is partial the defect is usually of an equal extent in both eyes. The reaction of the pupil in hemianopsia is always a valuable diagnostic sign, and the examination of the pupil should be made in a dark room, the eye illuminated with a weak light, while an intense light is thrown obliquely in various directions into the pupil. According to Wernicke, if, in hemianopsia, the light thus thrown upon both the seeing and blind sides of the retina causes contraction, the lesion is back of the primary optic centres. If there is contraction when the light falls upon the see- ing side of the retina and none when it falls upon the blind side, the lesion is either in or in front of the primary optic centres. Peripheral contraction of the field that remains in hemianopsia in- * Hemianopsia. Berlin. 1881. HEMIANOPSIA. Fig. 78. 417 L.r.r R.N. r P.O.C. G.A L.O.D Diagram illustrating the visual path and its relation to the visual field, left lateral hemianopsia being shown (Seguin). ly. T. F., left temporal half-field; R. N.F., right nasal half -field; O. S., oculus sin.; O. D., oculus dexter; N. T., nasal and temporal halves of retinae. N. O. S., nervus opticus sin.; N. O. D., nervus opticus dext. ; F. C. S., fasciculus cruciatus sin.; F. L. D., fasciculus lateralis dext.; C, chiasraa, or decussation of fascicula cruciati; T. O. D., tractus opticus dext.; C. G. L., corpus geniculatum laterale; L,. O., lobi optici (corpus quad.); P.O.C, primary optic centres, including lobus opticus, Corp. genie, lat., and pulvinar of one side; F. O., fasciculus opticus (Gratio- let) in the internal capsule; C. P., cornu posterior; G. A., region of gyrus angularis; L. O. S., lobus occip. sin.; I^. O. D., lobus occip. dext.; Cu., cuneus and subjacent gyri constituting the cortical visual centre in man. The heavy or shaded lines represent parts connected with the right halves of both retincs. dicates some additional complication. Pressure on the insensitive sides of the ej^e will not cause phosphenes. Ophthalmoscopic ex- 27 41 8 AMBI.YOPIA AND AMAUROSIS. amination shows no lesion, except in the later stages of the disease, when there is sometimes a paleness of the papilla. Lateral homonymous hemianopsia usually develops suddenly and is often associated with hemiplegia, and at times diminution of the cutaneous sensibility. If on the right side of the field it may be accompaned by aphasia. The line of demarcation is usually nearly vertical at the point of fixation. Transient hemi- anopsia, and generally of the homonymous lateral type, has been noticed. Mauthner says in right homonymous hemianopsia the right optic nerve will appear atrophic, while the left remains normal. Blindness of the right side of the field causes more trouble in read- ing than when the left side is gone. Central vision may be either perfect or impaired. Homonymous lateral hemianopsia results from intra-cranial and generally cerebral disease, which may be either tumors, haemor- rhage, embolisms, injuries, softening, etc. The seat of the lesion may be in any part of the visual tract between the eyeball and the cortex of the brain. The explanation as to the path through which pathological lesions result in the various forms of hemianopsia has been the subject of prolonged investigation and discussion. The accompanying dia- gram illustrating the visual paths and their relation to the visual field will give all that seems necessary here. Fuller details in the study of this subject falls under the domain of the neurologist to whom the student is referred. As to the nature of the lesion, the diagnosis must depend upon the history, nature of the attack and concomitant symptoms; but in all cases of cerebral disease, especially where the ophthalmo- scope reveals no lesion, the visual field should be examined. Prognosis. — Restoration of the visual field is rare, but when it does occur, it is apt to be symmetrical in both eyes. If both hemiplegia and hemiansesthesia are present, the former may dis- appear and the latter remain. The hemianopsia is usually but one of other cerebral symptoms which may end in death. Nasal ^ homonymous hemianopsia generally affords a better prognosis "than temporal. Treatment. — Half vision is usually only a symptom of some HEMIANOPSIA. 419 deep disorder of the eye, but as it is sometimes the onl}' S3'mptom to be found those remedies appropriate to it will be mentioned: Upper half of visual field defective: Aurinn, Dig. and Gels. Right half of visual field defective: C3'clamen, Lith. carb. and Lyco. Vertical hemiopia, either half invisible: Calc. carb., Chin, sulph., Mur. ac, Nat. mur., Rhus, Sep , and Stram. 420 DISEASES OF THE VITREOUS BODY. CHAPTER XXI. Diseases of the Vitreous Body. Anatomy. — The vitreous humor is the transparent, jelly-Hke structure occupying the space between the lens and the retina. The vitreous has somewhat of a depression on its anterior surface called the lenticular fossa in which rests the crystalline lens, and to the posterior capsule of which the vitreous is attached, while behind, it is adherent to the optic nerve. The presence of a hyaloid mem^brane inclosing the vitreous is claimed by some au- thorities; but, according to others, the so-called hyaloid is identical with the internal limiting membrane of the retina, which, accord- ing to Lieberkuehn, from the developmental standpoint, belongs to the vitreous. The structure of the vitreous has not with cer- tainty been determined. It is claimed that it can be split into concentric layers and various forms of cells have been found in it. These cells are toward the centre roundish in shape and more stellate or fusiform toward the peripheral layers of the vitreous. Chemically the vitreous is 98 per cent, water, with salts, extractive matter and a trace of albumin. Its consistency becomes less as age advances and in adult life is slightly more tenacious than the white of an ^. Knapp,* in a paper on " Glaucoma After Discission of Sec- condary Cataract," says that the first or + shaped discission gives the truly ideal results, i. e., clear pupils, and is made by making at first a horizontal incision, then, by cutting from above down to the horizontal section and from below upward in the same way. But, owing to the occurrence of glaucoma in about i per cent, of his cases during the last six years, he has returned to the T-shaped discission. Care should be taken not to enter the knife any deeper into the vitreous than is necessary for a sufficient opening in the capsule. In some rare cases the use of the two needles as described may be preferable to the knife. We believe that discission should be practiced in a large majority of cases of cataract extraction, as by so doing a greater improve- ment of vision can be gained. Disastrous results have been re- ported from discission, but so far we have been fortunate enough not to meet them, and hence do not consider our cataract opera- tions completed until a perfectly clear pupil has been secured by discission. The operation should never be made until all signs of irritation of the eye, after the extraction, has passed away. The knife must be very sharp, and all rough handling or dragging upon the resisting bands must be avoided. Cataract Extraction. — The various methods for the extraction of a cataractous lens that have been employed by different operators would, if described in detail, form a volume in them- *Archiv. Ophthal., vol. xxi., 2, 1892. OPERATIVE TREATMENT OF CATARACT. 447 selves. In fact, it may be said that no two operators follow pre- cisely the same method in ever}^ detail. The experience and technique of one will var}^ from that of another, and, in conse- quence, the procedure of one varies in some details from that of the other. On account of this variance, many so-called modifica- tions are being constantly brought forward. There are, however, two essentially different methods of extraction which will be con- sidered, viz.: Extraction with an iridectomy, and extraction without an iridectomy, or, as it is frequentl}^ called, the simple operation. Previous to all cataract operations are certain preliminary con- siderations worthy of attention. As to the season of the j^ear, it should depend upon the location, simply avoiding, if possible, ex- treme cold or heat. Age has less influence upon success than the general condition of the patient. Any chronic disease, such as nephritis or diabetes, that will impair the vital forces will tend to influence unfavorably recovery from the operation. A severe cough, asthma, incontinence of urine, or any condition affecting the general health, should be controlled as far as possible. All sources of infection, such as suppurating wounds, erysipelas, catarrh of the lachrymal sac, conjunctivitis, etc., must be pro- vided against. Thorough antiseptic measures should be strictly followed out. The room and bedding should be perfectl}^ clean and free from all sources of impurity; the patient should have the face, hair, beard and hands thoroughly scrubbed with soap and water once or twice before the operation. The surgeon and the assistant should have their hands scrubbed with soap and water and the nails carefully cleansed and then again washed in a solution of mercury or car- bolic acid. The instruments are thoroughly cleansed either in a solution of bichloride of mercury, i to 2,000, or in carbolic acid, I to 200, with the exception of the knife, which is immersed in a solution of boracic acid, or for a few minutes in boiling water. The face of the patient is then washed with one of the above solu- tions, taking great care to cleanse the margin of the lids at the root of the cilise. The conjunctival sac, especially if it contains any secretion, should be flooded with a i to 8,000 solution of the bichloride of mercury. General anaesthesia is not employed un- less the patient is particularly nervous and unmanageable, when 448 DISEASES OF THK CRYSTALIvINE LENS. ether is administered. A 2 or 4 per cent, solution of cocaine is dropped upon the cornea two or three times, at intervals of about ten minutes, when local anaesthesia is complete. Extractio7i with Iridectomy. — This operation as most generally performed is practically that introduced by von Graefe as his modi- fied linear operation, the slight variations or so-called modifica- FiG. 82. Fig. 83. Fig. 84. Fig. 85. Fig. 86. CiaS Q Graefe 's linear knife. Norton's cataract knife. Knapp's cystotome. Hard rubber lens spoon. Fenestrated lens spoon. tions being merely a slight variance in the position of the incision. Anesthesia being complete, the speculum is inserted and the globe steadied with the fixation forceps. The knife is then entered by making the puncture at the corneo-scleral margin at a point on a level with a semi-dilated pupil. The direction of the knife when making the puncture is toward the centre of the pupil, and, when OPERATIVE TREATMENT OF CATARACT. 449 well in the anterior chamber, is gradually, while being pushed across the chamber, brought parallel to the horizontal diameter until its point comes directly on a level with the puncture. The counter-puncture is now made and the knife cut out so that the whole section is about in the cor neo- scleral margin. (See Fig. 87. ) This first stage of the operation varies, as already referred to, with different operators merely as to the position of the puncture, counter-puncture and the completion of the section above, some making it further in the cornea and others deeper in the sclera, and some making a conjunctival flap above. In making the counter- FiG. 87. Cataract extraction — The incision. puncture the point may catch in a wrong position, when it may be slightly withdrawn and entered again, care being taken not to in- crease the size of the opening at the point of puncture and allow of the escape of the aqueous. In cutting out, the iris may fold ■over the knife, when one of two procedures should be followed — either slowly withdraw the knife and postpone the operation, or preferably complete the section, cutting through the iris, which does not materially interfere with the success of the operation, except by the bleeding in the anterior chamber. After the completion of the section, the iris, if not previously removed, is seized at its pupillary border with the iris forceps and 29 450 DISKASES OF THE CRYSTALLINE LENS. gently drawn out. As but a small iridectomy is necessary, no undue traction should be made upon the iris. The iris should be severed by one cut of the scissors, and, if its edges become caught in the wound, it may be made to free itself by gentle friction with the lid, or be replaced with the spatula. The cystotome is then introduced into the anterior chamber, the back of the instrument preceding and its cutting point held parallel to the surface of the lens; it is now pushed downward to the lower margin of the pupil or even beneath the iris, and the point turned toward the lens, the capsule of which it readily pierces. The division of the capsule is usually made by drawing the cystotome from the lower border directly upward, making a vertical incision through the capsule, and then a horizontal incision crossing it above, making a T-shaped opening. My method has been that practiced b}^ Knapp, making a peripheral cystotomy. The larger the opening in the capsule the easier the lens is removed. The final step in the operation is the removal of the lens, and for this purpose it is my preference to remove the speculum, hold- ing the upper lid with the index finger of the left hand while the assistant draws down the lower lid; (See Fig. 88), but most authorities recommend leaving the speculum in situ. Pressure is then made with a scoop upon the lower border of the cornea, directing the force backward, not upward, until the upper edge of the lens, having been titled forward, engages- in the wound: the direction of the force should now be slightly upward as well as backward, following the lens as it passes out. The cortical substance is usually more easily removed directly following the nucleus than after waiting for the anterior chamber to fill, and the effort should be made to remove as much of the cortical sub- stance as possible by gentle manipulation of the cornea with the scoop gradually coaxing it out. A too prolonged attempt in this direction, however, must not be made, as it tends to increase the danger of infiammatorj^ reaction, and a clear pupil can be obtained later by discission. After removal of the lens great care should be taken to thoroughly cleanse the wound from any cortical substance, shred of capsule, or prolapse of the iris. This is done with a hard rubber spud or spoon, dropping a solution of boracic acid upon the eye at the same time. The conjunctival sac is then thoroughly OPERATIVE TREATMENT OF CATARACT. 451 cleansed by irrigating with a solution of boracic acid, all shreds or blood-clots removed, and the dressing is then applied. Many forms of dressing have been used b}^ different operators from the simple application of strips of isinglass plaster to very elaborate bandages. My plan has been to apply to the closed eyes a piece of antiseptic gauze. The hollow at the inner canthus is then filled up with borated absorbent cotton, and over this another light layer of the cotton; the whole is then held in place by two strips of one-half inch adhesive plaster. These plasters are to run from the cheek to the brow, one over the inner the other the outer can- FlG. Cataract extraction — The removal of the lens. thus, care being taken that there be no pressure made upon the eyeball. This dressing when carefully applied makes no pressure upon the eye, and, while light and comfortable, supports the eye by keeping the lids closed and at rest. It is far more comfortable than the bandage and is easily raised for examination and dress- ing of the eye. After-Treatment. — The patient is placed in bed in a slightly darkened room and directed to lie as quietly as possible, turning from the back to the unoperated side as he desires. We believe it best that the patient be not allowed to sit up to eat, or, as a rule, 452 DISKA.SES OF THK CRYSTAI^LINE LENS. permitted to get up to urinate; but that rest in the prone position be followed for the first two or three days, unless the patient be- comes very nervous and restless, when more liberty may be allowed. After this time he may be permitted to sit up and gradu- ally allowed to do more and more each day. The dressing should not be removed for the first twenty-four or hours, if it has not be- come disarranged, or the patient has not complained of pain or discomfort of the eye. It is my custom to open the eye twenty- four hours after the operation, especially in the simple extraction, sufficiently to see if the anterior chamber is re-established and the iris in place. At the end of the second or third day, if there has been no trouble, the eye may be more thoroughly ex- amined for the first time. The covering of the unoperated eye may be removed at the end of the third or fourth day. Normally the patient will have some smarting and often pain in the eye for the first four or five hours after the operation. The application of the ice-bag to the side of the head, or raising the dressing enough to draw down the lower lid and let out a tear, will usually relieve the pain. It is the routine practice of the majority of operators to instil a drop of atropine every day after the first forty-eight hours; this seems hardly necessary unless there are indications of iritis present. The covering of the eye, as a rule, can be removed about the sixth day and the eye protected for a few days longer with a light shield or smoked glasses. The eye is gradually accustomed to more and more light and the patient allowed to go out from the tenth to the fourteenth day, Accide7its during the operation are apt to be met with. One in which the iris falls before the knife during the incision has already been referred to. Another unfortunate accident is, when the incision is too small to permit of the escape of the lens, as too great pressure at this time to expel the lens may cause rupture of the zonula and prolapse of the vitreous may ensue. When this oc- curs, the incision should be enlarged with the blunt-pointed scissors. Dislocation of the lens, either partial or complete, has occurred from too great pressure with the cystotome. If it is pushed back into the vitreous it should be removed with the scoop or wire loop. Escape of the vitreous may occur either before or after the ex- traction of the lens. If it occurs before the lens has become en- OPERATIVE TREATMENT OF CATARACT. 453 gaged in the external wound, further pressure on the cornea must be at once abandoned, as it will cause additional loss of vitreous without resulting in the escape of the lens. The lens will then have to be removed with the scoop or wire loop, which is gently in- serted well behind the lens, care being taken not to cause greater dislocation, and, bj^ gentle pressure forward to prevent its slipping off, is gradually drawn out. When the loss of vitreous has oc- curred after the escape of the lens, the eye should be at once closed, a bandage applied, the patient put to bed with an ice-bag to the eye and Ai:onite given. Loss of vitreous, while a frequent and undesirable accident, is not necessarily serious, as good visual results are often obtained even after a large loss. Kerschbaumer^ reports the loss of vitreous thirteen times out of two hundred cases operated upon, and in no instance did loss of the eye occur. In some cases the division of the capsule is not of sufficient ex- tent to allow of the shelling out of the lens, and when this occurs the cystotome must be again inserted and a larger laceration made. The absence of an anterior chamber is often noticed at the first dressings, but it should occasion no alarm if the wound is clear, as it is often not restored for a number of days. Of the evil results that ma}^ occur after the operation severe pain is usually the forerunner, and ma}^ set in within a few hours or several da3's after a perfectly smooth operation and may indicate an intra-ocular haemorrhage, suppuration of the wound or iritis. Intra-oadar HcBmorrhage is the most serious accident that occurs at the time of an extraction, and, as a rule, results in panoph- thalmitis and loss of the eye. It is fortunately of extremeh^ rare occurrence, as shown by the fact that, in the extended experience of Dr. Knapp, but one case had been seen by him up to Novem- ber, 1890, which he reports in the Archives of Ophthalmology ^ January, 1891. In this case the eye was saved by carefully re- moving the blood, washing the conjunctival sac with a mild anti- septic, sterilizing the outside of the lids and applying an anti- septic dressing, which should be changed once or twice daily, ac- cording to the discomfort and discharge. If panophthalmitis supervenes, the eye should be enucleated at once. Suppuration of the Cornea, since the general practice of anti- *Archiv. Ophthal., vol. xx., 3, 1891. 454 DISEASES OF THE CRYSTAI^LINE LENS. sepsis in ophthalmic surgery, has, fortunately, become of quite infrequent occurrence. It results from some infection of the wound, either introduced at the time of the operation or within the first few days following, from some lachrymal or conjunctival discharge, and in some cases occurs in the very old or debilitated patients from want of sufficient nutrition in the cornea. It occurs usually within the first three days, though may occur as late as two weeks after the operation . The onset of suppuration is usually ushered in with severe pain, and, upon examining the eye, we find the lids swollen and puffy, the conjunctiva chemosed, the cornea hazy and sloughing at the margins of the wound. The suppurative process may be checked and the wound healed with- out any damaging results, or it may result in slough of the cornea with leucoma, or extend into a general panophthalmitis. The treatment is practically the same as decribed under ulcerations of the cornea. • Iritis following cataract extraction generally makes its appear- ance about the eighth day, sometimes earlier or later, and should receive the usual treatment for this condition. To prevent as well as to arrest the progress of any form of in- flammation in its initial stage occurring soon after cataract ex- traction, no local remedy is equal to the use of ice. Internal medication is also of decided value in the treatment of the various complications which arise after cataract extraction. For the neuralgic pains, which often occur within the first twenty-four hours, relief can often be obtained from five- drop doses of the tinct- ure of Allium cepa, as first recommended by Dr. I^iebold. Morphine in rare cases may be of service to relieve this pain. In any in- flammation of the eye following cataract extraction, Rhus tox. is a most valuable remedy, and is given as soon as the patient begins to complain of pain, accompanied by lachrymation and puffiness of the lids. After pus has formed, Hepar, Silicea, or Calc. hypophos., either alone or in alternation with Rhus, are of value. In some cases a low form of chronic conjunctivitis follows for awhile after the operation, and one of the best things for this con- dition is to keep the patient out in the open air. Extraction Without Iridectomy . — Simple extraction, as this is usually called, is practically the same as the operation already de- scribed, with the exception of removing a section of the iris. All OPERATIVE TREATMENT OF CATARACT. 455 the preliminary precautions should be followed out in this as in any other operation, with the exception of the Atropia dilatation* The corneal incision varies somewhat, in that it is made wholly in the clear cornea in simple extraction and should involve about the upper two-fifths of the circumference of the cornea. The object of the making a more central incision in this operation is to avoid the greater tendency to incarceration and prolapse of the iris from a too peripheral incision. A free division of the capsule should be made by inserting the cystotome as before and carrying it well under the margin of the iris. The speculum may then be removed and the upper lid drawn back with the forefinger of the left hand, which at the same time may make slight pressure on the upper part of the globe. The spoon is now applied to the lower part of the cornea and pressure made directly backward until the lens is tilted upon its axis and presents at the opening, when the pressure should be upward and backward, which causes an extrusion of the lens with more or less prolapse of the iris. A gentle pressure and stroking of the cornea with the spoon below, together with pressure above to open the w^ound, will promote the escape of the cortical substance remaining. This may be aided by irrigating the lips of the wound and the conjunctival sac with a warm, saturated solution of boracic acid, many operators recom- mending the irrigation of the anterior chamber at the same time. The prolapsed portion of the iris, if it has not already returned to its place, can be made to do so by gently stroking and pushing it within the lips of the wound with a smooth probe or spatula. On replacing the iris it should return to a central position and assume its circular shape; if it should not, gentle massage through the closed lid will often cause it to do so. Before applying the dress- ing, as already detailed, the eye should be thoroughl}^ irrigated with the boracic acid solution and a few drops of Eserine solution may be instilled. In the use of Eserine, Bull* cautions against the instillations of a strong solution of Eserine, believing that it is apt to cause iritis, and claiming that half a grain to the ounce solution, or, in some cases, even one- tenth of a grain, is sufficient to produce any desired contraction. After forty-eight hours a solution of Atropia may ■^ Trans. Amer. Ophthal. Soc, 1890, p. 578. 456 DISEASES OF THE CRYSTAI^I^INE LENS. be instilled to prevent posterior synechise, which are apt to follow; in other respects the after treatment in uncomplicated cases is the same as in extraction with iridectomy. The accidents and complications liable to occur in this operation are the same as those already referred to, with the addition of pro- lapse of the iris, which may occur at the time of the operation or immediately afterward, before closure of the wound, and in some cases by the reopening of the wound after having partially healed. When it occurs soon after the operation and cannot be returned to its place, it should be cut off. Prolapse may also occur later, and when it does is almost always of traumatic origin, due to some sudden movement of the patient, from coughing, lying on the operated side, from a too early examination of the eye, etc. ; and w^hen occurring later, after the wound is partially healed, it should be left undisturbed, as they generally heal with a cystoid cicatrix which in course of time flattens down, and although it causes some upward distortion of the pupil the ultimate vision may still be good. In some cases of a very large prolapse the bulging may be reduced by simply pricking, allow the aqueous to escape and apply a compress bandage. Incarceration of the iris or anterior synechise is an adhesion of the iris in the lips of the wound without being prolapsed through it. This accident causes considerable distortion of the pupil and may be the source of irritation to the eye. Its occurrence, how- ever, is, w^e believe, becoming less and less frequent, owing to a more general adoption of the more central corneal incision. As previously stated, we believe the extraction without an iri- dectomy to be the ideal method of removing cataractous lenses; but, as it has its advantages and disadvantages, we quote from Bull (^loc. cit. ) a comparison of the same with the operation of extrac- tion with iridectomy : " I. If successful and without complication, it preserves the natural appearance of the eye — a central, circular and movable pupil. "2. The acuteness of vision, with the astigmatism carefully corrected, is somewhat greater than after the old operation. "3. Eccentric vision and orentation are decidedly better than by the old operation. "4. Small particles of capsule are much less likely to be in> APHAKIA. 457 carcerated in the wound, and thus act as foreign bodies and excite irritation. "5. It is a shorter operation in point of time, by reason of the abscence of an iridectomy. " 6. As there is no iridectomy, there is little or no hemorrhage,. and this may be considered a very decided advantage. " The disadvantages of simple extraction are as follows: " I. The technique of the operation is decidedly more difficult than that of the old operation. The corneal section must be larger, in order that the passage of the lens through it ma}' be facilitated, as the presence of the iris acts as an obstacle to its exit. The section must be performed rapidly, so as to avoid the danger of the iris falling on the knife and being wounded. This rapid passage of the knife across the anterior chamber renders it difficult to make the height of the flap an even curve, particularly when the incision is entirely in the clear cornea, as it should be. The cleansing of the pupillary space and the posterior chamber is much more difficult than after the old operation. " 2. Posterior synechiae, secondary prolapse and incarceration of the iris are more frequently met with than after the old opera- tion. The two latter may be largely avoided by making the cor- neal section, as before stated, in the clear cornea and not in the limbus, which is too peripheral and rather favors both prolapse and incarceration of the iris. " 3. The operation is not applicable to all cases. This objec- tion, however, may be applied to all operations." Aphakia. — Absence of the lens is recognized by greater depth of the anterior chamber; a peculiarly black pupil and often trem- ulousness of the iris is present. Dilatation of the pupil will often show traces of the opaque capsule left behind. The power of ac- commodation is also lost. Removal of the lens in an emmetropic eye will leave a high degree of hypermetropia equal to about 1 1 D., and, of course, much less in a previously myopic eye. For near vision, as reading, writing, etc., a still stronger convex lens must be used. In addition to the hypermetropia, after the ex- traction of the lens, there is usually a certain amount of astigma- tism, varying from i D. to 4 D., which is more often " contrary to the rule" and which should be corrected, together with the 458 DISEASES OF THE CRYSTAI^LINE IvENS. hypermetropia. Glasses, as a rule, should never be prescribed until all signs of irritation of the eye have passed away, and are not often worn constantly at first with comfort. It is usually best to wait one or two months, at least after the operation, be- fore prescribing permanent glasses. Luxatio Lentis (^Ectopia Lentis, Dislocation of the Lens). — This condition may be either partial or complete, and may be congenital (^ectopia le7itis) or from disease of the eye and from traumatism. The lens may be tilted obliquely, in the vertical plane or in any direction. It may be displaced backward into the vitreous or forward into the anterior chamber, and, from injury of the sclera, it may become lodged under the conjunctiva or entirely escape from the eye. Dislocation most often follows some dis- ease where the vitreous has become fluid and the suspensory liga- ment, stretched and atrophied, gives way. High degrees of myopia favor this displacement, and when but partial, the border of the lens being in the pupil, there will exist two different states of refraction in the same eye, and we then may have monocular diplopia. Symptoms. — A high degree of hypermetropia is produced in emmetropic eyes; the accommodation is lost, the anterior chamber is deepened from the sinking of the iris, the pupil is small and iridodonesis or trembling of the iris is usually present. When due to disease, atrophy of the choroid and opacities of the vitreous are generall}^ present. Diagnosis. — If the edge of the lens is in the pupil it will ap- pear with the ophthalmoscope by the direct method as a dark border and a double view of the fundus be seen, one image through the lens and the other beyond the lens. Total absence of the lens is determined by the catoptric test, which is made in a dark room with a lighted candle passed slowly before the eye, when, if the lens is present, three images should be seen — a clear, distinct, upright image from the cornea; a second, also upright, but diffused and faint image from the anterior surface of the lens, and a third, small, sharp and rather bright image, which is in- verted, from the posterior surface of the lens. If two or all of these images are seen, the lens is in place. A dislocated lens will frequently become cataractous and may give rise to attacks of glaucoma, iritis, etc. LUXATIO LENTIS. 459 Prognosis. — Congenital displacement, or ectopia lentis, usually occurs upward, upward and inward, or upward and outward. It is often hereditary and usually remains unaltered. Other defects are frequently found with congenital dislocation. When the dis- placement is due to disease, the vision is as a rule very bad and apt to grow worse. In traumatic cases the lens will usualh- be- come cataractous. Severe inflammation and glaucoma is apt to occur from a displacement into the anterior chamber. Treatment. — If the dislocation is forward into the anterior chamber, removal of the lens by a peripheral incision is a very simple affair. In some cases it is first necessary to transfix the lens with a needle to prevent it from slipping back through the pupil again. If the dislocation occur from a rupture of the sclera and it lies beneath the conjunctiva it is easily removed. If the lens remain clear and is but partiallj^ dislocated, it should be left alone and the most suitable glasses be prescribed. Dislocation of the lens backward into the vitreous is a much more serious affair. When it is of long standing and has caused no irritation of the eye, it may be left alone. If, however, it rests in the front part of the vitreous particularly, and there are signs of inflammation which may lead to destruction of the eye, its removal should be attempted. The operation recommended by Knapp and Bull for the removal of lenses dislocated into the vitreous is, after thorough local anaesthesia, to make an upper corneal section and remove the speculum. The upper lid is now lifted away from the eyeball by the assistant, and through the lower lid pressure is made on the lower part of the eyeball and made directly backward. The lens will usuall}^ rise into the pupil and ma}' come through the pupil and engage in the corneal wound, where the hook or spoon will usually become necessary to complete the removal. Failing to remove the lens by this procedure, or when the backward pres- sure causes an escape of the vitreous before the lens can be engaged in the wound, then the spoon or wire loop must be intro- duced into the vitreous and the lens extracted. Dr. Agnew devised a double needle or bident which has been successfully used in a number of cases for the removal of a lens dislocated into the vitreous. It is used to fish up the lens and hold it from being pushed further backward by transfixing the globe about 6 mm. behind the cornea. The usual corneal section is then made and the lens extracted with the scoop, after which the bident is removed. 460 GLAUCOMA. CHAPTER XXIII. Glaucoma. The name comes down from olden timcF, and was employed because, in certain advanced cases, the pupil acquires a greenish hue {y'Aayfcoz^ green). Glaucoma should be more broadly defined as a7i excess of pressure within the eye, plus the causes of and the co7isequences of that excess. In the preparation of this chapter ver}^ liberal use has been made of the most excellent work by Priestley Smith on '* The Pathology and Treatment of Glaucoma." Anatomy. — The important part which the iritic angle plays in the causation of glaucoma makes a knowledge of its anatomical construction important. According to Waldeyer the iritic angle is the point where the tissue of the iris, cellular stroma of the ciliary body, muscle of accommodation, and the posterior and ex- ternal portions of the cornea and sclerotic intersect (Fig. 89). These structures jointly form a peculiar cavernous tissue composed of flattened and rounded elastic trabeculse, which, as a continua- tion of Descemet's membrane, forms toward the canal of Schlemm true fenestrated lamellae. Into the composition of this trabecular tissue enters the elastic tendons and cellular tissue of the ciliary muscle. The membrane of Descemet splits up in this fenestrated lamellae. Toward the anterior chamber this trabecular tissue is arranged cross- wise, leaving in front of the more closely constituted trabecular tissue large spaces called Fontana's spaces, which are simply the large meshes of the trabecular tissue that merges into the membrane of Descemet and is then called the ligamentum pectinatum iridis. Fontana's spaces communicate in this way directly with the anterior chamber. The canal of Schlemm is formed by a series of spaces or fissures of the cavernous tissue toward the external surface of the eye in the sclerotic, hetice the spaces of Fontana and the canal of Schlenmi are nothing more than a series of continuous lacunae in the trabecular tissue and all com- Section through the ciliary region ( Waldeyer). «, cavernous tissue of the ligamentum pectinatutn; b, prolongation of the iris, c, canal of Schlemm; dd, blood-vessels, ee, spaces of Fontana;/, Descemet's membrane; /, iris; M^ ciliary muscle; Cr, cornea; Sc, sclera; EE^ epithelium. 462 GLAUCOMA. miinicating together. They belong to the lymphatic system and never contain blood during health. The canal of Schlemm com- municates with the sclerotic veins and thus completes the connec- tion between the anterior chamber and the venous circulation. A system of valves is supposed to exist which prevents the blood from passing into Schlemm' s canal and the anterior chamber. The zonula of Zinn is a transparent structure extending from the posterior surface of the ciliary processes to the lens. It is de- rived from the hyaline layer on the surface of the ciliary body, and, as it passes to the border of the lens, separates, leaving a small triangular space called the canal of Petit. Through this structure transfusion readily takes place from the vitreous to the aqueous humor. Physiology of Secretion and Excretion. — The normal in- tra-ocular pressure is equal to about 25 mm. of mercury, and the pressures in the aqueous and vitreous chambers are equal. An excess of even 5 mm. in the vitreous would cause a displacement of the lens and iris. A tension of + 3 is equal to an intra-ocular pressure of about 80 mm., but a pressure equal to 200 mm. of mercury has been produced experimentally in animals by com- pression of the aorta and simultaneous irritation of the fifth nerve. The maintenance of the normal pressure in ttie chambers of the eye depends upon the due secretion and excretion of the fluids which traverse them. , The intra-ocular fluid flows from the blood stream. The ciliary body supplies the fluid to the vitreous, lens and aqueous, and is well adapted for this purpose by the peculiar arrangement of its secreting surface into ridges and grooves, which are in direct contact with the vitreous and aqueous. Patho- logical changes confirm this fact, for eyes excised in the first stages of infiltration of the vitreous show an inflammatory exuda- tion extending into the vitreous from the ciliary body. In a shrinking of the vitreous it becomes detached from the retina, but remains adherent to the ciliary body. Disease of the ciliary body always tends to destruction of the vitreous. Priestley Smith has made an elaborate series of experments regarding secretion and excretion and concludes that ' ' the fluids which nourish the vit- reous body and lens and fill the aqueous chamber are secreted chiefly by the ciliary portion of the uveal tract. The larger part PATHOLOGY. 463 of the secretion passes directly into the aqueous chamber, forward through the pupil and out at the filtration angle. A ver}' much smaller portion passes backward through the vitreous body and escapes at the papilla. The hyaloid membrane and zonula, which separate the two chambers, are readily permeable by the vitreous fluid." The escape of the fluids from the anterior chamber by filtration through the ligamentum pectinatum into the canal of Schlemm and sclerotic veins has been proven by the experiments of Leber. Pathology. — In the advanced stages of glaucoma there may be found, from the long existing intra-ocular pressure, pathological changes in nearly all the structures of the eye. The pathological changes have only been determined from examination of eyes that have been lost from glaucoma, and therefore only show the results of the increased tension without giving any light as to the cause of the disease. The most important changes are those found occurring at the iritic angle and which result in a partial or total occlusion of the vessels composing or entering into the canal of Schlemm. They consist of inflammatory changes at the junc- tion of the cornea, sclera and iris. These changes seem to still further hinder the excretion of the fluids from the eye and in this way augment the trouble. The uvea in recent cases shows evidence of inflammatory oedema, with marked distension of its veins. The ciliary processes are greatly distended and push for- ward the periphery of the iris against the sclera and cornea, where there is formed a permanent adhesion. Later, from atroph}^, there is a retraction of the ciliary processes away from the iris, but peripheral synechia remain. The iris atrophies, its vessels walls become thickened and their calibre becomes contracted or obliter- ated. The ligamentum pectinatum becomes condensed into tough, fibrous tissue, and, finall}^ even Schlemm's canal disappears. The ciliary muscle as well, as the processes atrophy and the atroph}^ of the choroid, results in obliteration of its vessels. In the cornea there is found between the anterior lamellae, and especially between the epithelium and Bowman's membrane minute drops of fluid (Fuchs). The sclera gives evidence of in- flammatory action and fatty degeneration. The aqueous is more albuminous than normal. The flbres of the optic nerve become 464 GLAUCOMA. inflamed and atrophy in the later stages. The lamina cribrosa loses its power of resistance and is pressed backward. The retina shows a thickening and cystoid degeneration, with subsequent atrophy. There may be fluidity and detachment of the vitreous and the lens cataractous. Symptoms. — There are certain characteristic signs or symptoms of glaucoma more or less regularly found in all varieties of the disease which may be interestingly studied individually. Recession of the Near Point or diminution of the range of accom- modation is one of the earliest prodromal symptoms. As this dis- ease is CvSpecially one of old age, we naturally have more or less presbyopia, but in glaucoma the presbyopia increases rapidly and is greater than it should be at that time of life. It is due to the increased intra-ocular pressure upon the choroid, ciliary body and suspensory ligament of the lens, causing a partial paralysis of the ciliary nerves. Chayiges i7i Refraction. — Glaucoma may occur in any condition of the refraction, although hypermetropes are more predisposed to it, and it is found in from 50 to 75 per cent, of the cases. Glaucoma may also cause hypermetropia from a flattening of the cornea and slight shortening of the antero-posterior diameter of the eye from the pressure. Iridescent Vision. — The halo or rainbow of colors around a light is perfectly circular, and the size and breadth of ^ each colored ring increases the further the light is from the eyes. The inten- sity of the colors vary with the light, the red being the brightest by gas or candlelight and the blue by electric light. The arrange- ment of the colors is also the same. There is, first, a colorless space surrounding the light; the internal ring next to the color- less space is always the blue or bluish-green, while the outer ring is red. The generally accepted explanation as to the cause of the halo is, that it is due to a diffraction of the rays entering the eye, as a result of the opacity in the cornea. The Increased Tension. — This symptom is the essential one that characterizes the disease. Nearly all the other symptoms and the pathological results of the disease are either directly or indirectly due to the increased tension This sympton is due to an increase in the contents of the eye, but the cause of the increase in the contents is still not definitely settled. The degree of increased SYMPTOMS. 465 tension may vary from T+? to T+3. For the method of deter- minmg the tension of the eye see page 22. Haziyiess of the Cornea is usually present in all forms of glau- coma, excepting in glaucoma simplex, when it may be absent. The haziness is uniform, but most intense at the centre, and often shows a dull, stippled appearance of the surface. Haziness of the cornea either disappears immediately or soon after the tension becomes normal again. The haziness is due to an oedema of the cornea, and its rapid disappearance on the return of nor- mal tension is owing to the elasticity of the cornea. AncBsthesia of the Cornea is found in almost all cases of chronic glaucoma, and is apt to be more complete at some points than others. This anaesthesia is explained by Fuchs as due to an in- creased amount of fluid in the nerve channels, causing a disten- sion, and that the nerve-fibres become paralyzed by the infiltra- tion and pressure from this fluid, at some places he has found the nerve-fibres torn asunder. Dilatatioyi ajid Inactivity of the Pupil. — This is a very constant symptom of glaucoma. The pupil is often oval or egg-shaped, and, in this respect, differs from the dilatation in optic nerve atrophy when it is usually circular. The cause of the dilatation has been attributed to a paresis of the ciliary nerves from the pressure, and also, by some, to a constriction of the vessels of the iris. The irregularity of the dilatation is supposed to be due to a firmer attachment of the iris to the sclera at some points than at others. The Green Reflex from the Pupil is due to the bluish -white tinge from the haziness of the cornea and aqueous, combined with the physiological yellow tint of the nucleus of the lens caused by age. Shallow Ante7'ior Chamber. — This is due to a pushing forward of the lens and iris and in old cases to the peripheral adhesion of the iris to the posterior surface of the cornea. It may be so shallow in some cases as to render an iridectomy very difficult. The Haziness of the Humors is very slight and diffuse and is due to the increased amount of fluid within the ej^e. Enlargement of the Ciliary Vei?is is due to the compression upon the venae vorticosae, causing a damming up of the blood, which has to pass off through the anterior ciliary veins. 30 466 GLAUCOMA. Pulsatio7i of the Retinal Veins may be physiological and is found in normal eyes. It is due to a transmission of the arterial wave through the vitreous, and is apparent at the papilla because the veins bend and are contracted at this point. The walls of the veins are thin and the pressure from the vitreous causes a momen- tary stoppage of the circulation until another arterial wave pushes the blood forward again. It is also noticed, in some instances, where an artery crosses a vein and the pulsation is then given di- rect to the vein. When absent, it may be owing to a hyper- trophy of the walls of the artery, and, hence, no pulsation. As venous pulsation may be seen in normal eyes, it is not of especial diagnostic value. Pulsation of the Retinal Arteries at the Disc. — There is, of course, a normal physiological pulsation of the arteries, but it is so slight as not to be seen in normal eyes, yet it may be pro- duced by pressure upon the globe with the finger. It is so rarely seen under other circumstances that, when present, it is claimed by some to be almost pathognomonic of glaucoma. It is due to a resistance to the flow of blood, the current only being complete during systole. This resistance is caused by the increased intra- ocular pressure and possibly, as claimed by some, to an active spasmodic constriction of the vessels themselves. The absence of arterial pulsation in some cases is due to hypertrophy of the walls of the arteries. Pain. — This symptom varies from a slight sense of fullness or dragging to a most severe acute jieuralgia. over the whole region supplied by the fifth nerve, and may be associated with general symptoms of pallor, fever, nausea and vomiting. The cause of the pain is pressure upon the nerves from the increased tension. In acute attacks the pain may be an intense agony associated with symptoms of great depression. In sub-acute cases the pain is less marked, while in chronic cases there may simply be a sensation of fullness or discomfort. Swelliyig of the Lids, Chemosis and Exophthalmos are all due to infiltration from the pressure. Contraction of the Field of Vision is usually a loss of the inner or nasal side first, followed by a loss of the lower, then the upper part of the field, showing an affection first of the temporal or outer half of the retina and then of the upper and lower quadrants. This J SYMPTOMS. 467 order of retinal affection is due to the vascular distribution. The temporal portion of the retina being less freely supplied with ves- sels, it becomes first affected from the pressure obstructing its capillary circulation. There is, however, in glaucoma no abso- lute constancy in the manner in which the field is affected, as there may be concentric restriction of the entire field, or sectional defects, and even in some cases a central scotoma with the periphery of the field remaining good. The color fields are usually con- tracted proportionate with the form fields. Excavation of the Optic Disc. — More or less cupping of the disc is met with sooner or later in all forms of glaucoma, but it bears no close relation to the loss of vision. It is the result of the intra- ocular pressure upon the lamina cribrosa, which becomes pushed backward, and, when complete, the vessels are pushed to the inner or nasal side, the veins are large and the arteries small, the ves- sels bend sharply over the edge of the disc, becoming lost to view and reappearing again at the bottom of the cup, and the disc itself appears of a grayish-blue color. (See Chromo-Lithograph Plate III, Fig. 12.) Surrounding the papilla is a narrow yellowish- white ring, due to atrophy of the choroid. By an examination with the indirect method we can determine by the parallax test slight degrees of excavation. This shows, upon moving the ob- ject lens from side to side, an apparent movement, the edges of the papilla seeming to slide back and forth over the centre. From this we know that the edge of the papilla lies nearer to the eye of the observer than its centre. The depth of the excavation can be approximately estimated by the direct examination, allowing 3 D. to every millimeter of depth. It is important to distinguish the excavation of glaucoma from that occurring physiologically and from atrophy of the nerve. (See Chromo-Iyithograph Plate II., Fig. 2, and Plate III., Figs. II and 12.) The Physiological Cup is white, occurs in a normally tinted nerve-head and never involves very much of the nasal part of the disc over which the vessels can be seen to course. The vessels can always be followed down the side of the cup, which is funnel- shaped and not deep like the cup of glaucoma. The Cup in Atrophy of the Nerve is shallow and usually involves the whole, of the disc. The vessels never bend sharply over its 468 GLAUCOMA. margins. The nerve -head is abnormall>' white from diminished capillary circulation. The Cup of Glaucoma is abrupt and deep, the vessels disappearl ing at its edge. There is a crowding of the vessels to the nasa- side. It often has a greenish hue, and there is usually a yellowish choroidal ring around the papilla. The Impairment of Visio?i varies considerably. In every acute attack it fails rapidly and then recovers somewhat when the symp- toms subside, but each attack causes a little more destruction than the preceding one, until finally it becomes completely lost. The loss of vision is due to pressure upon the nerve elements of the retina and optic nerve, excepting in those cases where the loss of vision is sudden and complete, when it may result from an isch- semia of the retina. Photopsia, or subjective sensations of light, is an inconstant symptom which may be present especially during attacks and may persist even after complete blindness and is probably due to a dragging upon the retina. Course. — The history of a case of glaucoma will usually show a longer or shorter period of premonitory symptoms. This pro- dromal stage may have extended over several weeks or months, and then there will occur a sudden attack of acute glaucoma, last- ing from a few hours to several days, when the symptoms subside and the eye returns to normal or nearly so. These attacks return, the intervals becoming shorter and shorter, the vision more and more impaired until finally it leads to a chronic or absolute glau- coma. In some cases an acute attack may continue directly into an absolute form without any subsidence of symptoms. Glaucoma does not lead to spontaneous cure, but tends, if unchecked, to ab- solute blindness. Causks. — The statistics of glaucoma show it to form about one per cent, of all eye cases, varying, however, in different countries and different clinics. It is especially a disease of old age, some claiming that an attack of primary glaucoma under the age of thirty-five is extremely doubtful. Glaucoma simplex may occur in young people and it is also found in myopic eyes. Sex seems to have little or no influence, and in some cases it seems to be hereditary. Hypermetropia predisposes to glaucoma, 50 to 75 per cent, of the cases being found in hypermetropic eyes. CAUSES. 469 Neuralgia of the fifth nerve may caUvSe it, as does also irritation from decayed teeth. Attacks are often precipitated by hysteria, convulsions, nervous excitement, anxiety, mental disturbances, anger, fear, etc. Any condition causing vascular turgescence may cause it, as in gout, acute rheumatism, atheroma, climatric changes, intoxication, indigestion, fever, sleeplessness, etc. The use of atropine in some eyes will cause it. It has often occurred after an iridectomy for glaucoma in the other eye. Priestley Smith concludes, from a study of the immediate causes of increased intra-ocular tension, that it may result from three con- ditions, viz.: " Hypersecretion by the ciliary processes, serosity of the fluids and obstruction at the filtration angle." Hypersecretion may be expected from irritation of the fifth nerve or from dilatation of the ciliary vessels, and, while these conditions may serve to act as an exciting cause, he considers it a pure hypothesis. The serosity of the intra-ocular fluids is probably a supplemen- tary cause of increased tension, for, whenever the circulation of the blood is obstructed, serum is apt to escape from the capillaries. In a mild form of serous inflammation of the uveal tract there is a serous exudation, the aqueous is cloud^^ punctate spots on the posterior surface of the cornea, dilated pupil and an increased tension, which maj'- result in glaucoma from the serous nature of the intra-ocular fluids. To an obstruction in excretion he chiefly attributes the cause of increased intra-ocular pressure. This obstruction at the iritic angle in glaucoma was first demonstrated by Knies * and Weber f in 1876. Since then Priestley Smith has examined over eighty eyes having had various varieties of glaucoma and found obstruc- tion of the filtration angle in all but three or four. As predispos- ing causes to this obstruction he considers the rigidity of the sclera that increases with age and the extra rigidity of the sclera found in Jews (who as a race are found to have a greater liability to glaucoma) one factor in the causation of glaucoma. The smallness of the eye, as demonstrated in the Egyptians, who, as a race, have small eyes and are especially prone to glaucoma, may * Von Graefe's Archiv. Vol. xxii., 3. t Von Graefe's Archiv. Vol. xxiii., i. 470 GI.AUCOMA. be considered another feature. The increasing size of the lens in age, as demonstrated by him, seems, however, to be the most im- portant predisposing factor in the causation of obstruction at the iritic angle with resulting glaucoma. His measurements further show that a small cornea belongs to a small eye, that the horizontal diameter of the cornea in glaucomatous eyes is less than that in healthy eyes, and that the size of the lens in small eyes is not proportionately small. The increase of the size of the lens in age without proportionate increase in the other structures of the eye causes it to encroach upon the surrounding parts; its margins press upon the ciliary processes, its anterior surface approaches nearer the cornea and in this way the depth of the anterior cham- ber is decreased. Priestley Smith summarizes as follows: '' The causes of primary glaucoma, then, are various and com- plex, and are not yet completely known; but they are alike in this — they all lead to compression of the filtration- angle. With that compression the actual glaucoma process begins. The escape of fluid is retarded and the intra-ocular pressure rises; this, in its turn, increases the compression of the filtration-angle. The fluid which still exudes from the turgid ciliary body is albuminous and less diffusible than the normal secretion; it tends to accumulate behind the lens, and this latter, being pressed forward, intensifies the mischief. Thus cause and effect react upon each other in a vicious circle." The theory of Priestley Smith does not satisfactorily explain all the phenomena of glaucoma, hence many other theories have from time to time been presented. The latest, that of Abadie*, of Paris, presents features worthy of careful consideration. He argues that persistent changes at the iritic angle would necessarily cause persistent and not transitory symptoms. We know that we frequently have transitory attacks of both acute and sub-acute glaucoma, and he claims therefore that the nervous system must be interested in these transitory attacks that disappear without leaving a trace behind them. The old theory that the fifth nerve played this important role, in the light of recent investigations, must be abandoned, as it is a nerve of sensation only, and that the trophic influence which this nerve was claimed to have upon the *OphthalmologisclieKUnik, November, 1897. CAUSES. 471 nutrition of the eye must be attributed to the sj^mpathetic branch which accompanies it. He then claims that the true origin of the disease is an excita- tion, at times transitory, again permanent, of the vaso-dilator nerve-fibres of the blood-vessels in the eye resulting in either the acute or chronic forms. The increased tension results from the increased blood-pressure in the vessels, which perhaps also in- creases the intra-ocular secretions. He cites the action of my- driatics and myotics as the most positive proof that glaucoma is due to dilatation of the blood-vessels. Atropine producing dilata- tion of the vessels aggravates the glaucomatous symptoms. Eserine on the contrary constricts the vessels and lessens the in- tensity of the glaucoma. He further claims that the good results of an iridectomy in glaucoma substantiates his theory and says that the success of the operation rests solely upon breaking up the circular set of exciter nerves which regulate the dilatation and constriction of the blood- vessels. These nerves are situated in the middle part of the iris, and Abadie says that only this portion of the iris need be removed, and that even a simple slit without excision would be sufficient. That the reason the removal of either the pupillary or ciliary margin of the iris, or sclerotomy, is only a partial success is because this ring plexus of nerves in the centre of the iris is not removed. Galezowski * considers glaucoma to be due to an alteration of nutrition through an obliteration of the lymph-vessels and disten- sion of the lymph-canals, plastic exudation around the canal of Schlemm, hyaline degeneration of the walls of the vessels of the iris, rigidit3^ of the lamina cribrosa, and concentration of lymph at the entrance of the optic nerve. The causes of secondary glaucoma are those of some previous disease of the eye which obstructs the excretion. Annular Posterior Synechi(E, by partially or totally obstructing the passage of the fluids from the posterior to the anterior chambers, causes glaucoma because the secretion going on, the iris becomes pushed forward and closing up the filtration-angle increased tension sets in. Iridectomy maj' be advisable in annular synechiae to prevent glaucoma. . *Rec. d'Oph., July, August, 1894. 472 GLAUCOMA. Anterior Sy^iechicE, from some perforating wound or ulcer of the cornea, causes an insufficient access to the filtration-angle. Dislocatio7i a7id hijuries of the Lens will often be the cause of glaucoma. When dislocated into the anterior chamber it causes a stoppage of the filtration-angle, a lateral dislocation causes by pressing forward the iris and ciliary processes. An injury of the lens by the keratome in iridectomy, needling of a soft cataract, or penetrating wounds of the eye injuring the lens, causes swelling with pressure upon the iris and glaucoma. The lens should be immediately removed in these cases. Glaucoma occurs in some cases after extraction of the lens and also after discission for secondary cataract. Intra-ocular tumors and haemorrhages also cause increased tension. In serous exudations from the uveal tract, glaucoma results from diminished filtration power of the fluids. Glaucoma has also been seen in eyes with a detached retina. Diagnosis. — The importance of an early diagnosis in this dis- ease cannot be over-estimated, and the most usual prodromal symptoms are, a frequent changing of the reading glasses, the halos around a light and periods of obscuration of vision. In all cases, the chief symptoms to be looked for are the enlarged ciliary veins, anaesthesia and haziness of the cornea, irregularity of the pupil, contraction of the field of vision, pulsation of the retinal arteries, cupping of the optic disc and increased tension. Acute glaucoma has frequently been mistaken for iritis, and in some cases the differential diagnosis, which practically rests upon the increased tension and dilatation of the pupil in glaucoma, is extremely difficult. The inflammatory symptoms of both give the same appearance, the fundus is often not to be seen in either^ there may be haziness of the cornea in both, and the iridescent vision may occur in iritis as well as glaucoma. Add to this the fact that the two diseases may occur at the same age, that Atropia may have been used in the eye with partial dilatation of the pupil and the difficulty to accurately determine the tension in an acutely inflamed eye may render the differential diagnosis extremely un- certain. The two diseases may even exist together. For the dif- ferential diagnostic signs see page 290. Glaucoma simplex and optic nerve atrophy are, according to GLAUCOMA ACUTA. 473 Schweigger,"^ often mistaken for each other. The essential diag- nostic point seeming to rest upon a comparison of the field of vision in the two diseases, which would, of course, be aided by the presence of any or all of the following symptoms of glaucoma: The history, halos, pain, increased tension, more rapid progress, depth of the cup and arterial pulsation. The peripheral color sense is not so markedly defective in glaucoma as in atrophy. We have also seen cases where the failing vision has been at- tributed to cataract, but the mistake could hardly be made by any careful observer. Other cases we have seen attributed to a cold in the eye, the pain said to be neuralgia, and instillations of Atropia used. This inexcusable error could not have been made had the tension of the eye been examined. Prognosis. — In all forms of glaucoma the prognosis is always bad, if the disease is allowed to follow its own course, as blindness inevitably results sooner or later. When, however, the proper treatment is undertaken in acute glaucoma the prognosis ma}' be said to be favorable, doubtful in glaucoma simplex and unfavor- able in the absolute or haemorrhagic glaucoma. That is, in acute glaucoma, the further progress of the disease can often be stopped and vision, as a rule, preserved where it is without fur- ther loss; where the disease has been of but a short duration, there may be complete restoration of sight after an iridectoni}'. Varieties of Glauconia. — This disease may be divided into two general classes; primary glaucoma, which arises without previous disease of the eye, and secondary glaucoma, or that form in which we can see some previous disease of the eye to account for the glaucoma. Glaucoma Acuta. — Usually the patient has had warning of impending danger in the way of certain premonitory symptoms — due to an increased tension and not to inflammation. There is premature recession of the near point. This impairment of the accommodation, where the patient is unable to use his ordinary glasses, but keeps changing every little while for stronger and stronger ones, is always suggestive of glaucoma. He complains * Archiv. Ophthal., vol. xx., 4, 1891. 474 GIvAUCOMA. also of having noticed a periodic dimness of vision, as though clouds of smoke were coming before the eyes from time to time. There is seen a rainbow of colors encircling a light, and, upon examination of the eye at this time, there will be detected a slight increase of the tension; the cornea is a little dull and diffusely clouded, the pupil is dilated and sluggish, the field of vision may be contracted and there may be a hyperaemia of the retina. Such an attack lasts a few hours, when the eye returns to normal, and may remain so for weeks or months, when another similar attack occurs. These infrequent attacks may occur for years, the eye gradually undergoing changes so that it is not normal between attacks, and in this way gradually pass into a chronic glaucoma. As a rule, however, the attacks become more and more frequent, when suddenly there comes on an attack of acute glaucoma. The onset is apt to occur during the night and sets in with severe pain in the eye and head, which increases in severity and is accom- panied by rapid loss of vision and often by vomiting, fever and general prostration. These attacks are usually brought on by some sudden excitement or grief, or some venous congestion as from a feeble heart. Upon examination of the eyes we may find any or all of the following symptoms: The lids are swollen and may be oedematous; conjunctiva inflamed, possibly chemosed; scleral vessels injected, eyeball protruded, lachrymation, photo- phobia, cornea hazy and may have lost its sensitiveness to touch, iris discolored, pupils dilated and sluggish, greenish reflex from the pupils, aqueous cloudy and anterior chamber shallow. There is intense pain in the eye and head, the eyeball is hard, the vision impaired and the field contracted. Ophthalmoscopic ex- amination is often unsatisfactory on account of the haziness and general inflammation of the eye; but, if possible, there may be seen an excavation of the optic disc, the retinal arteries are small and pulsate, the retinal veins enlarged and there may be slight extravasations of blood. An attack of acute glaucoma may last from a few hours to sev- eral days or weeks, when the symptoms will gradually subside, the vision improves and the eye becomes normal again. These attacks usually follow one another, the intervals growing less and less, until it finally passes into what is called chronic or absolute glaucoma. In some cases the first attack will be of unusual GLAUCOMA CHRONICA. 475 severity, in which the vision does not return, the tension does not decrease and the dullness of the cornea persists. These cases are called glauco7na fulminans. The cupping of the optic nerve is. frequently not present in an attack of acute glaucoma. The im- pairment of the vision may mean that it is reduced to the faintest glimmer of light, which De Wecker sa3'S is due to ischaemia of the retina. The pain in acute glaucoma is often so intense that the patient may ignore a complete loss of vision and demand relief for his neuralgia, and in this way often mislead the physician. Glaucoma Chronica. — This form may develop from an acute attack, or directly from the premonitory stages. In fact, it gen- erally does not amount to an actual attack, but develops gradually the symptoms of the acute, irritation being absent. . Among its symptoms we find the anterior ciliary veins enlarged and tortuous, the sclerotic has a dull, leaden hue, the cornea is hazy and loses its sensitiveness to touch, the pupil is large and inactive, the iris is discolored and becomes atrophied, the anterior chamber is shallow^, the tension is increased, may be + 3. An ophthalmoscopic examination shows an excavation of the optic disc, the retinal veins large and the arteries small and pulsate. There is a progressive failure of sight, the field becomes more and more contracted and the halo around the light is seen. The pain in chronic glaucoma varies, though, as a rule, is not so violent. If the disease has come on gradualh' it may ])e entirely absent, though rarely so, and in other cases it may be severe. There may be a remission of the symptoms in some cases, or they may continue all the time, but become increased from nervous excite- ment. Chronic glaucoma gradually leads on to absolute. Glaucoma Simplex. — This is considered by those w^ho claim glaucoma to be a non-inflammatory disease to be the most charac- teristic form, as in this variety of glaucoma there are no inflam- matory symptoms. We will simply find an increased tension which ma}^ vary at different times, but usually not elevated to the degree we have in other forms, and in some cases we may never find the tension distinctly increased. The pupil is dilated and sluggish, though, as a rule, not so much so as in acute or chronic. The vision is impaired and the field contracted, there is no pain 476 GIvAUCOMA. or haziness of the cornea and with the exception of some disten- sion of the anterior ciliary veins the eye looks quite normal. With the ophthalmoscope there is seen an excavation of the optic disc, some choroidal atrophy around the disc and displacement of the retinal vessels. The characteristic signs of glaucoma simplex are the increased tension, excavation of the disc and the regu- larity with which the pressure acts upon the circulation of the retina, first limiting and then abolishing the field of vision. The central vision, as a rule, gradually diminishes but sometimes re- mains good until the field of vision has become almost lost. The absence of pain and inflammation together with the very gradual loss of vision renders the patient often unconscious of any trouble until late. In the excavation of the disc in glaucoma the edge of the disc overhangs so that the vessels wholly or partially disap- pear from view as they pass over the margin of the disc; some claim they are always displaced toward the inner side and believe that in any excavation where the vessels are not so displaced the cupping is not the result of glaucoma. The choroid around the excavated disc in glaucoma may be detached by the pressure, often presenting the appearance of posterior staphyloma. Glau- coma simplex is usually chronic in form and may terminate in acute inflammatory glaucoma or in absolute. Fuchs says: " Glau- coma simplex always attacks both eyes," but this statement is not borne out in my own experience. Glaucoma Hsemorrhagica. — This may be considered a primar}^ glaucoma when associated with haemorrhage, or second- ary when it is caused by haemorrhage. The symptoms are the same as those already detailed under acute or chronic forms, plus the greater tendency to haemorrhage on account of the degenera- tion of the vessels. The haemorrhage occurs especially from the retinal vessels. Varicose and aneurismal dilatations, together with changes in the walls of the retinal vessels, have been fre- quently found. Sudden relaxation of the tension by an iridec- tomy has often resulted in a serious intra-ocular haemorrhage, causing destruction of the eye. The pain in this form of glau- coma, when there may be but even a slight increase of the tension » is often unbearable and frequently necessitates enucleation. In many cases the haemorrhage is the cause of the outbreak of acute GLAUCOMA ABSOLUTOM. 477 symptoms when there were no glaucomatous signs before. Hsem- orrhagic glaucoma generally affects but one eye and is usually found in old people with arterio-sclerosis. Glaucoma Absolutura. — By this we mean a glaucoma that has run its course, or all cases that have resulted in a total loss of sight. The results vary somewhat, whether due to acute, chronic, or simple glaucoma. Result of Acute or Chronic Glaucoma. — In this the anterior ciliary veins are large and dark, especiall}^ at the recti muscles; the conjunctiva is thinned, the sclera pale, the cornea rough, hazy and not sensitive to touch; the pupil is dilated to a mere rim, which is in contact with the cornea; the lens is cataractous and pushed forward near to the cornea, the pain often continues severe and the patient has the subjective symptoms of photopsies and chromopsies. Result of Glaucoma Simplex. — In these cases the eyeball will usually appear healthy and may be free from pain, but there is extreme hardness of the ball, excavation of the disc, choroidal atrophy around the disc, arteries contracted, anterior chamber shallow, pupil dilated (may be contracted) and vision entirely lost. An eye may remain in this condition for years or pass into degenerative changes at any time. In the last stages of an absolute glaucoma from any form, the eyeball may enlarge, cornea flatten and sclera bulge. This pro- cess is accompanied by severe pain until finally the ej^eball rup- tures and passes over into atrophy. Another change is where the eyeball shrinks, the secretion all the time growing less, the tension becomes minus and atrophy ensues. This last change ma}' or may not be accompanied with pain, and inflammatory attacks maj^ occur. Glaucoma Consecutiva. — The preceding forms of glaucoma have resulted from a loss of balance between secretion and excre- tion in previously healthy eyes, that is, due to either an increased secretion or an obstructed excretion in eyes in which there was no other apparent disease. In this there is a similar disturbance in eyes showing other diseased conditions. All affections of the eye become glaucomatous when, with other symptoms, there is an 478 GLAUCOMA. increase in the tension. The symptoms, then, of secondary glaucoma are increased tension, which may be the only symptom. The accommodation and refraction may be impaired, but, as a rule, the other diseases of the eye will hide this. The vision is impaired, may have iridescent vision, the field is contracted, more or less severe pain, anterior chamber shallow, pupil dilated if not bound down by posterior synechiae from other disease. There is marked dilatation of the episcleral vessels and cupping of the disc. Often there are changes in the form of the globe and the condition terminates in atrophy, as in glaucoma absolutum. The most frequent causes of secondary glaucoma are total adhe- sions of the iris. Isolated adhesions may also lead to it. In- juries and luxations of the lens. Atheroma of the retinal vessels and tumors of the interior of the eye may cause. Treatment. — This should vary according to the stage of the disease ; taken in the premonitor}^ stage where the patient suffers from only occasional attacks of temporary blindness, pain, etc., while in the interval the vision is good, we may look for benefit from the use of remedies. The best local remedy to be considered is either the sulphate or salicylate of eserine, which may be em- ployed in the strength of from one-half to two grains to the ounce of water and may be instilled into the eye as often as every hour, and should in itself speedidly cut short an attack. Pilocarpine in twice the strength of eserine is preferred by some. Even in some cases of acute glaucoma, if used early and often, the necessity of an operation may be postponed, if not permanently avoided. In all cases the use of eserine should be early, very early, hence we believe it best in cases once having had a premonitory attack, that the patient should be supplied with the eserine with directions as to its use that no time should be lost. The action of the eserine is to cause contraction of the iris and in this way it is drawn away from the iritic angle and the filtration passages opened; it also, by con- striction of the vascular system of the eye, diminishes secretion. Mydriatics, especially atropine, must be avoided, as they are liable to cause an acute attack of glaucoma. Iridectomy , — The introduction of this operation for the relief of glaucoma was empirically made by von Graefe, in 1857, ^^^ is still the operation for this disease. Iridectomy has been the means of saving useful vision in thousand of patients who would other- TREATMENT OF GLAUCOMA. 479 wise have been hopelessly blind. While iridectomy is the most valuable remedial agency extant for this disease, still it is not in- fallible, as in some cases or forms of glaucoma even this operation will not check the disease. The operation is preferably made early, before the vision has been too long affected. In acute glaucoma we can expect to retain the vision where it is at the time of the operation, and if not too long standing we usually get more or less improvement in the sight. Iridectomy may also be made to relieve the pain even after the vision is totally and per- manentl}' destroyed. It sometimes happens where the first iridec- tomy has not relieved, that the second or even the third iridec- tomy or repeated sclerotomies will do so. In acute inflammatory glaucoma an iridectomy is, as a rule, extremely favorable. In Fig. 90. Parenteau's sclerotomy Icnife. Operating, the previous use of eserine is advisable, as it renders less liable accidents from sudden relief of the tension, and it has also been advised by Arlt and others that it be used in the sound eye as well, for the mental anxiety caused from the dread of an operation has been considered not infrequently to have been the cause of an attack in the good eye. Ether should, as a rule, be used in this operation, as thorough anaesthesia cannot be obtained from cocaine in a glaucomatous eye. The incision should be made entirely in the sclera, the iridectomy large and care taken not to injure the capsule of the lens, which is liable to occur owing to the shallow anterior chamber, and that the escape of the aqueous be yery gradual. The beneficial results of an iridectomy in glau- coma simplex are quite problematical, the statistics of many prominent operators showing that only about one-half of these cases are cured by an iridectomy. Sclerotomy has been strongly advocated by De Wecker, but it has not seemed to have met with the hearty support of the other authorities. In certain cases, especially the hsemorrhagic form of glaucoma, sclerotomy may with advantage take the place of iridec- tomy. The writer has had the best of results from this operation 480 GLAUCOMA. in a few instances. Sclerotomy is often only resorted to after an iridectomy has failed to give relief. Sclerotomy has usually been made with a Graefe cataract knife, the incision being made wholly in the sclerotic, a bridge of tissue being left above. I have, how- ever, used for the last three years Parenteau's sclerotomy knife (Fig. 90) as much safer and easier to use while giving equally good results. This knife is used exactly ,the same as a keratome in iridectomy. In the premonitory stage, as has already been said, our en- deavor should be to cure by the aid of internal medication, which may be done in many cases if we take into consideration the con- stitutional disturbances which are associated with or cause the intra-ocular trouble. The habits of our patient should receive careful attention. The excessive use of stimulants (either alcohol or tobacco), or any exhaustive mental or physical labor must be strictly forbidden. Only moderate use of the eyes should be allowed, and, during the attacks, or when they follow each other in rapid succession, complete rest is necessary. Bright light, either natural or artificial, should be avoided, or the eyes pro- tected by colored glasses. The diet should be good and nutritious, particularly in elderly persons, and all indigestble substances for- bidden. Massage, according to Kick, is of service in the after treatment and in cases of simple glaucoma where futile operations have been performed, to retard as long as possible the decline in visual acuity. "' The result of massage is instantaneous, the hard eyeball grows soft under the physician's finger, so to say, but its effect is not lasting. The patient should, therefore, learn to massage himself, and practice it daily. ' ' The results from the use of internal remedies alone in glaucoma seem to me somewhat problematical. In the majority of cases recorded, where no operation was made, the local use of eserine was employed as well as the remedy, and in consequence it is un- scientific to give the credit to the remedy alone. Gelsemium. — Is one of the principal remedies in this disease and is, perhaps, more frequently used than any other. There seems to be no especially characteristic symptoms upon which it is given, hence we come to the conclusion that its use has de- pended upon the fact that clinically it has proven its value. TREATMENT OF GLAUCOMA. 48 1 Bryonia. — From its value in serous inflammations in general, this remedy has been given with benefit in glaucoma. It is more often indicated in the prodromal stage. The eyes feel full, as if pressed out, often associated with sharp, shooting pains through the e3"e and head. The eyes feel sore to touch and on moving them in any direction. There may be a halo around the light, with heavy pain over the ej^e, worse at night. The usual concomitant symptoms will decide us in its selection. Aconite may be of service at the commencement of an acute attack when we have much heat, redness and burning pain in the eye, together with fever and other symptoms of the drug generally. Osmium. — This remedy has proven of value in the hands of some, and from its symptoms should be given a more thorough trial. It has sudden, sharp, severe pains in and around the eye. Dimness of vision, objects seen in a fog. Halo of various colors around a light. Phosphorus. — Of great importance in improving vision and removing many subjective symptoms after iridectomy. Fundus hypergemic and hazy, halo around the light, and various lights and colors (especially red) before the eye. Sensation as if some- thing w^as pulled tightly over the eyes. Vision impaired, better in the twilight. Belladonna. — Of benefit in relieving the severe pains of glau- coma, especially if accompanied by throbbing headache and flushed face. The eyes are injected, pupils dilated, fundus hy- persemic and pain both in and around the eye. The pains are usually severe and throbbing; maj^ come and go suddenly and are worse in the afternoon a?id eve7iing. The e3'es are hot and dry, with sensitiveness to light. IJalo around the light, red predomi- nating. Photophobia. Asafcetida. — Glaucoma, with severe, boring pain over the eye, and around it. Cedron. — For the relief of the pains of glaucoma, when they are severe and shooting along the course of the supi'a- orbital nerve. Colocynth. — Of service in relieving the pains of glaucoma when they are severe, burning, aching, sticking or cutting in character in the eye and around, always 7'elieved by firm pressui^e 31 482 GI.AUCOMA. and by walking in a warm room; aggravated by rest at night and upon stooping. Nux vom. — Indicated if the morning aggravation is very marked and for the resulting atrophy of the optic nerve. Prunus spin. — Pain severe^ crushing, in the eye, as if the eye were pressed asundef , or sharp, shooting through the eye and corre- sponding side of the head (Spig.) Aqueous and vitreous hazy, fundus hypersemic. Rhododendron. — Incipient glaucoma, with much pain in and around the eye, periodic in character and always worse just before a storm, a7neliorated after the storm commences. Spigelia. — Pai?is sharp and stabbing through the eye and heady worse on motion and at night. Our range of drugs will be extensive in this affection, as we must take into consideration all the general symptoms to make a sure prescription. The above remedies have been most often called for in the cases we have met, though the following may be found useful: Arn., Ars., Aur., Cham., Con., Crot. tig., Ham., Kaliiod., Macrotin., Merc, and Sulph. I PART II THE OPHTHALMIC THERAPEUTICS OPHTHALMIC THERAPEUTICS, ACETIC ACID. Clinical. — The benefit obtained from Acet. ac. in croupous in- flammation of the air-passages led to its use in croupous conjunc- tivitis. Though empirically prescribed at first, it has proved of decided value in certain forms of this inflammation. It is adapted to those cases in which the false viembrane is dense, yellowish- white, tough and so closely adherent that removal is almost impos- sible; thus differing from Kali bichr., in which the membrane is loosely attached, easily rolled up and separated in shreds or strings. The lids are oedematously swollen and red, especially the upper, which hangs down over the lower. It does not seem to correspond to the diphtheritic form of conjunctivitis, for, though the false membrane is closely adherent, it does not extend deeply into the conjunctival tissue — no scars remaining after resolution — and at no time is there firm, rigid infiltration of the lids. Little or no benefit can be derived from its use if the discharge is profuse and purulent, mixed with small portions of the membrane, or if the cornea has become involved. Compare Arg. nitr., Pulsat. and Hepar. ACONITE. Objective. — The lids {^especially the upper) are swollen, red and hard, with a tight feeling, w^orse mornings. Edges of lids sore, red and inflamed. Pupils dilated. The conJ2inctiva is intensely hypercEmic and oedematous, mostl}^ toward the inner canthus. Lachrymation with local inflammations is usually slight, if any. Subjective. — In the lids, dryness, burning, se?isitiveness to air. Pressure into the upper lids, as if the whole ball were pushed into the orbit, causing a bruised pain in the eye; itching, smarting, burning in the eyes, especially worse in the evening. Sticking 485 486 OPHTH ATOMIC THERAPKUTlCS. and tearing pains around the eyes, worse at night. The eye is generally sensitive, with much heat, burni7ig and aching, worse on looking down or turning the eyes; feeling as if the eyes were swollen, or as if sand was in them. The ball, espe- cially the upper half, is sensitive if moved; feeling as if it would be forced out of the orbit, relieved on stooping; the ball feels en- larged, as if protruding and making the lids tense. Sparks before the eyes, flickering. Vision as through a veil; it is difficult to distinguish faces, anxiety and vertigo. Photophobia. Clinical. — Aconite is the remedy for inflammations of the eye in general, which are very painful, with^^'e. In one case of ciliary blepharitis with entropium, caused by being over a fire, and ameliorated in the cold air or by cold applications, it ef- fected a cure. Acute conjunctivitis resulting from bathing, with profuse dis- charge and dark redness of the conjunctiva, has been relieved. Nitrate of silver is not homoeopathic to granular lids in the later stages, but is the appropriate remedy in the early stages of acute gra?iular co7iju7ictivitis, in which the conjunctiva is intense!}' pink or scarlet-red and the discharge is profuse and inclined to be muco-purulent. xVlthough these may be confounded with Eu- phrasia cases, there is a wide difference , more easy to recognize than to describe. In Euphrasia the profuse discharge causes soreness of the lids and more or less swelling; the character of the inflammation is more acute and short lived and, as a rule, the red- ness is much less brilliant. In Nitrate of silver cases we mav, in- 496 OPHTHALMIC THERAPEUTICS. deed, have very little discharge, except, perhaps, flakes of mucus, when the patient complains of itching and biting in the eyes and a dry, burning sensation without real dryness. (Cantharis has intense heat and real dryness; Sulphur is very often indicated in these dry conjunctival catarrhs, especially if there be sharp stick- ing pains under the lids as if splinters were sticking into the eye- balls. Compare also Alumina, Graphites and Natr. mur.) The greatest service that Argent, nitr. performs is in purulent conjunctivitis. With large experience in both hospital and private practice, not a single eye has been lost from this disease when seen before the cornea has been destroyed, and most of them have been treated with nitrate of silver, which should be used inter- nally and in all severe cases locally as well. In the mild cases where the discharge is not excessive and the chemosis not great I am in the habit of using a solution of from ten to twenty grains of the first potency to the ounce. When the discharge is thick, yellow and profuse, especially if the chemosis is extensive, it should be used locally in a solution of from two to five or even ten grains to the ounce. In the very first stages of purulent con- junctivitis it may sometimes be aborted by a single application of a solution of nitrate of silver, thirty grains to the ounce. The most ~ intense chemosis, with strangulated vessels, most profuse purulent discharge, even the cornea beginning to get hazy and looking as though it would slough, have been seen to subside rapidly under this treatment. The subjective symptoms are almost none; their very absence, with the profuse purulent dis- charge and the swollen lids, swollen from being distended by a collection of pus in the eye or swelling of the sub-conjunctival tissue of the lids themselves (as in Rhus or Apis) indicates the drug. It has also relieved and contributed to the cure of diseases with destruction of tissue, as ulceration of the cornea; in one case with pains like darts through the eye mornings, better evenings; in another case there were small ulcers on the upper part of the cornea with much inflammation, burning pain and profuse dis- charge. It has also been useful in kerato-iritis, with violent congestion of the conjunctiva; the cornea was vascular and eroded, with terrific pains from the vertex into the eye and with burning heat in the eyes.— T. F. A. ARNICA. 497 Coldness of the eye, with boring pain in the head and sensation as if the scalp was drawn tightly, has been removed by Arg. nitr. — T. F. A. (Fluor, ac. has a sensation of cold air blowing into the eye.) In the Arg. nitr. cases we sometimes meet with trembling of the whole body and headaches. A case of retino-choroiditis was successfully treated by this remedy. — W. H. Woodyatt. Arg. nit. has greatly improved two cases of atrophy of the optic nerve. — C. M. Thomas. Dr. Woodyatt was the first to call attention to Arg. nitr. as a remedy for weakness or paralysis of the accommodation. Since then it has been found of great service in mam^ cases of this kind, especially if dependent upon errors of refraction, in which the asthenopic symptoms on using the eyes are not relieved after cor- rection with the proper glasses. ARNICA. The margins of the upper eyelids are painful when the lids are moved, as if they were too dry and a little sore. Cramp-like tearing or pressure in the eyebrow (left). Headaches between the eyes. There is some burning and itching of the eyes with slight lachrymation and photophobia. Feeling of heaviness of eyes; eyeballs are inflamed. Clinical. — Arnica has been employed with marked success in a variety of eye troubles resulting from blows and various injuries; sometimes applied locally (tincture diluted with water) and some- times given internally. It seems to be better adapted to contused than lacerated wounds, and to injuries before inflammatory symp- toms have become prominent, although benefit has been derived from its use in inflammations of the lids, conjunctiva, and even of the whole globe, when of traumatic origin. (Aeon., Calend. ) In hastening the absorption of extravasations of blood in the conjunctiva, aqueous humor, retina, or other ocular tunics, espe- cially if resulting from injuries or the straining in whooping- cough. Arnica often acts well; it seems also, sometimes, to correct the relaxed condition of the blood-vessels and the too fluid condi- tion of the blood, which predisposes to sub-con junctival haemor- rhages in whooping-cough. (HamameHs is more frequently 32 498 OPHI^HALMIC THERAPEUTICS. used in haemorrhages into the anterior chamber, and Ledum in sub-conjunctival ecchymoses. ) In two cases of traumatic detachment of the retina, Dr. Hunt has observed the retina become re-attached under the influence of Arnica^". ARSENICUM. Objective. — Eyelids swollen and (edematous, first the upper and then the lower (this swelling is mostly non-inflammatory and pain- less) ; the oedematous lids are firmly and spasmodically closed and look as if distended with air. Blepharo-adenitis; edges of lids very red. Continual trembling of the upper eyelids, with lachry- mation. Cornea degenerated. Conjunctiva inflamed; extreme redness of the inner surface of the eyelids. Lachryrnation and dis- chai^ges from the eye excoriate the lids and cheek. Anxious expres- sion of the face. Subjective. — Sub-orbital pain on the left side with prickings as with needles, sometimes quite severe. Pain in the margin of the eyelids on moving them, as if they were dry and rubbed against the eyeballs. Burjiing on margins of lid. In the evening a feel- ing as of sand in the eyes, obliging him to rub them. Burning in the eyes ; eyes hot, with burning, sore pain in the balls, and a feeling as if they had no room in the orbit. Pulsative throbbing in the eyes and with every pulsation a stitch; after midnight. Photophobia. Ciliary neuralgia with fine burning pains. Clinical. — Only by concomitant symptoms can we distinguish between Arsenicum and Apis for non-inflammatory oedematous swelling of the lids, as both are indicated in this condition. Blepharitis following erysipelas ten years previous, with scaly condition of edges of the lids and dry, smooth, scaly skin, was cured by this remedy. — J. H. Buffum. Its value in croupous conjunctivitis following ophthalmia neona- torum was illustrated in a child three weeks old. The discharge was moderately tenacious, stringy and yellow-white in color. The lids were slightly oedematous. The right cornea was clear, but the palpebrae (especially lower lid) w^as covered with shreds of exudation, loosely attached but easily removed, leaving a bleed- ing surface and hypertrophied papillae. On the lower half of the left cornea was a large ulcer which had perforated and the remain- ARSENICUM. 499 der of the cornea was opaque. The conjunctiva of the lower lid was covered with a dense, white, semi-transparent, fibrinous ex- udation which could not be remov^ed without much force. A sim- ilar membrane was present on the upper lid, but not as dense nor as firmly attached. After Arg. nitr. , Bromine and Chlorine water had failed to improve, Arsen.^'^ was given on account of the rest- lessness after midnight and desire to nurse often and little. A solution of alcohol (3j ad .^ij) was used locally at the same time. The membrane rapidly disappeared and the ulcer healed, leaving a slight purulent discharge which Arg. nitr. controlled. Arsenicum may be called for in chronic tracho??ia, in w^hich the internal surfaces of the lids are inflamed, painful, dry and rub against the ball, especially if there are intense bnr7ii7ig pains a7id excoriating lachrymation. In scrofulous ophthalmia this remedy has been frequently em- plo3'ed with success, especially in ulcers of the cornea, with sore- ness of the internal surface of the lids, w^hich are swollen and spasmodically closed, so that opening them causes intense burn- ing, sticking pains, worse at night, excessive photophobia and acrid lachrymation; tears gush out on opening the eyes; eyes can be opened well in the cool, open air, but not in the house, even in a dark room; eyes feel as if they had no room in the orbit; throb- bing, pulsating in the eyeballs and around the orbit, with general ulceration of the cornea recurring first in one eye and then the other, especially in young people who are anaemic (in one case when the eyes were better the feet w^ere swollen); ulcer on outer side of cornea with elevated edges, pain like the pricking of needles, excoriation of the external canthus, burning and stick- ing pains. Vascular elevations on the cornea resulting from ulceration, ag- gravated by opening and closing the eyes, with violent, burning pains every afternoon, have been benefited. Parejichymatous kei'atitis may require the use of this remedy, as, for example, the following case occurring in my clinic and treated b}^ Dr. Charles C. Boyle: Mrs. J., aet. 30, had suffered from an inflammation of the eyes for eleven weeks. Both corneae were ver}' hazy, densel}^ infiltrated and vision nearly lost, especially in the right eye. There was deep ciliary injection and commenc- ing vascularity of the cornea; much photophobia and lachryma- 500 OPHTHALMIC THERAPEUTICS. tion; burning pain in the eye and over the brow^ worse about four A. M. ; shooting pain in the ball, over the head and down the cheek; sensation like pins and needles sticking in the eyes, worse at night. Pupil dilated slowly under Atropine. No specific history. For one week Cinnab.^ and Aur. mur.^ with Atropine externally, were prescribed with only an aggravation of the symptoms. Arsen.^ was then given with almost immediate ame- lioration of pain and rapid diminution of the inflammatory symp- toms. One week later the 30th was prescribed. In about four weeks the haziness of the cornea had so nearly disappeared that with correcting glasses vision was f^. Several cases of kerato-iritis with burning pains over the orbit, worse at night and with profuse acrid lachrymation, have been cured. . Benefit has been derived from its use in syphilitic iritis and also idiopathic iritis, characterized by burning pains in the eye, worse at night, especially after midnight, with great restlessness and much thirst. Arsen. cured a progressive choroiditis disseminata which alter- nated with bronchial catarrh; when the eyes were better the chest was worse, and vice versa. There was heat in the eyes and burn- ing in the chest, with dyspnoea and a whole train of Arsenic chest symptoms. — T. F. A. The favorable results obtained from use of Arsen. in retinitis albuminurica are sometimes very gratifying, as shown in the fol- lowing case: Miss M. P., set. 20; retinitis albuminurica fully developed in both eyes. I^. V. counts fingers at two feet. R. V. y^. Right ventricle hypertrophied; appetite variable; bowels regular; great thirst for small amounts; occipital headache of a pricking character; tongue large, dry and yellowish; menses too often and venous; breath oppressed and pulse irregular. Cured in two months by Arsenicum 3d and 30th, and Sulphur^". lyast report: No albumin; R. V. |^; L. V. H-— W. S. Searle. Both Arsenicum and Rhus are often indicated in scrofulous cases, but the paroxysmal character of the pains, the extreme prostration often present, the burning, sticking pains and the ex- coriating discharges wall distinguish Arsenic. The brilliant red inner margins of the lids and the dryness of the inner surfaces are very marked indications for its use in trachoma. The nervous ARUM TRIPHYLLUM. 5OI irritability associated with the symptoms of Arsenic is a very pro- nounced anaemic hypersesthesia . Arsenic cases are generally relieved by warm applications. They are very frequentl}^ periodic in their occurrence, commenc- ing every fall, and often alternating from one eye to the other. ARUM TRIPHYLLUM. Clinical. — A brilliant cure of catarrh of the lachrymal sac, with desire to bore into the side of the 7iose, was made by this drug. — C. A. Bacox. ASAFCETIDA. Severe boring pains above the brows. Tearing pain in the fore^ head; dull pressure at the external border of the left orbit. Trou- blesome dryness of the eyes. Periodic burning in the eyes and pressing together of the lids, as if overcome with sleep. Burn- ing pain in the ball from within outward. Throbbing pain at night relieved by pressure. Clinical. — Asaf. is very useful in ciliary neuralgia, and from its power of relieving the intense boring, burning pain in the brows, especially at night, has arisen its very beneficial action in certain forms of deep-seated inflammation of the eyeball attended by these ciliar}^ pains and turbidity of the humors, as in iritis, kerato-iritis, irido-choroiditis and retinitis, especially if of syphi- litic origin. The pains are usually throbbing, beating, boring or burning in character, either in the eye, over or around it; they are often intermittent, extend from within outward and are ameliorated by rest and pressure (reverse of Aurum). Asaf. has relieved a sharp pain extending through the eye into the head upon touching. ASARUM. Clinical. — Asthenopia, accompanied by congestive headaches, has been cured. The eyes were worse morning and evening, when outdoors in the heat and sunlight; were better in the mid- dle of the day and from bathing them in cold water. — T. F. A. ATROPINUM. About 9 p. M. eyelids felt heavy and difficult to keep open. 502 OPHTHAI^MIC THERAPEUTICS. Sharp pain under the right eye, with slight pain in the temples. Neuralgic pains commencing under the left orbit and running back to the ear, lasting perhaps ten minutes at a time and then disappearing for fifteen or twenty; these have been noticed for several hours. Hard, tense eczematous swelling and redness of the lids. Clinical. — Its wholesale and empyrical application for thera- peutical purposes is unwise and often unsafe, since we have few accurate data upon which to base a prescription of Atropine to cure (it should never be used when Belladonna is indicated, since Atropine does not comprise Belladonna). It is a very happy provision that the local application of Atro- pine lo a healthy eye almost always spends its whole drug power upon the peripheral nerve-fibres of the iris and ciliary muscle and that very seldom do any constitutional symptoms arise. In twenty years' experience we have seen no single bad effect from the use of strong (four grains to the ounce) solution of Atropine for dilating the pupil in order to examine the fundus. Its use should always be avoided in all stages of glaucoma, as cases are reported of most violent inflammation following its use in that disease (though Belladonna does not seem to be at all homoeopathic ta glaucoma, as the action of Atropine is probably mechanical). If an attack of iritis could be promptly recognized and met at the very beginning, before the exudative stage is reached (that is, within twenty-four hours), there might be no need of Atropine; but if exudation has taken place and the inflammation is violent, use immediately a strong solution of Atropine, a drop every one to four hours; it will not materially interfere with the action of remedies. It is, however, in all cases, the safest plan, for, if ad- hesions take place, an iridectomy will usually be required. In severe cases, in which the congestion of the capillaries is enormous, and the iris, being so full of blood, cannot dilate, Aconite may be employed in frequent doses to reduce the hyperaemia. In rare cases of this kind even cupping of the temples may be justifiable as a temporary expedient to enable us to obtain a dilated pupih This being accomplished, remedial measures may be resumed and continued. its use is recommended for the relief of ciliary neuralgia. AURUM. 503 AURUM. Objective. — Redness and swelling of the lids. Redness of the sclerotic; constant lachrymation ; photophobia; morning aggluti- nation; eye very red and angry looking. Subjective. — Burning, stitching, drawing and itching in the inner canthus of the eyes and in the lids; sensation upon using the eyes, as of violent heat in them; pressure in the eyes and con- stant feeling of sand in them; pressive pain in the right ball from above downward, also from without inward, worse on touch; pain in the eye from blowing the nose. Bones around eyes feel bruised. Vision. — Hemiopia, the upper half of the field of vision seems covered by a black body, the lower half visible. He cannot dis- tinguish anything clearly, because he sees everything double and one object is seen mixed with the other, with violent tension in the eyes. Vision indistinct as through a veil. Clinical. — In considering the clinical application of Aurum in ophthalmic diseases, no distinction will be made between metallic gold and the muriate, for experience has not yet demonstrated that there is any practical difference between these two preparations; In blepharitis it is rarely useful, though it may be called for, especially in syphilitic patients after the abuse of mercury, if the lids are red, swollen and ulcerated. For trachoma ivith or without pannus (especially with), there is probably no remedy oftener indicated than Aurum. Its charac- teristics are not well marked, but its usefulness has been con- firmed in a variety of cases; there is commonly much photophobia, lachrymation and pain, burning or dull in character, compelling one to close the lids, usually worse in the morning and amelior- ated by the application of cold water; although one or more of these symptoms may be absent without necessarily contra-indicat- ing this remedy. For ulcerations and pannus-like thickening of the outer layer, Aurum is of great service, especially in cases of scrofulous oph- thalmia with ulcerations and vascularity of the cornea; with great irritability of the patient; great sensitiveness to noise; photophobia; profuse, scalding lachrymation; sensitiveness of the eyes to touch; swollen cervical glands; pains from without inward, worse on touch (reverse of Asaf.). 504 OPHTHALMIC THERAPEUTICS. No remedy has given greater satisfaction in the treatment of interstitial keratitis than Aurum muriaticum and many cases of this sluggish form of inflammation have yielded promptly to its use. Its sphere of action does not seem to be closely circumscribed, for rapid improvement has followed its use in cases of a scrofulous origin, as well as in those which can be traced to hereditary syphilis. The cornea is more or less opaque and may be very vascular or not. The degree of ciliary injection, photophobia and pain is variable. Its verification in cases dependent upon hereditary syphilis is of frequent occurrence. In old, obstinate cases of superficial ulcera- tion of the cornea with moderate redness, photophobia and lach- rymation. In low forms of episcleritis in which the cornea is becoming infiltrated from the sclera, with moderate redness, pain and photo- phobia, benefit has been derived from Aurum. Favorable results have followed its use in iritis and kerato-iritis, particularly the syphilitic variety, and after the abuse of mercury. There is usually much pain around the eye which seems to be deep in the bone and to extend from without inward; aggravated by touch. In one case recently under my care in which the im- provement and cure was remarkably rapid under Aur. mur,^, there was great swelling of the iris, extensive posterior synechise, large £"umma of the iris, haziness of aqueous, with deposits on posterior surface of the cornea, tending to extension into the parenchyma, together with much pain and soreness around the eye; worse at night. It is almost a specific for exudative chorio-retinitis with exuda- tions in the vitreous. — T. F. A. Hemiopia, in which the right half of objects is invisible, has been helped, though not cured. But the form of hemiopia to which Aurum is especially adapted is when the patient can see nothing above the median line, as the following case will illustrate: Some years ago a gentleman, who had taken large quantities of iodide of potash, complained that the vision of the left eye had been failing for a year and a half ; he could not see the upper half of a room or any large object, though the lower half was clear; no pains in the eye; objects seemed smaller and more distant; had some black spots before vision; was always worse as the day pro- gressed and better in the morning; twitching in the upper lid. BADIAGA. 505 On inquiry it was found that he had syphiHs ten years ago, but had not been recently troubled with secondary symptoms, except that a large bursa-like swelling on the wrist had persisted a long time. Vision was 2-fo^. Upon ophthalmoscopic examination there was found chorio-retinitis (chronic) with an accumulation of fluid beneath the retina, which settled to the lower portion of the eye and caused a large detachinent of the retina. Vitreous hazy froin infiltration. Right eye normal; refraction normal. Knowledge of the pathological conditions here gave no clue to the remed}^ and we were obliged, this time at least, to rely upon the symptom- atology (as one should always be ready to do). The remarkable symptom of not seeing anything in the upper half of the field of vision is of course the most prominent. Taking the history of the case into account and the previous dosing with iodide of potash, Aurum^°° was given, under which he steadily improved, the hazi- ness of the vitreous almost entirely disappeared; the inflammation of the retina subsided and in one year the vision rose to and re- mained at y^o^V' beyond which it would not go, for the retina was partly disorganized and could not be repaired with retinal tissue. — T. F. A. Since then several cases of retinal disease have been successfully treated with Aurum, though in some cases no improve- ment followed and the remedy only served to arrest further prog- ress of the malady (compare Gelsem.). Aurum cases will usually be found to follow overdosing by potash or mercury and perfect vision can never be expected from the nature of the tissue changes. Its reported benefit in paralysis of the muscles from syphilitic periostitis seems reasonable, though I have not yet had occasion to verify its action. BADIAGA. Bluish purple margins of lids. Headache, extending to the eye- balls. Pains in the eyeballs, extending into the temples, aggra- vated by turning them in either direction. Slight aching pains in the posterior portion of both eyeballs and in the temples (with headache from 2 p. m. till 7 A. M.). The left eyeball quite sore, even upon closing it tightly. Clinical. — This varietj^ of sponge has been useful in some cases of exophthalmic goitre and should always be thought of in this disease. 506 OPHTHAI^MIC THKRAPKUTICS. Has proven of value in some cases of scrofulous ophthalmia with enlarged cervical glands. BARYTA CARBONICA. Redness of the conjunctiva, with swollen lids and dryness of the eyes. Itching of the eyes. Sensation as of a gauze before the eyes in the morning and after a meal. Ivight dazzles the eyes, with fiery spots before the eyes in the dark. Photophobia. Clinical. — Dr. Dudgeon advises its use in scrofulous inflamma- tions of the eye characterized by phlyctenules and ulcers on the cornea, especially when associated with glandular swellings. Has been of service in checking the advancement of cataract. BARYTA lODATA. Clinical. — Up to the present time no proving has been rdade of this substance, so that its sphere of action is hypothecated from its composition; clinically, it has proved a great addition to our arma- mentarium. It was first introduced to notice as an ophthalmic remedy by Dr. Liebold, who says that it is especially adapted to diseases occurring in scrofulous subjects, in which there is great swelling of the glands, particularly of the lymphatics, "which feel like a string of beans everywhere between the muscles down to the spinal column; they can be felt of all sizes and all degrees of induration; some may be suppurating, while others have healed with an ugly scar. ' ' It has been used very successfully in chronic recurrences of phlyctemilar keratitis and conjunctivitis found in the above subjects. Dr. Woody att has reported a cure of specific interstitial keratitis of both eyes, in which vision had decreased so that fingers could not be counted at more than four feet, complicated with enlarge- ment of the cervical glands which were hard and painful on pressure. Since then I have verified its usefulness in one case of parenchymatous keratitis. BELLADONNA. Objective. — The eyes are protruding, staring and brilliant. The eyes become distorted, with redness and swelling of the face; spasms of the eyes; the eyes are in constant motion. Lids puffy, red and congested; inflammatory swelling of the lower lid near BEIvIvADONNA. 507 the inner canthus, with throbbing pains, etc. Conjunctiva red^ tumefied. Lachrymation, with great photophobia. Total ab- sence of lachrymation; motion of the eyes attended with a sense of dryness and stiffness; the conjunctival vessels fully injected. Pupils (at first, or from large doses) dilated; (afterward, or from minute doses) contracted. The optic disc greatly deepened in tint, and the retinal arteries and veins much enlarged, the veins 77iosf markedly so. Subjective. — Bye dry, motion attended with a sense of dryness aiid stiff 7iess. Pain and burning in the eyes. Feeling of heat in the eyes; it seems as if they were surrounded by a hot vapor. Burning heat in the eyes. The surface of the ball became quite dry, which caused a very disagreeable and uncomfortable sensa- tion, which could not be relieved by winking or continued closing of the eyes. Pressive pain deep in the ball when she closed the eyes; feeling as if the eyes protruded. Severe throbbing pain in the eye and head, worse at night. Vision. — Dimness of sight or actual blindness. Every object in the room, both real and spectral, had a double or at least a dim outline, owing to the extreme dilatation of the pupils. Every- thing he looks at seems red. A large halo appears round the flame of the candle, partly colored, the red predominating; at times the light seems as if broken up into rays. Occasional flashes of light before the eyes; sparks of electricity before the eyes, especially on moving them; large, bright sparks before the eyes. Photophobia. Diplopia. Flickering before the eyes. When walking in open air, black spots and stripes before the eyes, rapidly appearing and disappearing. Objects passing before the eyes have an undulating motion. Clinical. — The use of this drug in inflammator}^ diseases of the eye is much more limited than is generally supposed. Erythema and erysipelatous inflammation of the lids often re- quire the administration of Belladonna. It may be of service in some forms of co7iJ2inctivitis (especially catarrhal in the early stages) with dryness of the eyes, thickened, red lids and burning pains in the eyes, though not as frequently called for as Aconite. Its use may be necessary in acute aggra- vations of various chronic diseases, as in granular lids, when, after taking cold, the eyes become se?isitive to air and light, with dry- 5o8 OPHTHALMICA THERAPEUTICS. ness and a gritty feeling in them; or in chronic forms of keratitis in which the eye suddenly becomes intensely congested, with ex- cessive photophobia, heat and pains which may be throbbing or sharp, shooting through the eyeball to the back of the head. Idiopathic iritis has been cured in the early stages by this rem- edy, but it is not often indicated. Two cases, however, Qi simple plastic iritis, resulting from a cold on the eighth day after a cataract extraction, in which Wi^ pairis are severe and of a throbbing charac- ter in and above the eye, worse at 7iight, were promptly relieved under Bell.^*', after Atropine, cold and warmth externally, and Rhus, Merc, and Bry. internally had been given a faithful trial for several days with no improvement. Mydriasis resulting from nervous headache has been relieved. In diseases of the fundus, Belladonna has been a most valuable remedy. It has been employed with great advantage in hyperse- mia of the choroid and also in inflammation, especially the dis- seminate form of choroiditis. There will usually be found ac- companying these cases much headache, congestion of the head and considerable photophobia. Bell, has relieved temporarily the severe pains of glaucoma, though I have never seen any permanent benefit from its use. (Glaucomatous eyes are exceedingly sensitive to the action of this drug, and atropine should never be used in this disease). It is often the remedy for hypercssthesia of the retiyia dependent upon some anomaly in refraction, or due to reflex irritation. In hypercsmia of the optic 7ierve a?id reti^ia this remedy has been especially efficacious, particularly if dependent upon cerebral con- gestion and accompanied by aching pain in the eye, aggravated by any light; also, in chronic forms of h3^per3emia, if a red conjunc- tival line is very marked along the line of fissure of the lids. In some of these cases, as well as in some acute inflammatory affec- tions, retinal photopsies are present, such as red sparks, flames, bright spots, lights, etc. Its usefulness is not, however, confined to simple congestion of the optic nerve and retina, as it is one of our chief remedies in in- flammation of these tissues. The following cases will show the sphere of action in inflammation of the optic nerve and retina: Optic neuritis, in which the papilla was very much swollen, veins large, flashes of light before the eye and pains in the head. Bell. BELLADONNA. 509 cured speedily. Retinitis, occurring in a young lady who was sub- ject to congestive headaches, always worse in the afternoon. The retina was very hazy and oedematous, appearing as if covered with a bluish-gray film; outlines of disc ill-defined; vessels large and tortuous. Under Bell.^*^ a rapid disappearance of the above symp- toms took place. Neuro-retinitis. Edith G. , set. 5, had suffered from ' ' chills and fever, ' ' which had been relieved without quinine. Six weeks previous to my seeing her and immediately after the chills had been stopped, it was first noticed that her sight was poor, but variable; sometimes she seemed to be nearly blind, while again would distinguish medium-sized objects with comparative ease; complained very often of headache, especially every after- noon, when the head would be quite hot and the face flushed. She was more irritable and cross than formerly. The condition at the time was reported as follows: ** Child has a full face, light complexion and red hair; is bright and smart. Her vision is very poor; does not seem to be able to count fingers, though, owing to her age, her statements are unreliable; sight is markedly better in right than left eye; nothing abnormal is to be seen externally, with the exception of a slight convergent strabismus in left eye. Ophthalmoscopic examination after dilatation of both pupils with Atropine. Right eye: Optic disc very much swollen and outlines ill-defined; its edges, as well as the surrounding retina, are so in- filtrated that it is only by tracing the retinal vessels that the optic nerve entrance is discovered. The arteries are about normal in size, but they, as well as the veins, which are large and tortuous, are veiled here and there by the infiltration. In the macula lutea bright white patches are seen, of a triangular shape and extend- ing more toward the nerve than outward from the macula (are somewhat similar to the stellated arrangement usually found in retinitis albuminurica). Left eye: The same swollen condition of the optic nerve and surrounding retina is perceived as in the right eye, though mingled with the infiltration into the retina are spots of exudation of an opaque character. The retinal vessels are enlarged, especially the veins, which are full and tortuous; they are hidden at points by the exudation into the retina; while along their course, especially on the nerve entrance and immediately around, small points of extravasation of blood are noticed. The changes in the macula lutea are similar to those in the right eye, though the 5IO OPHTHALMIC THERAPEUTICS. white patches are more marked and divided into many by fine lines or inter-spaces. A careful examination of the urine shows not the slightest trace of albumin."- Bell.^ was given. In three days vision was better. In two weeks no haemorrhages were to be found in the retina, the swelling of optic papilla and retina were decidedly less and the headache was relieved. In one month the vision was very good, both nerves somewhat atrophic and the points of exudation in the retina could scarcely be distinguished, though no perceptible change could be seen in the white patches in the macula lutea. Convulsive movements of the eyeball in the light, with terrible pressive pain extending through the whole head, ameliorated in a dark room, have been cured by Bell.; hence its use has been recommended in strabismus due to spasmodic action of the mus- cles, or when resulting from brain affections. In orbital neuralgia, especially of the infra-orbital nerve, with red face and hot hands, it is a valuable remedy. Some cases of amaurosis and amblyopia will require this drug, especially if they are congestive in form and accompanied by the headache and other characteristic symptoms. BROMIUM. Great depression of mind; pain deep in the crown of the head. Protruding eyes. A gray point before the- right eye, moving up and down with movement of the eye. Particularly in blondes. BRYONIA. Objective. — Puffiness of the right upper lid. The conjunctiva is dark-red and swollen, with some discharge of pus. Morning agglutination and frequent lachrymation. Subjective. — Pressive pain above the left eye. Pressure from within outward over the left orbit into the brain, which changes to a pressure on the eyeball from above downward. Pain deep in the right orbit, aggravated by pressure upon the eyeball. Draw- ing together of the left upper lid, wdth a sensation of heaviness therein ; aching pains in the eyes. Severe burning and lachryma- tion of the right eye. Eye very sore, and worse on moving. Headache in morning on opening eyes. Photophobia. Very se7i- siiive pJ^essive pain (coming and going) in the left eyeball, especially BRYONIA. 511 violent on 7noving the ball, with a feeling as if the ej'e became smaller and retracted in the orbit. Vision. — Dim vision; on reading, the letters seem to run to- gether; appearance of all colors of the rainbow; every object seems covered with these colors. Clinical. — It is found that Bryonia is rarely indicated in dis- eases affecting the external tissues of the eye, although in one case of acute inflammation of both the ocular and palbebral con- junctiva, worse in the left eye and toward the outer can thus, wdth marked soreness to touch or upon any motion of the eyes and with a sticking sensation as of hairs in the eyes, a speedy cure resulted under Byronia. Its great sphere of usefulness is, however, in diseases of the uveal tract, especially when of a rheumatic origin. Favorable results frequently follow its use in iritis caused by a cold, especiall}^ in rheumatic subjects, in which there is sharp, shooting pain through the eye into the head, aggravated by motion and relieved by pressure; or if the pain is a steady aching in the posterior portion of the eye, extending through to the occiput, worse at night and on motion. It is also often indicated if the inflammation has extended to the choroid, as was shown in a case of acute irido- choroiditis of the left eye in which there were present opacities in the vitreous, tremulous iris, great ciliary injection, pus in the anterior chamber, soreness in eyeball on moving it and darting pains from the eye through the head, with heaviness of the head afternoons. Bryonia speedily relieved. In the serous variet}^ of choroiditis it is an important remed}^, as one would be led to suppose from its relation to serous inflam- mation in general. Experience has also verified its usefulness in this disease. Glaucoma appears to have been checked in its progress by Bryonia when the eyeball has seemed too full, as if pressed out, with sharp, shooting pains in the e3'e and head, worse at night; also, in a case in the prodromal stage, in which the symptoms were as follows: The vision of the left ej^e had been failing three months, and especially for one week; there was heavy pain over the eye, worse at night; halo around the light for one da}^; cup- ping of the optic disc, and T+. The patient was rheumatic and 512 OPHTHAI^MIC THKRAPEUTICS. nervous. Under Bryonia^" all the symptoms were relieved with the exception of the excavation of the nerve. A case of hyperaemia of the optic nerve and retina was imme- diately relieved by this drug; a bluish haze appeared before the vision (vision |^) ; with severe pain over the eye as from a needle going through the eye and head (compelling her to go to bed); with heat through the whole head, aggravated by stooping. Ciliary neuralgia often requires Bryonia, especially if the pains are sharp and severe, even making the patient scream out; the pains are aggravated by opening the eye and b}^ any motion of the eyeball; the eyes must be kept closed and at rest. The pains, when this remedy is indicated, are usually sharp in character^ pass- ing through the eye into the head^or from the eye downward into the malar region and thence backward to the occiput; the seat of pain becomes as sore as a boil, and the least exertion, talking, moving, or using the eyes, aggravates the trouble. The following symptoms have been reported as cured by this drug, though not found in any proving; some have been repeatedly verified, and seem to direct the choice of the remedy; they are mostly variations of sensation in different persons, dependent upon the great charac- teristics of the remedy — aggravation on motion, and amelioration on pressure: Pressing, crushing pain in the eyes, worse on motion; soreness and aching of the eyes on moving them; scalding in the corners of the eyes, aggravated at night; dull pain and soreness, especially in the left eye, worse in the morning and relieved by pressure. CACTUS GRAND. Clinical. — From its action on the heart, cases of exophthalmic goitre have been improved. Angell advises its use in hyperaemia of the eye, especially of the fundus. CALCAREA CARBONICA. Objective. — Swelling and redness of the lids, with nightly agglutination; during the day the eyes are full of mucus, with a hot sensation, smarting pain and acrid lachrymation. Redness of the conjunctiva with photophobia. I^achrymation on writing, lids hard and swollen, with induration and dry scales. Subjective. — Painful sensation as if a foreign body were in CALCARKA CARBONICA. 513 the eye. Pressure and itching in the eyes, worse in the evening. Itching, burning and stitches, especially on the margins of the lids and in the inner canthi. Tearing headache over the eyes, with nausea. Sticking pains in the eyes. Vision. — Only one side of objects visible, with dilated pupils. Dimness of the eyes after getting the head cold. Halo around the light. Flickering, sparks and black spots before the eyes. Clinical. — The clinical record of this drug, in superficial in- flammations of the eye, is very full. It has been found especially curative in various forms of blephar- itis occurring in unhealthy, "pot-bellied" children inclined to grow fat and who sweat profusely about the head; lids red, swollen and indurated; inflammation of the margins of the lids causing loss of the eye-lashes, with thick, purulent, excoriating discharge and burning, sticking pains; blepharitis with great itching in the lids. Induration remaining after styes and tarsal tumors have disap- peared under its use. Simple inflammation of the conjunctiva may call for this remedy, as in the following instance of acute conjimctivitis caused by bathing: There was moderate redness and lachrymation; eyes felt hot and feverish, with a sensation as of sand in them. Acon.^ failed to relieve; Calc.^° cured quickly. The discharges from the eye are often profuse and, therefore, this drug has been used with advantage in purulent ophthalmia , especially in that form found in new-born children, characterized b}^ profuse yellowish-white discharges, great swelling of the lids and ulceration of the cornea. Conjunctivitis trachomatosa, with pannus, much redness and lachrymation, caused from working in the wet, has been speedily relieved. A marked illustration of the curative action of the drug in affec- tions caused by working in water is shown by the following case: A boatman suffered for years from repeated attacks of sore eyes, caused by getting wet and cold. Pterygium developed and grew rapidly. Calc. c. speedily checked the progress of the disease, and w^hen last seen the cornea had cleared and but little thickness remained in the internal canthus. — T. F. A. Favorable results have followed the use of this preparation of 33 514 OPHTHAI^MIC THERAPEUTICS. lime in various forms of inflammation of the cornea caused from getting wet or aggravated in damp weather (Rhus). It is, how- ever, particularly in scrofulous inflammation of the cornea and con- junctiva, characterized by pustules and ulcers, that Calc. c. proves so beneficial. The following cases afford a good illustration of the prominent features of this drug: A man was attacked with phlyc- tenules on the conjunctiva, after a severe cold, caused by working at night washing carriages. There were severe, sharp, shooting pains from the eye up into the head, worse from two to three in the morning and ameliorated on closing the eyes. Sulph. failed to benefit, but Calc. c.^*' gave immediate relief. — Keratitis phlyc- tenularis, with much redness and photophobia; pain at night which wakes the child from vSleep, with cold perspiration; was cured under Calc. c.^*^. — Keratitis pustulosa, with profuse lachry- mation, excessive photophobia and sticking pains; lids closed, red and swollen, with painful itching in them; agglutination morn- ings; head scurfy; cervical glands swollen, also the upper lip; acrid discharge from the nose; eruptions that burn and itch; abdomen distended and hard; skin pale and flabby. After the administra- tion of Calc. the above symptoms were promptly relieved and the eye restored. It will be observed that the photophobia and lachry- mation are usually excessive, but cases sometimes occur in which they are absent or present only in a moderate degree, though the general indications lead us to prescribe this remedy. The pains are more commonly sharp or sticking in character (Sulph.), though they may vary greatly. Another form of ulceration of the cornea in which Calcarea is frequently indicated is when an ulcer or pustule appears in the centre of the cornea with more or less hazi- ness of the corneal tissue around it, no vascularity of the cornea, very little or no ciliary injection, and a variable amount of photo- phobia and lachrymation. (Compare Puis, and Sil.) It has seemed to hasten the absorption of the exudation into the cornea in interstitial keratitis, especially after the inflammatory symptoms have, in a measure, subsided. Benefit has also been derived from its use in opacities of the cornea resulting from vari- ous forms of keratitis. Dr. C. M. Thomas writes me: "I have lately treated three cases of transverse calcareous band of the" cor- nea, in two of which a complete clearing of the cornea followed a six to twelve weeks' use of Calcarea carb. , preceded by a number CALCAREA HYPOPHOS. 515 of doses of Sulph. The third and least marked of the three re- sisted all treatment. ' ' The following symptoms found vn asthenopia have been verified: Pain in the eyes after using them, worse in damp weather and from warmth. Burning and cutting pains in the lids, especially on reading, or sticking pains in the eyes, with dull hearing. Dim vision after fine work, like a cloud before the e5^es, objects run to- gether, with desire to close the eyes. Red and green halo around the light. The selection of Calcarea wall, in the majority of cases, depend mainly upon the general condition (cachexia) of the patient, since the eye symptoms are ver}^ often too general to individualize the remedy. The reverse may be said of Euphrasia and other remedies exhibiting no general dyscrasia. CALCAREA HYPOPHOS. Clinical. — The hypophosphite of lime has proved to be a remedy of the first importance in severe cases of abscess or ulcera- tion of the cornea. It is especially adapted to those cases in which the patient is in a very low state of general health and does not seem to have vitality sufficient to resist the ulcerative process. We meet with this condition not infrequently in sloughing ulcers of the cornea, and also in that dangerous form of ulceration, the crescentic, in which, although it may not primarily be dependent upon a debilitated state of the general system, the health usually becomes impaired from the severity of the ulcerative process and blennorrhoea of the conjunctiva, which commonly accompanies this condition. In some of these cases pus will be found in the anterior chamber (hypopyon) or the iris will become inflamed and so increase the intensity of the symptoms. CALCAREA lODATA. Clinical. — The provings of this preparation of calcium give no clue to its sphere of action in diseases of the eye. But it is found by clinical observation to be an important remedy in scrofulous i7i- flammations of the eyes and lids, as in chronic cases of blepharitis, complicated with enlargement of the tonsils. It is, however, of especial value in pustules and ulcers, particu- larly of the cornea, marked by great photophobia, acrid lachryma- 5l6 OPHTHALMIC THERAPEUTICS. tion, sticking pains and spasm of the lids; upon forcing open the lids a stream of tears flows down the cheek; also in erysipelatous swelling of the lids, chiefly of the upper, which is shining and red (compare Rhus). The inflammation of the eye is always worse from the least cold, to which these cases are very susceptible. It is chiefl}" indicated in pale, fat subjects who sweat much about the head, with enlargement of the tonsils and cervical glands. In several cases benefit seems to have been obtained from the use of iodide of calcium in checking the progress of both conical cornea and staphyloma; in one marked case of progressive staphyloma of the cornea, the sequela of trachoma and pannus, the bulging of the cornea was checked and the infiltration into its parenchyma absorbed under the use of Calc. iod. CALCAREA PHOSPHORICA. Eyes red; capillary vessels visible in streaks from corners to cornea. Sensation of something in the eye; always felt if it is mentioned. Cannot read; light hurts, particularly candle-light. Glittering circles of light before the eyes. Clinical. — Valuable results have been obtained from the use of Calc. phos. in parefichymatous keratitis, especially if occurring in patients of a scrofulous diathesis; in one case, in which the hazi- ness of the left cornea had been present two weeks and had ex- tended from above downward, the vision was almost wholly lost. On account of enlargement of the tonsils, Dr. C. C. Boyle pre- scribed Calc. phos.^, under which rapid improvement took place and six weeks later only a slight macula remained; vision f^. The photophobia has been well marked in all cases of corneal inflammation successfully treated with Calc. phos. In checking the progress of cataract, it has appeared to be of decided service. The range of usefulness of this drug in oph- thalmic disorders is, no doubt, much more extended than here given, but further experience is necessary to demonstrate its proper sphere of action. CALCAREA PICRATA. Dr. Sterling * reports valuable results from the use of this drug * Trans. Amer. Inst, of Homoeo. for 1885. CALCAREA SULPHURICA. 517 in st3'es and phlyctenules of both the cornea and conjunctiva. He has aborted styes within twenty-four hours and in phlyctenu- lar troubles has subdued them within forty-eight hours, especially where there has not been pronounced vascularit3\ CALCAREA SULPHURICA. Has proven of value in some cases of phlyctenular and pus- tular keratitis, with a thick j^ellow discharge and accompanied by enlarged cervical glands. CALENDULA. Clinical. — The most marked success which has attended the use of Calendula has been observed in injuries of the eye and its appendages, especially cut wounds. After all operations upon the eye or lids, this drug is useful in preventing any undue amount of inflammation and in hastening recovery. Its action is not, however, limited to the prevention of inflammation, as it has been of service in various forms of trau- matic inflammation of the eye. Benefit has been derived from this drug in blennorrhoea of the lachrymal sac. Only occasionalh' has this drug been used internally, its most marked results having been obtained from its local application. A solution of the tincture — from ten drops to two drachms to the ounce of water — ma}' be employed, but a decoction, made from the leaves, is the best preparation which can be used upon the €ye. CANNABIS SATIVA. (Under this drug the symptoms of Cannabis indica will be included, but •designated by '■^', as the clinical application of the two remedies is apparently the same.) Objective. — ^Injection of the vessels of the conjunctiva. ^ T/ie vessels of the conjunctiva of both eyes are injected in a tri- angular patch extending fro?7i the internal caiithus to the cornea; worse at night. The cornea becomes obscured. ^Lachrymation. Subjective. — "^ Heat in the eyes Sensation of spasmodic drawing in the eyi\ as if sand were in the eyes. Pressure from behind the eye forward. 5l8 OPHTHAI^MIC THKRAPKUTICS. Vision. — * While reading the letters run together. * Twink- ling, trembling and glimmering before the eyes. * Sensitiveness of the eye to light. Clinical. — Cannabis deserves to be employed more extensively in ophthalmic troubles than it has hitherto been, especially in affections of the cornea and conjunctiva. I would suggest its use in pterygium, though have not, at present writing, given it a trial. The following case will illustrate its action in pustular keratitis r Colored man, set. 28, duration of disease tw^o days. There was a large pustule on the inner margin of the left cornea, with exces- sive injection of the conjunctival vessels, commencing in a broad-^ base at the internal canthus and terminating in the pustule which forms the apex of a triangle, similar to a pterygium. He was entirely cured in three days under Cannabis ind. — A. Wanstall. Both varieties of Cannabis have been used with benefit in vascu- lar conditions of the cornea. Some cases of pannus have yielded to its influence, though more valuable results have been obtained from its use in parenchymatous keratitis, as a case recently under treatment will illustrate: A boy, set. 7, was brought tome on De- cember 24th for treatment of an interstitial inflammation of the right cornea of two weeks' duration. The history of hereditary syphilis was fairly clear. Under Aurum.mur.^ the eye was nearly well on January 20th, when the left ej^e became inflamed and con- tinued to grow worse until March 2d, notwithstanding the use of Aurum, Con., Arsen., etc., internally, and the instillation of Atropine in the eye. On March 2d the cornea was densely opaque and vascular, so that the iris could not be seen through it. The epithelial layer was a little rough, but there was no superficial ulceration. There was profuse lachrymation and ifitense photo- phobia; the child not being able to open his eyes in any light. He complained of some pain. Cannabis sativa^ had been given for four days with no relief; the tincture, ten drops in two-thirds of a glass of water, one teaspoonful every hour was prescribed. Im- mediate improvement followed its use and on March 8th the child could open the eye well, had no pain and the vascular infiltration into the cornea had diminished. The cornea continued to clear for a month or more, when, only a very moderate amount of hazi- ness remaining, other remedies were given for other symptoms. ) CANTHARIS. 519 CANTHARIS, Inflammation of the e3^es. Lachrymation. Burning in the eyes and glowing heat as from coals. Biting sensation as if salt were in them. Margins of lids pain on opening them. Clinical. — Has proved efflcacious in inflammations of the eye caused by burns, as in the case of a young man who had had a hot iron thrust into the eye, burning the conjunctiva and thus pro- ducing quite severe conjunctivitis, with burning pain in the eye. Cantharis quickly relieved the pain and cured. In another case, in which the cornea was inflamed as a result of a burn from fire- works, with some ciliary injection, great photophobia and moder- ate pain, a speedy cure was effected under Cantharis^^ after Aconite and Atropine had failed to relieve. CARBO VEGETABILIS. Subjective. — A heavy weight seemed to lie upon the eyes so that he must make a great exertion when reading or writing in order to distinguish letters. The muscles of the eye pain when looking up. Itching in the margin of the lids and about the eyes. Eyes become weak and ache from over work. Burning in eyes. Vision. — He became short-sighted after exerting the eyes for some time. Black floating spots, flickering and rings before the eyes. Clinical. — This drug has been too little employed in eye dis- eases and its clinical history is extremely scant. From its symptomatology we are led to recommend its use in cases of myopia, accompanied by posterior staphjdoma, in which it ought to relieve the unpleasant symptoms and prevent the increase of the staphjdoma, though I do not imagine that it would in any degree diminish the amount of myopia. In asthenopia, as the verified symptoms indicate, it has proved beneficial. CARBOLIC ACID. Very severe orbital neuralgia over the right eye. Slight pain over the right eyebrow; the same kind of pain, but in a milder de- gree, under the right patella, both of short duration. Piercing 520 OPHTHAI.MIC THERAPEUTICS. pain in a spot in left supra-orbital ridge. Swimming before the eyes. Clinical. — In conjtmctivitis trachomatosa, with or without pan- nus, remarkable success has often followed the use of Carbolic acid and glycerine as a local application. I have used it in the proportion of six drops to the ounce and in many cases it has acted much better than tannic acid or other astringents. As indicated by the above verified symptomatology, it has proved of service in some cases of supra-orbital neuralgia. CAUSTICUM. Objective. — Inflammation of the eyes, with burning and pres- sure in them and agglutination in the morning. Visible twitch- ing of the lids and in the left eyebrow. I^achrymation even in a warm room, but worse in the open air. Pupils dilated. Subjective. — Burning and stinging as with needles in the eyes, with dryness and photophobia, especially in the evening. Pressure m the eyes as if sand were in them. Pressive pain in the eye increased by touch. Biting and pressure in the eyes, which seem heavy, with redness of the lid. Itching of the eyes, especially in the lids; disappears on rubbing. Inclination to close the eyes; they close involuntarily. Sensation of heaviness in the upper lid as if he could not raise it easily, or as if it were agglu- tinated to the lower lid and could not be easily loosened. Open- ing of the lids is difficult. Itching on the lower lid and on its inner surface, with burning as soon as he touches the eye or moves it. Vision. — Photophobia; constantly obliged to wink. Flicker- ing before the eyes, as from swarms of insects. If he winks, he sees sparks of fire before the eyes, even on a bright day. The eyes become dim and the visioii indistinct; it seems as though a thick cloud were before the eyes. Obscuration of the vision, as if a veil were drawn before them; transient obscuration on blow- ing the nose. Diplopia from paralysis of the muscles, worse on turning the eyes to the right. Clinical. — It has been employed with benefit in some cases of blepharitis (especially if ameliorated in the fresh air — Liebold) and in certain forms of tumors of the lids, particularly warts on the lids and brow. CAUSTICUM. 521 Simple acute conjicndivitis, with a sensation of sa7id in the eye and dull pain in the eyeball as if sore, has been relieved under Caust.^°°. It is not, however, often the remedy for external in- flammations of the eye, though as intercurrent, in scrofulous inflammations and trachoma with pannus, it has been of decided service, if called for according to indications in the above symp- tomatology. The action of Caust. upon the lens is probably as pronounced as that of an}^ remedy in our materia medica, and many cases of cata- ract have been arrested i?i their pj'ogress and even the sight im- proved, where before its administration they were rapidl}^ going on to complete blindness. The following case will illustrate its action: A man appeared for treatment with well-marked hard cataract, which was rapidl}^ increasing. (Had been told by celebrated oculists of the old school that he would soon be blind and that he then could be operated upon.) He complained of the following symptoms: A sensation as if there was a substance in the eye too large, causing a kind of heaviness and distension, only in the evening; also a feeling as if there was something moving in the eyes in the even- ing; could not retain his urine and could not feel the urine pass- ing through the urethra. Under the influence of Caust. the prog- ress of the cataract was immediately checked, and one year after- ward the vision was found somewhat improved, though the white striae in the lens underwent no appreciable change. After seven years his vision remained fully as good as when he began treat- ment. — T. F. A. That this remedy has checked the progress of cataract and improved the vision has often been demonstrated to my satisfaction. It must not be supposed, however, that I believe cataract can be cured by internal medication, for I have never seen any change in the opaque striae found in the lens, but only a clear- ing of the diffuse haziness which often accompanies this condition. But its principal sphere of action is in paralysis of the muscles, and here it is the remedy "par excellence." It has been used more often with advantage in paralysis of the ciliary muscle, ex- ternal rectus, levator palpebrae superioris, or orbicularis, though indicated in paralysis of any of the muscles, particularly if caused from exposure to cold. In cases of paralysis following diphtheria it has also been of service. Selected from a number of cures are 522 OPHTHALMIC THERAPEUTICS. the following, which will serve to illustrate its action: A girl, eleven years of age, had complained of her vision gradually fail- ing for near objects for a week; supposed to be due to a cold. V. 1^ improved by + 24 to |-|. Could only read 3^- Snellen, at the distance of two or three feet, or with -f- 24 glasses. The eyes were perfectly normal, pupils not dilated and the action of the other muscles good. The diagnosis was paralysis of the accom- modation in both eyes. Caust.-°° was prescribed. Three days later, when next seen, she had fully recovered the power of ac- commodation, and reported that two hours after first taking the medicine the vision began to improve, and on the next day she could read as well as ever. For paralysis of the muscles brought on by getting wet, Rhus is more often called for than Caust. , as the latter is especially in- dicated in those cases resulting from exposure to cold. CEANOTHUS AMERICANOS. Dr. French reports in the Trans. Amer. Inst, of Homoeo., 1884, a case of glioma retinae, in which he found curative action of the extract of red clover. After enucleation the microscope revealed the characteristic gliomatous cell formation. For four days after enucleation the stump discharged an ichorous, excoriating and san- guinolent fluid with the appearance of unhealthy granulations in the centre of the stump. The Ceanothus was applied locally and the fluid extract given internally. The character of the discharge was changed within twenty-four hours to healthy pus and so re- mained until the stump was healed. On the sixth day the child was profusely salivated, which disappeared upon stopping the drug. Two years had elapsed with no sign of recurrence of the disease and the child was in perfect physical health. Another case reported by G. S. N. will be found under Glioma Retinae. CEDRON. Pain across the eyes from temple to temple. Severe shooting pain over the left eye. Severe pain in the eyeball, radiating pains all around the eye, shooting into nose, scalding lachrymation. Clinical. — The sphere of usefulness for Cedron, so far as ex- perience has taught us, is confined to neuralgic affections of the CHAMOMILLA. 523 eye, particularly when involving the supra-orbital nerve; and in supra-orhital neuralgia so often found in iritis, choroiditis, etc., it is among the first remedies to be thought of. The pains are usually severe^ sharp and shooting-, starting from one point over the eye (more often over the left) and then extending along the branches of the supra-orbital nerve up into the head; in some cases the pains would come and go suddenly and would be worse in the evening or upon lying down, though these may not be character- istic. CHAMOMILLA. Objective. — The eyelids are swollen in the morning and agglu- tinated with purulent mucus. Conjunctiva swollen and dark-red» Lachrymation, Intense photophobia. Inflammation from ex- posure to cold, damp atmosphere, worse by every cold change of weather. Profuse acrid discharge. Subjective. — Burning and sensation of heat in the eyes; pressure in the eyes, wdiich are inflamed and full of mucus in the morning. Violent pressure in the orbital region; sensation in the eyeball as if it were compressed from all sides, with momentary obscuration of vision. Stitches in the orbital region and soreness in the canthi. Clinical. — Chamomilla is especially adapted to superficial in- flammations of the eye occurring in children, being rarely, if ever, useful in diseases of the deeper tissues. It is an excellent remedy in ophthalmia neonatorum charac- terized by the usual symptoms (even if the cornea has been attacked) if the child is very fretful and wants to be carried all the time. It should also be thought of in inflammations of the eye in which the congestion is so great that the discharges are bloody as well as purulent (Nux). Cham, has proved very serviceable in scrofulous ophthalmia oc- curring in cross, peevish childreji during dentition, and it will often relieve the severity of the symptoms, even though it does not complete the cure. The symptoms which call for this drug are usually severe; the pustules and ulcers are chiefly situated on the cornea, and are attended with great intolerance of light, consider- able redness and lachrymation. 524 OPHTHAI^MIC THERAPEUTICS. CHELIDONIUM MAJUS. Objective.— Twitching and blinking of the lids. The white of the eye is of a dirty yellow color. Redness of the conjunctiva, especially of the lower lid. lyachrymation. Eyehds swollen and red. Redness and swelling of the margins of the lid. Hordeolum. Thick yellow discharge. Photophobia. Subjective. — Tearing pain in and about the eyes. Neuralgic j)ain above the right eye, especially in the evening when reading by artificial light. Pressive pain above the left eye, which seems to press down the upper lid. Aching or pai?i iji the eyeballs on look- ing up or moving the eyes. Sharp, piercing, sticking p^ins. Vision. — Dimness of vision. A blinding spot seems to be before the eyes, and, if he looks at it, the eye waters. Blackness before the eyes, with a sensation of fainting. Clinical. — At one time remarkable success was claimed to have followed the use of this drug in a variety of eye troubles, as in- flammations, opacities of the cornea, intermittent ciliary neuralgia, etc., but later observations have failed to verify much of its vaunted success. The pain in and over the eye upon looking up has occasionally led to its employment with favorable results; as for instance in a case of acute aggravation of chronic trachoma in which the right •eye had been very red and inflamed for five davs, wfth much pain all night and a hard, sharp pain on turning the eye upward. Under Chel.^° the pain was at once relieved and the acute condi- tion had entirely subsided in three days. This remedy may be of service in affections of the muscles, as suggested by the following case: A lady (age 40) reported that her eyes had been growing weak for three days from no apparent cause. She complained of distant objects being blurred and that upon attempting to fixate an object, two were seen. Near vision was not affected. Examination showed decided weakness of the right external rectus muscle. Chel.^*^'' relieved all the symptoms in two days. — T. F. A. CHIMAPHILA UMBELLATA. Clinical. — A large number of cases of pterygium have been treated by this drug, a few of which have been improved, while others have exhibited no good results from its use. CHINA. 525 Dr. Bushrod James reports favorable results from the use of this remedy in checking the progress of incipient senile cataract. CHINA. Motion of eyes painful, with sensation of mechanical hindrance. Lachrymation, with crawling pains in the eyes and in the inner surface of the lids. Dimness of vision. Neuralgia about the eyes. Yellow color before eyes. Photophobia. Pressure in eyes. Clinical. — The clinical application of China in ophthalmic dis- orders has been varied according to the reports in our literature, though it is a remedy not often called for in ophthalmic thera- peutics. It is especially adapted to those diseases of the eye which are of a malarial origin, or in which the pains are of an intermittent type; also, to those affections in which there is impairment of tone from loss of vital fluids. CHININUM MURIATICUM. Clinical. — This form of quinine, in appreciable doses, has been used with great success in controlling the severe neuralgic pains occurring in iritis and various other diseases of the eye. In some cases it does more than control pain, as it exercises a very bene- ficial influence over the progress of the disease. This is especially so if malaria complicates the trouble and the pains are intense and intermittent i7i type. Favorable results have been observed from its use in trachoma with or without pannus. In ulceration of the cornea it is of service if the iris has become involved and there is severe pain, either in the eye or above, periodic in character, especially if accompanied by chills. The intensity of the pains and their intermittent character will furnish our chief indications. CHININUM SULPHURICUM. Disc and retina both very anaemic. Pupils dilated. Neuralgic twinges in the supra and infra-orbital nerves, generally periodic in character. Photophobia and lachrymation. Vision. — Dimness of vision as from a net before the eyes and 526 OPHTHAI^MIC THERAPEUTICS. as from a dark fog. Bright light and sparks before the eyes. Black spots before the eyes. Clinical. — From the physiological action of quinine upon the eye, it should prove a valuable remedy in affections of the optic nerve and retina. It has not, however, been employed to any extent, although cases of optic neuritis are said to have been cured by its use. An interesting case of intermittent strabismus, occurring in a child and continuing for some time (would squint one day and be entirely well on the next), was cured by the use of this remedy in the hands of an empiric. CHLORALUM. Clinical. — The hydrate of chloral has a marked action upon the eye, in some persons producing injection of the conjunctiva, weakness of the eyes, paleness and congestion of the optic nerve, dimness of vision, etc. The clinical verifications of these symp- toms have not, howeyer, been made. Dr. Buffum reports that he has cured with Chloral, hyd.^ the following symptoms in asthenopia: " Burning, smarting, itching; lids gummed in the morning; lids heavy, droop at night and after use; eyeballs feel too large; lids puffed; all symptoms brought on by use; eyes feel better in cool air." CHRYSOPHANIC ACID. Clinical. — This drug is of especial value in obstinate cases of blepharitis ciliaris, especially in scrofulous, poorly nourished children, with pustules or eczematous eruption about the eyes. In phlyctenular keratitis and conjunctivitis when but little pain, photophobia or lachrymation with eczematous eruption of the face. May be used locally as an unguentum, eight grains to the ounce of vaseline, at the same time it is given internally. CICUTA VIROSA. Objective. — Eyes staring. Pupils dilated and insensible. Pupils first contracted then dilated. Eyes sensitive to light. Trembling and twitching of lids. Vision. — When she attempts to stand she wishes to hold on to something, because objects seem now to come nearer, and now to recede from her. Objects seem double (and black). CIMICIFUGA. 527 Clinical. — It is in spasmodic affections of the eye and its ap- pendages that this remedy is especially indicated. Thus we find it very valuable in strabismus, particularly if periodic and spas- modic in character; many cases of which have been cured (this, of course, excludes that form of periodic squint dependent upon an anomaly of refraction). Strabismus occurring after a fall or blow, has been relieved. CIMICIFUGA. Subjective. — Eyes congested during headache. Pain over the eyes, extending from them to the top of the head. Pain over the left eye, extending along the base of the brain to the occiput. Pain in the centre of the eyeballs, and also sensation as if pain were situated between the eyeball and orbital plate of the frontal bone, worse in the morning. Dull pain in occiput. Aching pain in both eyeballs. Black specks before the eyes. Sensation of swelling or heaviness of the eyelids. Dilatation of the pupil. Clinical. — Cimicifuga is not often required if there has been much tissue change, unless it be to control the pains which arise in the course of the disease, as for instance in occasional cases of ulceration of the cornea in which the pains are sharp, extending through the eye into the head. It may be indicated in asthenopic troubles, as in a case of ac- commodative asthenopia in a myope of one-sixth, with aching in the eyeballs and shooting pains back into the head, aggravated at the menstrual periods. Cured by Cimicif. — J. H. Buffum. In certain forms of ciliary neuralgia its value has been frequently demonstrated. It is indicated by aching pains in the eyeball or in the temples extending to the eyes so severe, especially at night, that in some instances it seems as if the patient would go crazy; also if the pains are sharp or shooting, extending either from the occiput through to the eyes, from the eyes to the occiput or from the eyes to the top of the head; these pains are generally worse on the right side, in the afternoon and at night, and are amelior- ated on lying down. . Macroiin, a resinoid from Cimicifuga, has often been employed in place of the whole drug, especially in ciliary neuralgia. Its action upon the e3^e is very similar to Cimicifuga, and, by some, 528 OPTHAIvMIC THKRAP:EUTICS. it is usually given in preference to the latter. Angell highly reccommends it for hyperaesthesia of the retina. CINA. Pulsation of the superciliary muscles; a kind of convulsion. A slow stitch extending from above the upper orbital margin deep into the brain. Pupils dilated. On rising from the bed all becomes black before the eyes, with dizziness in the head and faintness; he totters to and fro, relieved on lying down. Yellow vision. Optical illusions in bright colors. Clinical.— Cina or Santonine may be of service in strabismus or other ophthalmic disorders depending upon helminthiasis, if the child has a pale, sickly look, with blue rings around the eyes, pain about the umbilicus, boring of the nose, etc. In scrofulous keratitis, in feverish, fretful children, who cry out in sleep. Santonine has been used with favorable results in asthenopia caused by anomalies in refraction. The second decimal potency was employed. — W. H. Woodyatt. CINNABARIS. Subjective. — Inflammation of the eye. Aching soreness of the eyes, worse in the evening. Pain fro7n inner canthus of left eye across eyebrows. Weakness and sleepiness in the eyes about noon; could scarcely keep them open. Di^awiiig sensation from right i7iner canthus across the malar bone to the ear. Shooting pains in inner canthus of right eye, with a burning and itching. Pain from right lachrymal duct around the eye to the temple. Clinical. — This form of mercury is an important remedy in ophthalmic therapeutics, and the indications for its use are gen- erally very clear. In various forms of blepharitis, conjunctivitis and keratitis, even when severe ulceration of the cornea has occurred, it has proved especially serviceable, if accompanied by that characteristic symp- tom of pain above the eye, extending from the internal to the ex- ternal canthus, or a pain which runs around the eye, usually above but sometimes below; this pain may vary greatly in intensity and character, being sometimes sharp, stinging or stitching, at other times dull or aching, and may extend into the eye or up into the head. The photophobia and lachrymation are usually very CLEMATIS. 529 marked as well as the redness. The lids frequently feel so heavy that it is with difficulty they are kept open, especially in the evening. Keratitis parenchymatosa and scleritis, in which there has been more or less pain over the eye, have been benefited by Cinnabar. In iritis and kerato-iritis it is often called for, especially in the syphilitic variety and if gummata are present in the iris. The chief indication will be found in the characteristic pain over the €ye, although, in addition to this, there may be shooting pains through the eye into the head, or soreness along the course of the supra-orbital nerve and corresponding side of the head. The pai7is - York. 1892. Gowers: Medical Ophthalmoscopy. Philadelphia. 1890. Graefe and Ssemisch: Handbuch der gasammten Augenheilkunde. 7 vols. Leipzig. 1880. Haab: Atlas of Ophthalmoscopy New York. 1895. Hartridge: The Ophthalmoscope. London. 1891. Hartridge: Refraction Philadelphia 1892. Holden: Embryology of the Eye. New York. 1893. Jackson: Skiascopy. Philadelphia. 1895. Jeffries: Color Blindness. Boston. 1880. Jennings: Color Vision and Color Blindness. Philadelphia. 1896. Juler: Ophthalmic Science and Practice. London. 1884. Knapp: A Treatise on Intra-ocular Tumors. New York. 1869. Knies: Eye in General Diseases. 1895. Landolt: Refraction and Accommodation of the Eye. Edinburgh. 1886. Landolt and Gygax: Ophthalmological Therapeutics. Philadelphia. 1398. 40 626 BIBLIOGRAPHY. Linnell: The Eye as an aid in General Diagnosis. Philadelphia. 1897. Loring: Text-book Ophthalmoscopy. Parts i and 2. New York. 1886 and 1891. Mackenzie: Diseases of the Bye. Philadelphia. 1855. Macnamara: A Manual of the Diseases of the Eye. Philadelphia. 1876. Maddox: Clinical Use of Prisms. London, 1889. Mauthner: Sympathetic Diseases of the Eye. New York. 1881. Meyer: Diseases of the Eye. Philadelphia. 1887. Morton: Refraction of the Eye. London. 1881. Nettleship: Diseases of the Eye. Philadelphia. 1890. Norris and Oliver: System of Diseases of the Eye. Philadelphia. 1897. Norris and Oliver: Text-book of Ophthalmology. Philadelphia. 1893. Noyes: Diseases of the Eye. New York. 1890. Phillips: Spectacles and Eye-glasses. Philadelphia. 1892. Quain: Anatomy. Vol. III., Pt. III. London. 1894. Ranney: Eye-strain in Health and Disease. Philadelphia 1897. Ranney: Lectures on Nervous Diseases. Philadelphia. 1889. Roosa: Clinical Manual of Diseases of the Eye. New York. 1894. Savage. New Truths in Ophthalmology. Nashville, 1893. Schmidt- Rimpler: Ophthalmology and Ophthalmoscopy. New York. 1889, Smith: Pathology and Treatment of Glaucoma. London. 1891. Stellwag: Treatise on Diseases of the Eye. New York. 1873. Stephenson: Epidemic Ophthalmia. Edinburgh. 1896. Stevens: Functional Nervous Diseases. New York. 1887. Swanzy: Hand-book of Diseases of the Eye. London. 1897. Thorington: Retinoscopy. Philadelphia. 1897. Tiffany: Anomalies of Refraction and of the Muscles of the Eye. Kansas City. 1894, Valk: Lectures on the Errors of Refraction. New York. 1889. Vilas: Diseases of the Eye and Ear. Chicago. 1890. Walker: Students' Aid in Ophthalmology. Philadelphia. 1895. Wells: Diseases of the Eye. Philadelphia. 1883, Wolfe: Diseases and Injuries of the Eye. Philadelphia. 1882, Zander: The Ophthalmoscope. London. 1864. MONOGRAPHS. American Ophthalmological Monographs. Cincinnati. Beitrage zur Pathologie des Auges. Eduard Jaeger. Wein. 1870, Deutschmann: Ophthalmia Ueber die Migratoria, 1889. Lucanus: Ulcus Cornese Serpens, Inaug, Dissert, Marburg, 1882. New York Eye and Ear Infirmary Reports. New York. Ophthalmic Hospital Reports. London. Ophthalmoscopischer Atlas. Dr, Hugo Magnus, Leipzig, 1872. Peltzer: Die Ophthalmia Militaris sive granulosa. Berlin. 1870, Schweigger: Vorlesungen ueber den Gebrauch des Augenspiegels. Berlin. 1864. Societe d' Ophthalmologic, Paris, BIBLIOGRAPHY. 627 Wilbrand: Hemianopsia. Berlin. 1881. Transactions American Homoeopathic Ophthalmological, Otological and Ivaryngological Society. Transactions American Institute of Homoeopathy. Transactions American Medical Association. Ophthalmological Section. Transactions American Ophthalmological Societ}-, Transactions Homoeopathic Medical Society of the State of New York. Transactions International Medical Congress. ( Fifth. ) Transactions International Ophthalmological Congress. Transactions Ophthalmological Societ}^ of the United Kingdom. London. American Year-book of Medicine and Surger\-. Philadelphia. Annales de la Societe Medico-Chirurgicales. DeLiege. Annual of the Universal Medical Sciences. Philadelphia. PERIODICALS. American Journal of Ophthalmolog}-. St. Louis. Annales d' Oculistique. Paris. Annali de Ottalmologie. Pavia, Italy. Annals of Ophthalmology. St. Louis. Archiv fiir Augenheilkunde. Wiesbaden. Archiv fiir Ophthalmologic. Albrecht von Graefe. Berlin. Archives of Ophthalmology. New York. Centralblatt fiir praktische Augenheilkunde. Hirschberg. Leipzig. Homoeopathic E3'e, Ear and Throat Journal. New York. Jahresbericht der Ophthalmologie. Nagel. Tiibingen. Journal of Ophthalmology, Otology and Lar3-ngology. New York. Klinische Monatsblatter fiir Augenheilkunde. Zehender. Stuttgart. Mittheilungen aus der Ophthalmia trischen Klinik in Tiibingen. Ophthalmic Record. Chicago. Ophthalmic Review. London. Recueil d' Ophtalmologie. Paris. Refractionist. Boston. Revue Generale d' Ophtalmologie. Paris. 1890. American Journal of Medical Sciences. Philadelphia. Berliner klinische Wochenschrift, Berlin. British Medical Journal. London. Hahnemannian Monthly. Philadelphia. Homoeopathic Review. London. Journal of Nervous and Mental Disease. New York. Medical Century. Chicago. Medical Era. Chicago. Medical Record. New York. New England Medical Gazette. Boston. New York Medical Journal. New York. North American Journal of Homoeopathy. New York. St. Petersburger Medicinische Wochenschrift. Therapeutische Monatschefte. Berlin. LIST OF ILLUSTRATIONS. Fig. Page 1. Method of examining the eye in children, 19 2. Method of oblique illumination, 20 3. Method of determining the tension, 22 4. Skeele's perimeter, 25 5. Loring's ophthalmoscope, 28 6. Ophthalmoscopic examination by the indirect method, 30 7. Ophthalmoscopic examination by the direct method, 31 8. Schematic eye showing cardinal points, 35 9. Changes in the lens during accommodation, 36 10. The metre angle, 38 11. Schematic eye showing the angle alpha and the angle gamma, . . 40 12. Diffusion circles formed on the retina of hypermetropic eye, ... 42 13. Far point of hypermetropic eye, 43 14. Correction of hypermetropia by a convex lens, 43 15. Diffusion circles formed on the retina of myopic eye, 46 16. Far point of a myopic eye, 47 17. Correction of myopia by a concave lens, 47 18. Refraction of the rays in regular astigmatism, 51 19. Range of accommodation at different ages, ... 56 20. The visual angle, . . 59 21. Wallace's astigmatic chart, 63 22. Helf rich's changeable test-type, €6 23. De Zeng's refractometer, 68 24. Type for testing the accommodation, 70 25. Correct position for retinoscopy, 74 26. Movement of the light area on the retina with the plane mirror, . . 74 27. Movement of the light area on the retina with the concave mirror, 75 28. The point of reversal of a myopic eye, .... 76 29. Javal and Schiotz ophthalmometer, 79 30. Section through upper eyelid, .... 103 31. Wecker's operation for ptosis, 117 32. Wecker's operation for ptosis (completed), 117 33. Symblepharon, 119 34. Epilation forceps, 120 35. Arlt's operation for trichiasis, .... 121 36. Knapp's entropium forceps, . . , 122 37. Wharton Jones' operation, 124 38. Wharton Jones' operation (completed), .... 124 630 LIST OF ILLUSTRATIONS. 39. Dieffenbach's operation, 125 40. Dieffenbach's operation (completed), 125 41. Large chalazion of the upper lid, 127 42. Dissection of the lachrymal apparatus, .... ....132 43. Agnew's canalicula knife, 134 44. Norton's modification of Stilling's knife for stricture of the lachry- mal passage, 136 45. Bowman's set of probes, 136 46. Agnew's lachrymal syringe, . 137 47. Axes of ocular muscles, 153 48. Lawrence's strabismometer, 166 49. Mittendorf's speculum, 170 50. Fixation forceps, .... 170 51. Strabismus hook 170 52. Steven's hook, 170 53. Blunt pointed curved strabismus scisssors, . . , 170 54. Blunt pointed straight scissiors, 172 55. Operation of advancement, 173 56. Steven's phorometer, 176 57. The Harold Wilson phorometer, . . . . 179 58. Everted granular lids, . 205 59. Johnson's grattage knife, 209 60. Knapp's roller forceps, 209 61. Conjunctivitis phlyctenularis, • . 211 62. Pterygium, 227 63. Vertical section through anterior part of the globe, 243 64. Malarial keratitis (Kipp), 259 65. Diagrammatic representation of the ocular vessels, . .~ 284 66. Posterior synechiae, 288 67. Angular keratome, 306 68. Straight keratome, 306 69. Curved iris forceps, 306 70. Straight iris forceps, 306 71. Curved iris scissors, . " 306 72. Iridectomy — the incision, 307 73. Iridectomy — cutting the iris, .... 308 74. A section through the ciliary region, 310 75. Choroido-retinitis, 335 76. Diagram showing minute anatomical structure of retina, 355 77. Scheme of the central visual apparatus, . . 388 78. Diagram illustrating the visual path and its relation to the visual field, 417 79. Bowman's stop needle, 444 80. Knapp's scalpel needle, . . 445 81. The needle operation, 445 82. Graefe's linear knife, 44^ 83. Norton's cataract knife, 44^ I^IST OF II,I,USTRATI0NS. 63 1 84. Knapp's cystotome, 448 85. Hard rubber lens spoon, 448 86. Fenestrated lens spoon, . 448 87. Cataract extraction — the incision, 449 88. Cataract extraction — the removal of the lens, 451 89. Section through the ciliary region, 461 90. Parenteau's sclerotomy knife, 479 CHROMO-LITHOGRAPHS. DESCRIPTION ON PAGE Plate I., Figure i. — Chalazion, 126 " I., " 2. — Iritis, 287 " I , " 3. — Follicular Conjunctivitis, 203 " I, " 4. — Conjunctivitis Trachomatosa et Pan nus, 205 " I., " 5. — Hypopyon Keratitis, 255 " I., " 6. — Keratitis Parenchymatosa, 264 " II., " r. — Normal Fundus Oculi, 32-^57 " II., " 2. — Physiological Cupping of the Optic Disc, .... 32 " II., " 3. — Posterior Staphyloma, 344 " II., " 4. — Choroiditis Disseminata Simplex, 332 " II., " 5. — Retinitis Pigmentosa, 374 " II., '• 6. — Retinitis Albuminurica, 363 " III, " I, — Retinitis Hsemorrhagica, 368 ." III., " 2. — Detachment of Retina, .... 376 " III., " 3. — Neuro-Retinitis, 395 " III., " 4. — Opaque Nerve Fibres, 390 " III., " 5. — Atrophy of the Optic Nerve, . , . _ 401 " HI., " 6. — Glaucoma, 467 PLATE r'"^. '>-■* ^C'-^ y PLATEJI, PLATE. IK. INDEX. Abdominal growths, 94 Ablatio retinse, 375 Abscess of cornea. 261 of lids, 113 of orbit, 142 Abscission of staphyloma, 271 Acetic acid, 485 Accommodation, amplitude of, 37 relative amplitude of, 39 mechanism of, 36 paralysis of, 314 range of, 37, 56 spasm of, 316 Accommodation and Convergence associated, 39 Acne, of lids, 113 Aconite, 485 Addison's disease, 94 Advancement operation, 172 Agaricus, 487 Albinism, 347 Albuminuria, 94 Alcoholism, 94 Allium cepa, 489 Alumen exsic, 490 Alumina, 490 Amaurosis, 408 Amblyopia, 408 ex anopsia, 408 central, 397 from loss of blood, 409 hysterical, 410 from lightning, 409 Pretended, 410 traumatic, 409 Ammonium carb., 491 Amotio retinae, 375 Amplitude of accommodation, 37 Amyl nitrite, 491 Amyloid degeneration of conjunc- tiva, 225 Anaemia, (cerebral), 94 constitutional, 94 of retina, 379 Aneurism, of aorta, 94 of arteria innominata, 94 of internal carotid, 94 of orbital artery, 94 Angle alpha, 39 gamma, 39 Aniridia, 305 Anisometropia, 55 Ankyloblepharon, 119 Anterior chamber, exam, of, 22 Antimonium crudum, 491 Antimonium tart., 492 Aphakia, 44, 457 Apis mel., 492 Apoplexy, 94 of corona radiata, 94 of cortex, 94 of crus, 94 of pons varolii, 94 of pons, 94 of ventricles, 94 Arcus senilis, 269 Argentum met., 494 Argentum nit., 494 Argyll-Robertson pupil, 22 Arlt's operation for trichiasis, 121 Arnica, 497 Arsenicum, 498 Artificial eyes, 272 Arum triph., 501 Asafoetida, 501 Asarum, 501 634 INDEX. Asthenic ulcer, 258 Asthenopia, muscular, 175 Astigmatism, 51 compound hyperopic, 51 compound myopic, 51 hyperopic, 51 irregular, 51, 54 mixed, 51 myopic, 51 regular, 51 test for, 62 by skiascopy, 78 by ophthalmometer, 79 Astigmia, 51 Atheroma, 95 Atrophy of optic nerve, 400 progressive muscular, 95 Atropine, 65, 501 Aurum, 503 Axial neuritis, 397 Badiago, 505 Baryta carb., 506 Baryta iod., 506 Basedow's disease, 95, 148 Belladonna, 506 Binocular diplopia, 155 vision, 38 Birnbacher's operation, 117 Blepharitis, 104 Blepharophimosis, T18 Blepharospasm, 117 Brain, abscess of, 95 basilar affections of, 95 cerebral cortical affections, 95 cerebral affections, -95 cerebellum, affections of, 95 concussion of, 95 hypersemia of, 95 tumor of, 95 Bromium, 510 Bryonia, 510 Buphthalmus, 274-281 Burns of conjunctiva, 231 of eyelids, 131 Cactus grand., 512 Calcarea carb., 512 Calcarea hypophos. , 515 Calcarea iod., 515 Calcarea phos., 516 Calcarea pic, 516 Calendula, 517 Canaliculi, anomalies of, 134 Cannabis sativa, 517 Cantharis, 519 Carbo vegetabilis, 519 Carbolic acid, 519 Cardinal points, 36 Caries of orbit, 145 Cataract, 429 anterior polar, 435 capsular, 437 complete congenital, 433 extraction, 446 operation, 442 with iridectomy, 448 lamellar, 434 posterior polar, 436 pyramidal, 435 secondary, 437 traumatic, 436 varieties, 431 zonular, 434 Causticum, 520 Ceanothus amer., 522 Cedron, 522 Cellulitis orbitse, 142 Central amblyopia, 397 Chalazion, 126 Chamomilla, 523 Chancre of eyelids, 130 Chelidonium majus, 524 Chimaphila umbellata, 524 China, 525 Chininum mur., 525 Chininum sulph., 525 Chloralum, 526 Choked disc, 392 Cholera, 95 Choroid, diseases of, 327 anatomy of, 327 coloboma, 352 detachment of, 351 haemorrhages in, 350 hypersemia of, 328 INDEX. t>35 ossification of, 349 in panophthalmitis. 339 rupture of, 351 senile changes of, 347 tumors of, 347 Choroiditis, 328 areolaris, 334 • circumscripta, 333 disseminata simplex, 330 metastatica, 339 serosa, 329 suppurativa, 339 syphilitica, 334 traumatic purulent, 339 Choroido-retinitis centralis, 333 sclerotico-choroiditis anterior, 343 sclerotico-choroiditis posterior, 343 Chrysophanic acid, 526 Cicuta virosa, 526 Ciliary body, 310 anatomy of, 310 injuries of, 314 irido-choroiditis, 317 paresis musculi ciliaris, 314 spasmus musculi ciliaris, 316 Cimicifuga, 527 Cina, 528 Cinnabaris, 528 Clematis, 529 Cocculus indicus, 529 Colchicum, 530 Coloboma, of choroid, 352 iridis, 305 optic nerve sheath, 391 Colocynthis, 530 Color-blindness, 412 Coma, alcoholic, 95 ursemic, 95 syphilitic, 96 Commotio retinae, 383 Comocladia, 530 Conium maculatum, 530 Conjunctiva, 191 amyloid degeneration of, 225 anatomy of, 191 angioma of, 233 burns, 231 carcinoma of, 234 chemical injuries, 231 cysticercus, 234 cysts of, 233 dermoid tumor of, 232 emphysema sub-conjunctival, 230 epithelioma of, 233 examination of, 19 fibroma of, 233 fleshy excrescences of, 233 foreign bodies, 231 gummata, 234 hyperaemia of, 191 lesions of, 231 lipoma of, 232 lupus of, 234 melano-sarcoma of, 233 osteoma of, 233 ophthalmia neonatorum , 1 95- 1 97 pemphigus of, 225 Pinguecula of, 232 pterygium of, 227 pigment spots of, 233 sarcoma of, 233 sub-conjunctival ecchymosis, 228 syphilitic ulcerations of, 234 trachoma, 204 papillar}', 208 tuberculosis of, 230 tumors of, 232 erectile, 233 vascular, 233 wounds, 23 1 xerosis of, 226 Conjunctivitis, blennor.hoea, 195 catarrhalis, 192 crouposa, 201 diphtheiitica, 200 follicularis, 203 gonorrhoica, 195-197 herpetic, 214 membranacea, 201 phlyctenularis, 211 purulenta, 195 636 INDEX. pustular, 211 scrofulous, 211 strumous, 211 trachomatosa, 204 vernalis, 224 Contusions of eyelids, 130 Convergence, 38 relative amplitude of, 39 test for, 69 Corelysis, 309 Cornea, 235 abscessus 261 anatomy of, 235 arcus senilis, 269 buphthalmos, 274, 281 conica, 273 descemetitis, 263 eczema of, 237 examination of, 20 Felchenfeld's operation, 248 gerontoxon, 269 globular, 274 herpes, 240 hypopyon keratitis, 243, 255 inflammation of, 236 injuries of cornea, 275 keratitis, bullosa, 260 dendritica, 259 diffusa, 264 fascicularis, 239 furrow, 256 interstitialis, 264 malarial, 259 mycotic, 259 neuro-paralytica, 260 pannosa, 239 parenchymalosa, 264. phlyctenularis, 237 posterior, 263 profunda, 264 punctata, 263 pustular, 237 scrofulous, 237 strumous, 237 syphilitica, 264 vesiculosa, 240 keratocele, 242 keratoconus, 273 keratoglobus, 274 leucoma of, 268 leucoma adherens, 245 macula of, 268 nebula of, 268 onyx, 243 opacities of, 268 pannus, 239 paracentesis. 247 sclerosis of, 269 staphyloma of, 270 abscission of, 271 Saemisch's incision, 247-257 tattooing of, 270 tumors of, 276 ulcus corneae, 241 ulcer, asorption, 258 asthenic, 258 clear, 258 infecting, 255 marginal ring, 259 non-inflammatory, 258 rodent, 258 serpiginous, 255 wounds of, 275 Corneal abrasions, fluorescin in, 20 Crocus sativus, 532 - Crotalus horridus, 533 Croton tiglium, 534 Crystalline lens, 428 Cyclamen, 535 Cycloplegics, 64 Cyclitis, 312, 327 plastica, 312 purulenta, 313 serosa, 313 Cysticercus in vitreous, 426 Cundurango, 534 Cuprum aceticum, 535 Cuprum alum., 535 Cuprum sulph., 535 Dacryoadenitis, 133 Dacryocystitis, catarrhalis, 135 phlegmonosa, 139 Dazzling of retina, 361 Death, signs of, 96 INDEX. 637 Decentering of lenses, 82 Dental affections, 96 Dermoid cysts of eyelids, 126 Descemetitis, 263 Detachment, of choroid, 351 of retina, 375 of vitreous, 426 De Zeng's refractometer, 67 Diabetes, 96 Dieffenbach's operation for ectropi- um, 124 Digestion, disorders of, 96 Digitalis, 535 Dilatation of the pupil, 21 Dioptometry, objective, 59, 71 subjective, 59 Diphtheria, 96 Diplopia, monocular, 155 heteronymous, 155 homonymous, 155 binocular, 155 Dislocation of lens, 45S Distichiasis, 120 Duboisia, 536 Duboisine. 65 Dynamic refraction, 36 Ectopia lentis, 458 Ectropium, 105, 123 Eczema corneae, 237 Electricity, 538 Embolus of arteria centralis retinae, 379 Embolism, cerebral, 96 Encephaloid of retina, 384 Entropium, 121 Enucleation of eye, 271 Epicanthus, 120 Epilepsy, 96 Episcleritis, 277 Eserine, 541 Esophoria, 175-180-185 Eupatorium perfoliatum, 542 Euphrasia, 542 Eversbusch's operation, 117 Evisceration of eye, 272 Examination, of the eye, 17 of field of vision, 23 by focal illumination, 20 oblique illumination, 20 of tension, 22 of the outer structures 18 Exenteration of eye, 272 Exophthalmic goitre, 95, 148 Exophoria, 175-180-186 Eyelids, 102 abscess of, 113 acne, 113 anatomy, 102 ankyloblepharon, 119 blepharitis, 104 ciliaris, 104 hypertrophic, 104 marginalis, 104 seborrhoea, 104 simplex, 104 squamosa, 104 ulcerosa, 104 blepharo-adenitis, 104 blepharophimosis, 118 blepharospasm, 117 burns, 131 canthoplasty, 246 chalazion, 126 chancre, 130 contusions, 180 dermoid cyst, 126 distichiasis, 120 ectropium, 105, 123. entropium, 121 epicanthus, 120 epithelioma, 128 furuncle of, 113 gummata, 130 herpes zoster ophthalmicus, 130 hordeolum, 113 lagophthalmos, 120 lippitudo, 105 lupus, 129 madarosis, 105 meibomian cyst, 126 milium, 126 molluscum contagiosum, 125 nsevi, 126 nictitatio, 118 638 INDKX. i papillomata, 126 phlegmon of, 113 phthiriasis ciliarum, 105 ptosis, 115 sarcoma, 129 scalds, 131 stye, 113 symblepharon, 118 syphilitic ulcers, 130 tarsal cyst, 126 trichiasis, 105, 120 warts, 126 wounds, 131 xanthelasma, 125 Far point, 37 Ferrum, 544 Ferrum phos., 545 Fever, puerperal, 96 typhoid, 96 relapsing, 96 Field of vision, 23 Fistula lachrymalis, 140 Fifth nerve, affection of, 96 Fluorescin in corneal abrasions, 20 Fluoric acid, 545 Focal illumination, 20 Foreign bodies in vitreous, 424 Fourth ventricle, lesions in, 96 Friedreich's disease, 96 Frontal sinus, empyema of, 146 Fundus, as seen by ophthalmoscope, 32 Fungus haematodes, 384 Galvanism, 538 Gelsemium, 545 Gerontoxou, 269 Glaucoma, 460 absolutum, 477 acuta, 473 anatomy, 460 causes, 468 chronica, 475 consecutiva, 477 course, 468 diagnosis, 472 hsemorrhagica, 476 pathology, 463 physiology, 462 simplex, 475 symptoms, 464 treatment, 478 varieties, 473 Glioma of retina, 384 Globular cornea, 274 Gout, 96 Graphites, 548 Grapho-vaseline, 107 Graves' disease, 148 Green's operation for entropium, 122 Gummata of eyelids, 130 Hamamelis virginica, 550 Haemorrhages, in choroid, 350 of optic nerve, 392 into retina, 367 into vitreous, 424 Heart, aortic insufficiency, 96 endocarditis, 97 organic affections of, 97 hypertrophy of left ventricle, 97 valvular lesions of, 97 Helminthiasis, 97 Hemeralopia, 411 Hemianopia, 415 Hemianopsia, 415 Hemiopia, 415 Hepatic affections, 97 Hepar sulphur, 551 Herpes corneae, 240 zoster ophthalmicus, 130 Heterophoria, 175 Heteronymous diplopia, 155 Heterochroma, 305 Hippus, 21, 304 Homatropine, 65 Homonymous diplopia, 155 Hordeolum, 113 Horopter, 154 Hyalitis suppurativa, 420 Hydraemia, 97 Hydrops of anterior chamber, 274 Hydrocotyle, 553 Hydrocephalus 97 Hygiene, of the eye, 84 school, 85 INDEX. 639 Hyoscyamine, 65 Hypsemia, 304 Hyperaemia, of the choroid, 328 iridis, 285 of retina, 358 of the disc, 391 Hypercesthesia of retina, 382 Hyperesophoria, 175 H3-perexophoria, 175 Hypericum, 554 Hypermetropia, 42 Hyperphoria, 42-175-179-185 Hyperopia, absolute, 45 axial, 44 causes, 44 correction of, 45 curvature, 44 facultative, 45 latent, 44 manifest, 44 test for, 61 by skiascopy, 77 total, 44 symptoms, 44 relative, 45 Hypopyon keratitis, 243-255 Hysteria, 97 Ignatia, 554 Injuries, of ciliary region, 314 of cornea, 275 of optic nerve, 405 of orbit, 147 of sclera, 281 Insanity, 97 Ipecacuanha, 555 Iridavulsion, 309 Iridectomy, 305 Iridersemia, 305 Irido-choroiditis, 317 Irido-cyclitis, 317 Iridodesis, 309 Iridodialysis, 304, 309 Iridodonesis, 304 Iridoncosis, 304 Iridotomy, 308 Iris, 283 anatomy, 283 aniridia, 305 coloboma of, 305 corectopia, 305 corelysis, 309 diplokoria, 305 examination of, 21 heterochroma, 305 hippus, 304 hyphemia, 304 hyperaemia of , 2S5 iridavulsion, 309 iridectomy, 305 irideraemia, 305 iridodesis, 309 iridodialysis, 304, 309 iridodonesis, 304 iridoncosis, 304 iridotomy, 308 membrana pupillaris persistans, 305 mydriasis, 302 myosis, 303 operations on, 305 physiology, 285 polycoria, 305 tumors, 301 Iritis, 286 parench^-matosa, 293 purulent, 293 rheumatica, 192 serous, 293 spongiosa, 292 suppurativa, 293 syphilitic, 292 traumatic, 293 Iritomy, 308 Ischsemia of retina, 379 Jaborandi, 556 Jones's operation for ectropium, 124 Kali bichrom,, 558 Kali carb., 559 Kaliiod., 559 Kali mur,, 561 Kalmia latifolia, 562 Keratitis, bullosa, 260 dendritica, 259 fascicularis, 239 640 INDEX. neuro-paralytica, 260 pannosa, 239 parenchymatosa, 264 phlyctenularis, 237 pustular, 237 scrofulous, 237 strumous, 237 vesiculosa, 240 Keratocele, 242 Keratoconus, 273 Keratoglobus, 274 Kidney, diseases of, 97 Kreosotum, 563 Lachesis, 563 Lachrymal apparatus, 132 anatomy, 132 anomalies of puncta, 134 canaliculi, 134 dacryoadenitis, 133 dacryocystitis catarrhalis, 135 phlegmonous, 139 duct, stricture of, 135 fistula, 140 gland, hypertrophy of, 134 gland, hypertrophy of, 134 gland, tumors of, 134 puncta, examination of 19 sac, examination of, 19 Lactic acid, 564 Lagophthalmos, 120 Ledum palustre, 564 Leucoma adherens, 245 of cornea, 268 Lens, anatomy of, 428 dislocation of, 458 ectopia lentis, 458 examination of, 22 luxatio lentis, 458 Lenses, bifocal, 83 concave, 81 convex, 81 cylindrical, 81 decentered, 82 Leprosy, 97 Lids, 102 Lilium tigrinum, 565 Lippitudo, 105 Lithium carb., 565 Luxatio lentis, 458 Lung, disease of, apex, 97 Lupus of eyelids, 129 Lycopodium, 565 Lvcopus virginicus, 566 Macula of cornea, 268 Madarosis, 105 Maddox test, 177 Malaria, 97 Malingering, 410 Mania, 97 Marginal ring ulcer, 259 Masturbation, 97 Meibomian cyst, 126 Melancholia, 97 Membrana pupillaris persistans, 305 Meningeal haemorrhage, 9S Meningitis, cerebral, acute, 98 chronic, 98 cerebro-spinal, 98 of the convexity, 98 spinal, 98 tubercular 98 Menstruation, disorders of, 98 Mercurialis perennis, 567 Mercurius corrosivus, 567 Mercurius dulcis, 569 Mercurius iodatus flavus, 570 Mercurius iodatus ruber, 571 Mercurius nitrosus, 572 Mercurius prsecipitatus flavus, 572. Mercurius praecipitatus ruber, 573 Mercurius solubis, 573 Metre angle, 39 Mezereum, 576 Milium, 126 MoUuscum contagiosUm, 125 Monocular diplopia, 155 Morbus Basedowii, 148 Muriaticum acidum, 576 Muscse volitantes, 422 Muscles, ocular, 152 paralysis of, 155 Muscular asthenopia, 175 Musculi ciliaris, paresis of, 314 spasm of, 316 i INDEX. 641 Mydriasis, 302 Myelitis, acute and chronic, 98 Myodesopsia, 422 Myopia, 46 axial, 41 causes, 48 curvature, 48 symptoms, 49 test for, 62 by skiascopy, 77 treatment, 49 Myosis, 303 Myxcedema, 98 N8e\-i of eyelids, 126 Xaphthalin, 577 Natrum carb., 577 Natrum mur., 577 Nattum salic, 580 Natrum su'ph,, 580 Near point, 37 Nebula of cornea, 268 Necrosis of orbit, 145 Nephritis, 98 Neuralgia of the fifth nerve, 98 Neuritis, multiple or pseudo-tabes, 98 optica, 392 retro-bulbaris, 397 Nicotine poisoning, 98 Nictitatio, 118 Nightblindness, 411 Nitricum aciduni, 581 Nux moschata, 582 Nux vomica, 582 Nyctalopia, 411 Nystagmus, 173 Oblique illumination, 20 Ocular muscles, 152 anatomy of 152 asthenopia, 175 diplopia, 155 esophoria, 175-1 80-1 85 exophoria, 175-180-1S6 heterophoria, 175 hyperesophoria, 175 hyperexophoria, 175 hyperphoria, 1 75-179-185 nystagmus, 173 orthophoria, 175 ophthalmoplegia, 157 oscillation of eyeball, 173 paralyses, localizing value in cerebral disease, 162 paralysis of, 155 external rectus, 158 fifth nerve, 163 fourth nerve, 162, inferior oblique, 159 inferior rectus, 159 internal rectus, 158 sixth nerve, 163 superior oblique, 158 superior rectus, 159 third nerve, complete, 159- 162 strabismus, 163 squint, 163 convergens, 164 dorsum vergens, 168 divergens, 167 sursuni vergens, 168 CEdema of retina, 358 Onosmodium, 584 Onyx, 243 Opacitates vitrei, 422 Opacities of cornea, 268 Opaque nerve fibres, 390 Operations, abscission of staphyloma, 271 advancement, 172 Arlt's trichiasis, 121 Birnbacher's ptosis, 117 canthoplasty, 246 cataract extraction, 446 corelysis, 309 Dieffenbach's extropium, 124 discission, 444 enucleation of eye, 271 Everbusch's ptosis, 117 evisceration of eye, 272 exenteration of eye, 272 Felchenfeld's, 248 Forsters, 443 graduated tenotomy, 184 642 INDEX. Green's entropium, 122 iridectomy, 305 iridodialysis, 309 iridototny, 308 iridodesis, 309 iridavulsion, 309 iritomy, 308 Jones' ectropium, 124 neurectomy, optico-ciliary, 325 Pagenstecher's ptosis, 116 Panas' ptosis, 117 paracentesis, 247 roller forceps, 209 Saemisch's incision, 247, 257 sclerotomy, 479 Stevens' advancement, 184 Streatfeild's entropium, 123 subconjunctival, 171 tattooing of cornea, 270 tenotomy of internal rectus, 169 Wecker's abscission, 271 ptosis, 116 Wolff's ptosis, 117 Ophthalmia, migratoria, 324 neonatorum, 195-197. Ophthalmo-dynamometer, 69 Ophthalmometr}^, 79 Ophthalmoplegia, externa, 157 interna, 157 totalis, 157 Ophthalmoscope, use of, 27 Optical center of lenses, 82 Opium, 585 Optic nerve, 387 anatomy of, 387 axial neuritis, 367 atrophy of, 400 central amblyopia, 397 choked disc, 392 coloboma of sheath, 391 haemorrhage of, 392 hyperaemia of disc, 391 injury of, 405 neuritis optica, 392 neuritis retro-bulbaris, 397 opaque nerve fibre, 390 orbital optic neuritis, 397 papillitis, 392 toxic amblyopia, 397 tumors of, 405 Orbit, 141 abscess of, 142 anatomy of, 141 caries of, 145 cellulitis of, 142 empyema of frontal sinus, 146 exophthalmic goitre, 148 froatal sinus, empyema of, 146 Graves' disease, 148 injuries of, 147 morbus Basedowii, 148 necrosis of, 145 periostitis of, 144 phlegmon of, 142 tenonitis, 144 tumors of, 146 wounds of, 147 Orbital optic neuritis, 397 Orthophoria, 175 Ossification of choroid, 349 Pagenstecher's operation, 116 Panas' operation, 117 Pannus, 239 Papillitis, 392 Papillo-retinitis, 361^ Papillomata of eyelids, 126 Paralyses of orbital muscles in cere- bral disease, localizing value, 162 Paralysis, agitans, 98 conjugate, 157 of external rectus, 158 of fifth nerve, 163 of fourth nerve, 162 general (paralysis of insane) paresis, 98 of inferior oblique, 159 of inferior rectus, 159 of internal rectus, 158 of ocular muscles, 155 of sixth nerve, 163 of superior oblique, 158 of superior rectus, 159 of third nerve, 159, 162 INDEX. 643 Paresis, 98 Paris quadrifolia, 586 Pemphigus conjuiictiv?e, 225 Periostitis orbitse, 144 Persistent hyaloid artery, 426 Petroleum, 587 Phlegmon of orbit, 142 Phosphoricum acidum, 587 Phosphorus, 588 Phthiriasis ciliarum, 105 Physostigma, 589 Phytolacca decandra, 591 Pinguecula, 232 Plantago major, 592 Polio encephalitis superior, 99 Pons varolii, lesions of, 99 Posterior staphyloma, 49 Presbyopia, 55 test for, 70 Proptosis, 22 Prunus spinosa, 592 Psorinum, 593 Pterygium, 227 Ptosis, 115 Pulsatilla, 593 Puncta, anomalies of, 134 Punctum, proximum, 37 remotum, 37 Pupil, contraction of, 21 dilatation of, 21 Pyaemia, 99 Pyoktanin, 137 Rachitis, 99 Range of accommodation, 37 Ranunculus bulbosus, 597 Refrac. and accommodation, 35 Refrac. and accom., abnormalities, 42 Refraction, dynamic, 36 estimation of by direct method, 71 by indirect method, 73 static, 36 Refractometer, 67 Relative amplitude of accom., 39 amplitude of convergence, 39 Remedies: Acetic acid, 485 Aconite, 485 Agaricus, 487 Allium cepa, 489 Alumen exsic, 490 Alumina, 490 Ammonium carb., 491 Amyl nitrite, 491 Antimonium crudum, 491 Antimonium tart., 492 Apis mel., 492 Argentum met., 494 Argentum nit., 494 Arnica, 497 Arsenicum, 498 Arum triph., 501 Asafoetida, 501 Asarum, 501 Atropine, 501 Aurum, 503 Badiago, 505 Baryta carb., 506 Baryta iod., 506 Belladonna, 506 Bromium, 510 Bryonia, 510 Cactus grand., 512 Calcarea carb., 512 Calcarea hypophosph., 515 Calcarea iod., 515 Calcarea phos. , 516 Calcarea pic, 516 Calendula, 517 Cannabis sativa, 517 Cantharis, 519 Carbo vegetabilis, 519 Carbolic acid, 519 Causticum, 520 Ceanothus amer., 522 Cedron, 522 Chamomilla, 523 Chelidonium majus, 524 Chimaphila umbellata, 524 China, 525 Chininum mur., 525 Chininum sulph., 525 Chloralum, 526 Chrysophanic acid, 526 644 INDEX, Cicuta virosa, 526 Cimicifuga, 527 Cina, 528 Cinnabaris, 528 Clematis, 529 Cocculus indiciis, 529 Colchicnni, 530 Colocynthis, 530 Comocladia, 530 Conium maculatum, 530 Crocus sativus, 532 Crotalushorridus, 533 Crotoii tiglium, 534 Cundurango, 534 Cuprum aceticum, 535 Cuprum alum., 535 Cuprum sulph,, 535 Cyclameu, 535 Digitalis, 535 Duboisia, 536 Electricity, 538 Eserine, 541 Eupatorium per., 542 Euphrasia, 542 P'errum, 544 Ferrum phos., 545 Fluoric acid, 545 Galvanism, 538 Gelsemium, 545 Graphites, 548 Hamamelis virginica, 550 Hepar sulphur, 551 Hydrocotyle, 553 Hyoscyamus, 554 Hypericum, 554 Ignatia, 554 Ipecacuanha, 555 Jaborandi, 556 Kali bichrom., 558 Kali carb., 559 Kali iod., 559 Kali mur., 561 Kalmia latifolia, 562 Kreosotum, 563 Lachesis, 563 Eactic acid, 564 Ledum palustre, 564 Lilium tigrinum, 565 Lithium carb., 565 L3^copodium, 565 Lycopus virginiciis, 566 Mercurialis perennis, 567 Mercurius corrosivus, 567 Mercurius dulcis, 569 Mercurius iodatus flavus, 570 Mercurius iodatus ruber, 571 Mercurius nitrosus, 572 Mercurius prsecipitatsus flavus, 572 Mercurius pracipitatus ruber, 573 Mercurius solubis, 573 Mezereum, 576 Muriaticum acidum, 575 Naphthalin, 577 Natrum carb., 577 Natrum mur., 577 Natrum salic, 580 Natrum sulph. , 580 Nitricum acidum, 581 Nux moschata, 582 Nux vomica, 582 Onosmodium virg., 584 Opium, 585 Paris quadrifolia, 586 Petroleum, 587 Phosphoricum acidum, 587 Phosphorus, 588 Physostigma, 589 Phytolacca decandra, 591 Plantago major, 592 Prunus spinosa, 592 Psorinum, 593 Pulsatilla, 593 Ranunculus bulbosus, 597 Rhododendron, 598 Rhus toxicodendron, 598 Ruta graveolens, 602 Sanguinaria, 603 Secale cornutum, 603 Senega, 603 Sepia, 604 Silicea, 607 Spigelia, 608 Spongia, 611 INDEX. 645 Stannum, 611 Staphysagria, 612 Sulphur, 612 Syphilinum, 618 Tabacum, 618 Tellurium, 618 Terebinthina, 618 Thuja, 619 Veratrum viride, 621 Zincum, 622 Renal retinitis, 361 Retina, diseases of, 354 ablatio retinae, 375 amotio retinse, 375 anatomy of, 354 anaemia of, 379 commotio retinae, 383 dazzlinsT of, 361 detachment of, 375 embolus of arteria centralis ret- inse, 379 encephaloid of, 384 fungus haematodes, 384 glioma, 384 hyperaemia of, 358 hyperaesthesia of, 382 ischaemia, 379 oedema of, 358 thrombosis of vena centralis, 381 Retinitis, albuminurica, 361 apoplectica, 367 of Bright's disease, 361 central punctate, 372 diabetica, 366 diffusa, 358 glycosurica, 366 haemmorrhagica, 367 leukaemica, 366 papillo, 361 pigmentosa, 373 proliferan, 372 punctata albescens, 372 renal, 361 serosa, 358 simplex, 358 splenic, 366 syphilitica, 370 Retinoscopy, 73 Rheumatism, 99 Rhododendron, 598 Rhus toxicodendron, 598 Rupture of choroid, 351 Ruta graveolens, 602 Sanguinaria, 603 Sarcoma of eyelids, 129 vSavage test, 178 Scalds of eyelids, 131 School, buildings, construction of, 89 examination of eyes, on entrance of, 87 furniture, 91 hygiene, 85 Sclera, 277 anatomy of, 277 episcleritis, 277 injuries of, 281 scleritis, 278 sclerotitis, 278 sclerotico-choroiditis anterior, 280, 281, 343 posterior, 281, 343 staphyloma annular, 281 sclerae, 280 Sclerosis multiple, 99 Sclerectasia posterior, 340 Scopolamine, 65 Scotomata, 23 Scrofula, 99 Secale cornutum, 603 Senega, 603 Sepia, 604 Shadow test, 73 Silicea, 607 Skiascopy, 73 Skin, extensive burns of, 99 Snake poisoning, 99 Snow blindness, 412 Spigelia, 608 Spinal cord, degenerative diseases of, 99 inflammation and congestion of, 99 Spinal irritation, 99 Splenic retinitis, 366 646 INDEX. Spongia, 611 Squint, 163 Stannum, 611 Staphyloma, cornese, 270 posterior, 343 sclerse, 280 Staphysagria, 612 Steven's phoronieter, 175 Strabismus, 163 convergens, 164 deorsum vergens, 168 divergens, 167 operation for, 169 sursum vergens, 168 Streatfield's operation for entro- pium, 123 Strictura ductus lachrymalis, 135 Sturm's focal interval, 52 Stye, 113 Sub-conjunctival ecchymosis, 228 emphysema, 230 Sulphur, 612 Symblepharon, 118 Sympathetic irritation, 321 ophthalmia, 321 Synchysis, 422 scintillans, 422 Syphilinum, 618 Syphilis, 99 Syphilitic ulcers of eyelids, 130 Tabacum, 618 Tabes, 100 Tabulated statement of diseases, with eye symptoms, 94 Tarsal cyst, 126 Tattooing of cornea, 270 Tellurium, 618 Tenonitis, 144 Tenon's capsule, 141 Tenotomy of internal rectus, 169 Tension of eye, 22 Terebinthina, 618 Test-type, Helfrich's, 66 Thrombosis of vena centralis, 381 Thuja, 619 Toxic amblyopia, 397 Trachoma, 204 Trachoma, papillary, 204 Trichiasis, 105, 120 Trichinosis, 100 Tuberculosis, loi Tuberculosis conjunctivae, 230 Tumors, of choroid, 347 of conjunctiva, 232 of cornea, 276 of iris, 301 arbitse, 146 of the optic nerve, 405 Typhoid fever, loi Ursemia, 101 Ulcer, astlienic, 258 absorption, 258 clear ulcer, 258 corneal, 241 infecting, 255 marginal ring, 259 non-inflammatory, 258 rod.nit, 253 serpiginous, 2^5 Urticaria. lor Uterine aTections, loi Veratrum viride, 621 Vitreous bod}-, 420 anatomy of, 420 cy>ticircas in, 426 detachment of, 426 foreign bodies in, 424 hsemorrh.-ge into, 424 hyalitis suppurativa, 420 muscse volitantes, 422 myodesopsia, 422 opacitates vitrei, 422 persistent hyaloid artery, 426 synchysis, 422 scintillans, 422 Visual angle, 59 Visual field, 23 Vision, acuteness of, 60 Warts of eyelids, 126 Wecker's operation, 116 Wilson's phorometer, 179 Wolff's operation, 117 Wounds, of conjunctiva, 231 cornea, 275 INDEX. 647 eyelids, 131 I Xerosis conjunctivae, 226 orbit, 147 Yellow oxide ointment, 107 Xanthelasma, 125 Zincum, 622 '4