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DISEASES 
 
 OF THE 
 
 EYE AND EAR 
 
 /•_ 
 
 C. H. VILAS, A. M., M. D., 
 
 PROFESSOR OF DISEASES OF THE EYE AND EAR IN THE HAHNEMANN 
 MEDICAL COLLEGE AND HOSPITAL, CHICAGO, ILL., Etc., Etc. 
 
 
 >'■ 
 
 FOR SALE BY 
 
 BOERICKE & TAFEL, 
 CHICAGO. 
 
 IV* 
 
 ^\^ 
 
Entered according to Act of Congress in the year 1890, 
 
 By C. H. YILAS, 
 
 In the Office of the Librarian of Congress, at Washington. 
 
INTRODUCTORY NOTE. 
 
 When the author began his teaching on the diseases of the eye 
 and ear, as part of a regular medical education at the Hahnemann 
 Medical College and Hospital, of Chicago, he found no text-book 
 adapted to the wants of beginners. This volume is the outgrowth 
 of some notes then prepared for the students and printed for the 
 author's convenience as a teacher. They were never designed as, 
 or thought to be, complete, or "necessarily original, but were sup- 
 plemented by clinical teaching, demonstrating the great majority of 
 known diseases, and affording the opportunity to witness operations 
 incidental to all branches of the art. From time to time they have 
 been added to, and, though including but a portion of the diseases 
 familiar to the intelligent specialist, it is believed that the text com- 
 prises fully as much as will be mastered in the time now allotted 
 in a general medical education to these subjects. More must be 
 sought in the larger books, with which the profession is abundantly 
 supplied. * The words of commendation heretofore received from old 
 students (now practitioners), indicate that this new volume will prove 
 valuable to others who, though they decline all operations, are com- 
 pelled, from the nature of the diseases, to treat many of them, and 
 to alleviate others, until such time as the patients can be safely sent 
 away. Should this prove to be true, the aim of the author will be 
 accomplished. 
 
 Chicago, January, 1890. 
 
Diseases of the Eye and Ear, 
 
 THE OPHTHALMIC DISEASES. 
 
 SECTION ONE. 
 
 To practically diagnosticate the diseases of the eye is essential 
 to their successful treatment. There are certain leading symptoms 
 which may indicate the disease or give a clue to its origin. 
 
 A patient consulting a physician about his eyes will generally dwell 
 upon defective sight alone, some external inflammatory or irritative 
 symptom, some disfigurement, or of pain only, etc. 
 
 When there are symptoms of external irritation or inflam- 
 mation, if there is also watering, photophobia, or swelling of the lids, 
 with or without redness of the eye, and defective sight, carefully look 
 for foreign bodies, such as bits of coal, etc. , in the cornea or folds of 
 transmission of the conjunctiva. If any are found on or imbedded 
 in the former, a spud may be necessary to remove them; if on the 
 latter a touch of the index finger, or a bit of twisted paper, will remove 
 them. Examine also the lids for ophthalmia tarsi, styes, irregular 
 growth of the lashes, meibomian and other tumors. Eczematous 
 patches are often found on the lids in phlyctenular troubles, which 
 may also extend to the malar region of the face and nose, and not 
 infrequently to the ears. Crusts may also be found on the lids, 
 exposing, on removal, an inflamed edge of the lids (blepharitis or 
 blepharadenitis). Examine also the inner surface of the lower lids: 
 if there is thickening or redness, evert and examine the upper lid for 
 granular disease. 
 
 To evert the upper lid (eversion is not required for the 
 lower one), seize hold of the lashes with the thumb and finger and 
 draw it out from the globe, then place the tip of the forefinger of the 
 other hand about its center, to act as a fulcrum, and, telling the 
 patient to look down, quickly turn the lid up and over. A lid elevator 
 is of no value in looking at conjunctival troubles, but it is useful in 
 
6 Diseases of the 
 
 those of a corneal nature. Sometimes it may be found necessary to 
 give chloroform or ether to quiet children in corneal or iritic trouble. 
 
 Examine the surface of the eyeball carefully as to the degree and 
 character of the congestion, whether local or general, affecting the 
 exposed or only the covered parts, due to superficial, tortuous, bright 
 red vessels, as found in conjunctivitis, or to deeper, straighter, pink or 
 purplish vessels suggesting ulcers of the cornea, or iritis, or cyclitis. 
 Spots or pustules, with local congestion, may be present, indicating, 
 perhaps, phlyctenular ophthalmia. The cornea may show one or more 
 spots or patches of opacity due to injuries, foreign bodies or ulcers of 
 the cornea, or be hazy all over as in keratitis, or show a number of 
 minute dots at its lower part, indicating keratitis punctata. The chief 
 symptom may be persistent watering of one eye, as in lachrymal ob- 
 struction, etc., or slight soreness, blinking, a little watery or gummy 
 discharge, and inability to use the eyes long, or to bear bright light 
 or strong winds, as is seen in mucocele, hypermetropia, myopia, and 
 asthenopia; or discharge with congestion of the eye and lids, indicat- 
 ing conjunctivitis; or spasmodic closure of the lids, and photophobia, 
 as in the corneal diseases. 
 
 Defective sight may be especially complained of, with more 
 or less inflammatory signs, and with or without severe pain. In which 
 case examine the cornea for ulcers and other haziness; the pupil for 
 size, mobility, and clearness, and the iris for color and general appear- 
 ance, in order to avoid overlooking iritis, or glaucoma. Take the 
 tension and ascertain roughly the condition of the visual field and note 
 accurately the near and distant sight. 
 
 Should the complaint be f>i defective sight in one or both eyes, 
 without other symptoms, it may indicate an error of refraction or 
 accommodation, or opacity of some of the media, or disease of the 
 retina, choroid, or optic nerve. Hence ascertain whether one or both 
 eyes are affected; the duration of the defect, and under what circum- 
 stances as regards the distance of objects and brightness of light it is 
 most observed. A defect of one eye often remains undiscovered for 
 years. If the failure of sight is related to bad health or to pain in the 
 head, albumen uric retinitis, optic neuritis, or atrophy may be thought 
 of. Take the near and distant vision, and examine the transparency 
 of the cornea, of the lens for cataract, and of the vitreous; also note 
 the color and appearance of the irides, and the size, shape and mobil- 
 ity of the pupils, so as not to overlook iritis, and try the tension of 
 the globe for glaucoma. If the media are clear, the iris and pupil 
 healthy, and the ophthalmoscopic appearances normal, examine the 
 
Eye and Ear. 7 
 
 refraction and accommodation for hypermetropia, myopia, presbyopia 
 and paralysis of the accommodation. If an opacity of the lens or vit- 
 reous is suspected, or if the defect of sight is not corrected by glasses, 
 it is usually best at once to make a thorough ophthalmoscopic exami- 
 nation, and desirable to examine the fundus carefully, by the erect 
 image, in all doubtful cases. If the disc appears markedly oval, either 
 before or after the use of atropine, astigmatism is to be suspected. 
 A.s to atropine, it is, as a rule, far better to use it to the extent of 
 dilating the pupil, than by examining with a small pupil to run the 
 risk of overlooking small but important changes in the lens, vitreous 
 or fundus. The necessity for its use will depend very much on the 
 skill of the observer, and on how much time can be spent over the 
 case; for the larger the pupil the more easily and quickly is the 
 fundus explored. When the sight is fair, the patient should always 
 be warned that the atropine will dilate the pupil and make the sight 
 dim for a day or two, or even much longer. Hydrobromate of hom- 
 atropine, one grain to the ounce of distilled water, is superior to atropia 
 sulphate for such purpose, as the pupil contracts in much less time. 
 Cocaine sometimes works well and the effect speedily passes away. 
 When there are changes in the optic disc or reason to suspect disease 
 of the optic nerve, the color perception should be tested. Further, 
 the complaint being of double vision, ascertain by closing one eye 
 whether it is binocular or monocular; monocular diplopia or polyopia 
 is rare, and is recognized by the persistence of the symptoms when 
 one eye is closed. 
 
 When there is a squint or some other disfigurement, or ina- 
 bility to open the lids, ptosis or blepharospasm should be thought of. 
 Inability to close them may be caused by paralysis of the facial nerve; 
 defective movement of the globe in one or the other direction by mus- 
 cular paralysis; prominence of one or both eyes may suggest Basedow's 
 or Graves' disease. Swollen, but not inflamed lids may be caused by 
 emphysema or orbital tumors. In myopia the eyes are often prom- 
 inent, and if the myopia is one-sided, this appearance may be unsym- 
 metrical. 
 
 When pain is the only or chief symptom dwelt on, note whether 
 it is referred to the eyeball, or to the forehead or temple, etc. ; 
 whether periodic and not related to the use of the eyes, as in neuralgia, 
 or irregular in onset and related to the genera] health, or distinctly 
 related to the use of the eyes, as in myopia, hypermetropia, and asthen- 
 opia. In all these cases the sight should be tested, .and a careful 
 ophthalmoscopic examination made. 
 
8 Diseases of the 
 
 Xasal diseases are often important factors in originating and 
 perpetuating certain forms of eve disease*, and when present must be 
 cured as a preliminary stage to successful treatment of the eye. 
 
 The treatment of eye disease demands the use of solutions prepared 
 from various alkaloids. First among such, and without which the 
 treatment of eye diseases would at times be extremely hazardous, is 
 atropia sulphate, commonly called atropine. But atropine 
 is insoluble in water, and hence the former is made by treating it with 
 sulphuric acid. When rightly prepared atropia sulphate is wholly 
 devoid of anv acid effect in the eve. no tingling or smarting: effect 
 being observed. Unfavorable results may be caused by bad prepara- 
 tions, and their results attributed to the atropia rather than its improper 
 preparation. 
 
 Pure, neutral atropia sulphate, when rightly used, will diminish 
 the intra-ocular tension, draw back the iris and prevent adhesions to 
 the anterior capsule of the lens; prevent adhesions to the posterior 
 layer of the cornea, tear away adhesions when formed; prevent pro- 
 lapse of the iris, and not infrequently restore it when prolapsed: com- 
 pel it to rest: and diminish its congestion. It will also diminish the 
 congestion of the ciliary body; compel the ciliary muscle to rest: les- 
 sen ciliary neuralgia, and act as a local anaesthetic during its passage 
 through the cornea, allaving irritation. 
 
 Irritation of the conjunctiva with an eczematous condition of the 
 lids may be caused by its use, however, and its effect should be care- 
 fully observed when the posterior portion of the uveal tract is affected, 
 and in persons over forty years of age. Acute glaucoma may be hastened 
 in eyes already attacked, and there is danger that its prolonged use 
 may cause detachment of the retina in predisposing cases. In addi- 
 tion paralysis of the fibers of the iris may be caused by the prolonged 
 use of a strong solution, and slightly unpleasant effects by the solu- 
 tion running from the conjunctival sac into the throat through the 
 lachrymal canaliculi may occur: or it may even be absorbed to this 
 extent. 
 
 Its strength may be varied according to the necessities of the case. 
 One-half a grain of atropia sulphate to an ounce of distilled water, is 
 sufficient to dilate the pupil for examination of a healthy eye. but 
 when inflammation is present, solutions of two to four grains to the 
 ounce are required — one drop from a drop-tube to be placed in the eye, 
 the lower lid being slightly everted. 
 
 The antidote to atropine mar be a strong decoction of coffee, 
 which in cases requiring a more powerful antidote is best alternated 
 
Eye and Ear. 9 
 
 with hot vinegar. When an immediate antidote is required, however, 
 a hypodermic injection of morphia is essential, and excells all others. 
 
 The four-grain solution may be used in all cases where the rapid 
 and full mydriatic action of the drug is required. The ciliary muscle 
 and iris do not usually thoroughly recover from the effect of its use 
 for about ten days. The two-grain solution may be used when it is 
 desired to keep the pupil partially dilated for a long time, as in imma- 
 ture nuclear cataract. A single drop two or three times a week will 
 generally suffice. Solutions will keep for an indefinite time; the sedi- 
 ment which often forms does not impair their efficiency. 
 
 Hoiliatropilie is a substitute for atropine and is sometimes 
 valuable in that its mydriatic effects pass off quickly in comparison. 
 A solution of two grains to the ounce of distilled water may be used 
 with value in examinations, as the pupil will usually return to its nor- 
 mal size in about twelve hours. 
 
 Dllboisilie, the alkaloid of duboisa myoporoides, is similar in 
 its effects to atropine, but more powerful, and as it often causes rather 
 alarming symptoms, care should be exercised in its use. Preferably 
 in the form of the sulphate, its strength should not be equal to that 
 of atropia, one-half the quantity being usually sufficient. 
 
 Hyoscyamilie, the alkaloid obtained from hyoscyamus, may be 
 used when atropine is not well borne, and fully considering the various 
 statements, it would seem that under its use the pupil will dilate more 
 rapidly, remain longer dilated, and of not less maximum degree, than 
 when atropine is used. Unlike duboisine, its effects are not distressing 
 at times, but it does not keep as well. 
 
 Pilocarpine, and usually the hydrochlorate, is the alkaloid ob- 
 tained from jaborandi. It causes profuse salivation and sweating and 
 is used to quite an extent in optic nerve troubles. 
 
 Eserine, the alkaloid of calabar bean, has been justly greatly 
 praised for its effects on the eye, especially in corneal troubles. It may 
 be used of about the same strengths as atropine. The salicylate of 
 physostigmine, now officinal in the new United States Pharmacopoeia, 
 is another preparation of value from the bean. The great value of es- 
 erine, aside from its use in corneal troubles, is found in that it is the 
 only myositic on which dependence can be placed. While antagonistic 
 to atropine mydriasis, and displacing it and substituting its myositic 
 effect, eserine can not long hold the ascendency, but gives way after a 
 short time, and the mydriasis reappears. A solution of the alcoholic 
 extract of the bean (four grains to the ounce of distilled water) or a 
 little of the extract itself may sometimes, with advantage, be substi- 
 tuted for the alkaloid. 
 
10 Diseases of the 
 
 Datill'iiie, the alkaloid of datura stramonium, is also useful, es- 
 pecially when atropine can not be borne. A solution of four grains to 
 the ounce of distilled water is usually the strength required. 
 
 Cocaine is valuable both as a mydriatic and as an anaesthetic. 
 Some twenty minutes after instillation, dilatation of the pupil begins, 
 but never progresses to the maximum degree, and may be readily over- 
 come by instilling a drop of eserine. It will not appear again, even 
 though more cocaine is used afterward. 
 
 Our literature is already laden with cases where harm has been 
 done by its use. By the experienced only should it be freely used in 
 e ye diseases, and its effects in combination with other drugs, as atro- 
 pine, should be carefully studied in individual cases. 
 
 The temporary anaemia produced by the drug is of great value in 
 operating, as it renders conjunctival operations bloodless, or nearly so. 
 The value of this alone in strabismus operations is evident. In ex- 
 tracting foreign bodies from the cornea and other external 
 portions of the eyeball, its value can hardly be over- stated. AY hen 
 the tissue is fully under its influence, deep indentations can be made 
 on the cornea, spuds and finger readily used, and any foreign body 
 removed. Thus these painful little operations, often not to be done 
 without chloroform heretofore, become a matter of a few moments' 
 painless, procedure. A solution of two grains to the ounce of distilled 
 water is sufficient for all ordinary eye operations. 
 
 Care should be taken to avoid spurious or imitation alka- 
 loids of all these substances, of which there are many in the market. 
 All the mydriatics and myositics may be obtained in the form of small 
 gelatine discs of known strength, which are sometimes more conven- 
 ient than the solutions. 
 
 The best solutions for antisepsis are made from powerful poisons, 
 mercuric bichloride, or carbolic acid. The former may be used in 
 solutions varying from one to five thousand to one to two thousand: 
 the latter, usually, one to one hundred to five to one hundred. Boracic 
 acid (five to one hundred) is valuable, as are others. 
 
 For disinfectants there are many preparations but nothing 
 better than Piatt's Chlorides. This mixture may be readily burned, 
 when desirable, by dissolving three drachms of potassa nitrate in eight 
 ounces of the undiluted chlorides. In this thin strips of muslin should 
 be saturated, thoroughly dried, and then burned in different parts of 
 the room. Bromo-chloralum, Labarraque's Solution, and many other 
 forms of disinfectants are also easily available. 
 
 Very many of the remedies used locally are prepared for sale in 
 
Eye and Ear. 11 
 
 the form of cerates, as belladonna, rhus toxicodendron, etc. Others 
 may be ordered made when desired. 
 
 Bandages for the eyes should be of thin flannel. A linen or 
 knitted cotton bandage, about ten inches long, with four tails of tape, 
 or a loop of tape embracing the back of the head (Liebreich's band- 
 age) is very convenient. The protective bandage consists of a roller 
 of thin flannel about one to one and one- quarter inches wide, and 
 four to six feet long. Placing one end a little in front of the auricle 
 opposite to the eye to be protected, the bandage is brought across the 
 forehead and around the head to the point of beginning, and thence 
 down over the eye (over which and to fill up even with the brow and 
 face, cotton or lint has been placed upon a piece of cloth about two 
 inches square, oiled to prevent adhesion to the skin of the lid and 
 face) around under the opposite auricle, and back to the beginning, 
 where it may be fastened and held in place by a safety pin. The pres- 
 sure bandage is similar, but of finer flannel and longer. It is more 
 carefully adjusted, all wrinkles being smoothed out so as to firmly 
 bind on the forehead and head. When so arranged, a firm but gentle 
 pressure can be made and strongly secured. 
 
 It requires a little practice to get them properly adjusted, but 
 nothing can exceed their efficiency for the purposes intended. When 
 absolute exclusion of light is desired, it is best to use a bandage made 
 of a double fold of some thin black material. Fine old linen is bet- 
 ter than lint for placing next the skin in dressing after operations. 
 
 The hermetical bandage is for use where it is desirable to seal up 
 an eye to protect it from contagion, as in purulent conjunctivitis. It 
 is made by covering the eye with a piece of soft linen, over 
 which is placed a pad of charpie, or picked lint, over the charpie a 
 piece of oiled silk, over the silk a piece of linen, and the whole then 
 coated with collodion, and fastened by it to the skin at the edges of 
 the bandage. 
 
 Where this form is not advisable, take two pieces of India-rubber 
 plaster, one four inches, the other four and a half inches, square. 
 Cut a round hole in the center of each, and stick them together with 
 a watch crystal inserted between and covering the hole. Then fasten 
 with collodion, leaving an opening below for ventilation. 
 
 Shades. Should a shade be required, it may be made of thin 
 cardboard covered with some dark material, or of stout, dark blue 
 paper, like that used for making grocers' sugar-bags. Shades of 
 black plaited straw are also very light and convenient. To be effect- 
 ual, they should extend to the temple on each side, so as to exclude 
 
12 Diseases of the 
 
 all side light. An excellent one, with a spring extending half way 
 around the head to hold the shade in place, is for sale at the opticians' 
 shops. 
 
 SECTION TWO. 
 
 The Ophthalmoscope is the only instrument by which a 
 thorough examination of the eye, without and within, can be made. 
 In many respects its use is. like that of the otoscope, or laryngoscope; 
 it would be even more like these instruments, but for the fact that its 
 successful use requires the harmonious adjustment of two complicated 
 and separate dioptric systems, the eye of the examined and that of 
 the examiner. Such is the case with no other diagnostic instrument; 
 hence the difficulty so often met with by the novice. 
 
 This fact, thoroughly comprehended, will serve to eliminate all 
 the discouraging elements, and enable anyone with a small amount of 
 labor, to grasp the wonders which the ophthalmoscope reveals. 
 
 Previous to 1851, when the discovery of the principles of this in- 
 strument was published to the profession, nothing beyond a few scat- 
 tered observations had been evolved in the way of solving the problem 
 of the illumination of the fundus of the eye. This had been due to 
 the fact that it was believed that the choroid absorbed the rays of 
 light reaching the fundus, and that none were returned. This error 
 being practically refuted, a new era dawned in the progress of oph- 
 thalmic exploration. Nearly all diseases of the eye posterior to the 
 lens were also either unknown, classed under amaurosis, or the sub- 
 jects of mistaken conjecture. By this one invention, the innermost 
 and hitherto uuseen recesses of the eye were lighted up, and unknown 
 diseases placed within the range of vision. 
 
 As the use of the instrument began to be known and appreciated 
 in eye diseases, it was but natural that the phenomena here observed 
 should in time be associated with those occurring in more remote parts 
 of the system. The results obtained have been most gratifying: for 
 the ophthalmoscopic appearances of the base of the eye (fundus oculi) 
 are now recognized as important factors in the diagnosis of many dis- 
 eases of the general system. 
 
 The eye itself is an optical instrument in which the refractive 
 media combined are about equal to a convex lens of one inch focus. 
 
Eye and Ear. 13 
 
 By means of these media, images of external objects are formed upon 
 the retina in an inverted position. In a normal and healthy eye, 
 images of objects at various distances are distinctly focused upon the 
 retina, although it is evident such would not be the case without some 
 change in the refractive power of the media. A change takes place 
 which is called the accommodation of the eye. 
 
 By its accommodative power, the eye adjusts itself involuntarily 
 for perception of objects at distances varying from a few inches to 
 about eighteen to twenty feet, which is regarded as an infinite dis- 
 tance, and usually spoken of as infinity. Divergent rays from near 
 objects and parallel rays from distant objects, are just as accurately 
 focused by a simple change in the focal distance of the lens, in a man- 
 ner as yet in some obscurity, different theories being advanced and 
 seemingly well sustained by their authors, in conjunction with other 
 changes not necessary to now consider. 
 
 As has been stated, it was formerly believed that rays of light en- 
 tering the eye reached the fundus and were there absorbed by the 
 pigment layer of the choroid; hence no rays were reflected outward 
 through the pupil to convey to the eye of the observer an image of the 
 interior. This belief seemed confirmed by the black appearance of 
 the pupil. The reason for such a mistake was due to the fact that 
 rays of light projected into the eye are returned to the point whence 
 they came. By means of the refractive media the ingoing and out- 
 coming rays form a cone of light whose base is at the pupil, an'd whose 
 apex is at the source of illumination. This cone of light is nowhere 
 wider than the pupil, and diminishes in width as the distance from 
 the pupil increases. It is therefore evident that any attempt of the 
 observer to place the head so as to receive the emergent rays within 
 the pupil, would cut off the whole source of illumination; for the 
 width between the observer' s pupil and the temporal side of the head 
 is much greater than that of the cone of light at any point. 
 
 The emergent rays from the fundus are generally slightly conver- 
 gent. They may be rendered parallel by either placing behind the 
 mirror a concave lens, with which all instruments are supplied, or by 
 requiring the patient to look at a distant object, the latter way being 
 used as experience permits. 
 
 By looking at a distant object, the eye is accommodated for parallel 
 incident rays, hence the emergent rays being equally refracted become 
 parallel. Parallel rays are better adapted to the formation of distinct 
 images upon the retina of the observer. 
 
 Ordinarily the concave mirror is preferred to the plane. By con- 
 
14 Diseases of the 
 
 centrating the incident rays, it not only reflects more light into the 
 eye, but as the rays are convergent when they enter, they are brought 
 to a focus before reaching the retina, and as a result cross each other 
 and form circles of dispersion. A larger portion of the fundus is 
 thereby lighted up at one time. 
 
 There are many modifications of the ophthalmoscope devised by 
 ingenious brains to develop and clear up the seeming difficulties, but 
 all involve the same principle. An examination of their mechanism 
 with a careful study of their advantages will render the modes of use 
 quite plain, and familiarize the examiner with the details of the prac- 
 tical principles involved. 
 
 A skillful operator can obtain in most eyes a very good idea of the 
 condition of the fundus without the use of a mydriatic. It is usually 
 quite unnecessary in cases where it is only desired to examine the 
 optic disc and its immediate vicinity. In such cases care should be 
 taken to use a moderate degree of illumination only; a bright light 
 causes contraction of the pupil, and dazzles the eye. 
 
 To make a practical use of the ophthalmoscope, the 
 room should be darkened and the patient seated erect near a table, 
 resting the arm upon the table, or with the back firmly supported by 
 a chair. A light with a clear, steady flame should be stationed at one 
 side, and about a foot behind the patient's head; it is better, but not 
 essential, that it be upon the side of the head corresponding to the 
 eye to be examined. Any good light will answer, and it is unnecessary 
 to have any special' standard, though what is known as an oculist's 
 bracket, with a double -armed, adjustable swinging movement, is very 
 convenient. 
 
 The observer should now be seated opposite the patient, their eyes 
 on a level or nearly so, and this position is best attained by having one 
 or each seated upon a revolving adjustable chair. The observer may 
 use either eye for examination of one of the patient's eyes, but it is 
 preferable to use the one corresponding to the one to be examined — 
 that is, the right for the right, and the left for the left. 
 
 Direct method. — Let the ophthalmoscope be taken in the 
 right hand, if about to use the right eye, delicately holding it by the 
 handle near its free end, and lightly resting the upper portion of the 
 rim of the mirror against the brow while the eye is applied to the 
 sight-hole. The companion eye should now be momentarily closed to 
 be sure the observer is looking through the sight-hole, and then both 
 eyes should be kept open. The mirror must be so inclined to the 
 light that the reflection will fall directly upon the patient's pupil. 
 
Eye and Ear. , 15 
 
 Having thus far followed directions, the pupil of a healthy eye will 
 present a reddish appearance from the bright reflection of the fundus. 
 The patient should now be directed to look slightly inward and fix 
 the gaze upon some distant object over the observer's right shoulder, 
 and about on a level with the tip of the ear. If the left eye is to be 
 examined, the patient should look over the observer's left shoulder in 
 the same manner. 
 
 As soon as the eye is turned inward, the red appearance of the 
 pupil changes to a light yellow, seemingly white in persons of dark, 
 swarthy complexions. This change is caused by the optic disc coming 
 into view. The disc is usually the starting point in exploring the sur- 
 rounding parts of the fundus, but before proceeding to a closer ex- 
 amination it is well to first ascertain from a distance with the ophthal- 
 moscope whether the red reflection of the fundus is clear. Some 
 slight opacity of the lens or vitreous may thus be detected, and explain 
 an appearance which would perhaps otherwise be referred to the fundus. 
 
 Next the observer should ascertain the refraction by observing if 
 the retinal vessels can be seen clearly from a distance. If the vessels 
 are distinctly visible at a distance, the eye is either myopic or hyper- 
 metropic: the first if the vessels move in an opposite direction from 
 the observer's head when moved sideways, and the second if they 
 move in the same direction. In emmetropic eyes, the details of the 
 fundus can be distinctly seen at a distance of two or three inches from 
 the patient's eye, while in the other conditions, myopia and hyperme- 
 tropia, the mirror must be held at a distance of about fourteen to six- 
 teen inches. However, if an appropriate correcting lens is held be- 
 hind the mirror, the emergent rays from the fundus of the patient's 
 eye may be rendered parallel, and a clear image obtained at a short 
 distance, the same as in emmetropia. A concave correcting lens will 
 be needed for examination of myopic eyes, and a convex for hyperme- 
 tropic eyes. The power of this correcting lens will, of course, depend 
 upon the degree of ametropia to be overcome. Furthermore, as there 
 are usually unconscious efforts of accommodation in either the eye of 
 the observer or of the observed, a ten or twelve inches concave cor- 
 recting lens may be found useful in examining an emmetropic eye. 
 These unconscious efforts in the eye of the observer may be also over- 
 come by experience, those of the observed by the use of a mydriatic. 
 
 This way, called the direct method, shows only a very limited field 
 at a time. Seemingly the simpler, it requires much careful and pa- 
 tient practice for its mastery. 
 
 The indirect method of examination requires the use of one 
 
16 Diseases of the 
 
 of the large convex lenses in conjunction with the mirror. The lens 
 of two and one-half or three inches focal distance is most commonly 
 used. Following the manner laid down in the direct method as far as 
 necessary, the observer then takes such a lens between the thumb and 
 forefinger of the unoccupied hand and brings it up before the observed 
 eye from the temporal side, resting the extended little finger on a spot 
 near the temple to steady the hand. Not moving the little finger from 
 its resting place, nor the ophthalmoscope from the brow, the observer 
 tells the patient to look slightly inward and observe some distant ob- 
 ject, as in the direct method, and at the same time adjusts the lens to 
 its focal distance. The reflected rays from the mirror now pass 
 through the interposed lens and enter the pupil. The mirror is held 
 at some distance in all the conditions of refraction; for by the use of 
 this lens the distinctions of myopia and hypermetropia and invol- 
 untary accommodation in the observed eye may be practically disre- 
 garded so far as searching for a distinct image is concerned. This image 
 is actually on the observer's side of the lens, inverted and in the air; 
 and the observer's eye need only to be moved a little nearer in myopia, 
 and a little farther away in hypermetropia, in order to see it well. If 
 the optic disc is only partly in view, it can be brought fully under 
 observation by the observer moving either the head or the object lens. 
 The image moves in a direction opposite to the movement of the head, 
 and in the same direction as the movement of the lens. 
 
 An apt observer will soon become able to easily move the head in 
 various directions, all the while keeping the light accurately focused 
 upon the pupil. Not only should one become adept in this, but also in 
 focusing a clear and sharply defined image of each detail. The head 
 of the observer must be at such a distance from the aerial image as is 
 sufficient for the perception of small objects. The image may be en- 
 larged with advantage by using a convex lens of about ten inches focus 
 behind the mirror. 
 
 The lateral, or oblique illumination may be employed with 
 much benefit for parts of the eye as far back as the posterior lens cap- 
 sule. It is much used in conjunction with the ophthalmoscope, hence 
 its consideration now. 
 
 In this method, the lamp is placed in advance and to one side of 
 the head of the patient and the observer sits in front or stands behind 
 the observed. Either of the large lenses usually accompanying the 
 ophthalmoscope may be used to concentrate the light from the lamp 
 upon the observed eye, and the other lens used as a magnifying glass, 
 is desirable, through which the observer looks at the parts under exam- 
 
Eye and Ear. 17 
 
 ination. Diffused daylight may also be employed. By successive 
 movements of the observed eye, occasionally varying the position of the 
 lens, the cornea, crystalline lens and iris may each be thoroughly 
 examined. 
 
 All changes of the crystalline lens and parts anterior to it may be 
 seen in their true colors, but with the ophthalmoscope all opacities 
 appear black. ' Foreign bodies, nebulae, synechiae, etc. , invisible to the 
 eye alone, may be easily denned by this method. The minutest facet 
 or indenture on the cornea may also be detected by placing the patient 
 with the face toward a window through which strong daylight is fall- 
 ing. Any such irregularity will at once become apparent by the disper- 
 sion of the rays from it, looking on a smaller scale not unlike a mir- 
 ror indented and cracked by a sharp blow which causes the glass to 
 splinter. It is best seen by looking in a direction nearly at a right 
 angle to the course of the incident rays of light. 
 
 As in other branches of physical diagnosis, a familiarity with the 
 appearances in health is necessary to the detection of disease, so it is 
 with the eye; the condition of the parts in health must be the standard 
 by which to estimate the nature and extent of disease. 
 
 As already mentioned, the reflection from the fundus is reddish, 
 but its tint varies greatly in different individuals. Among dark races 
 the fundus of the eye is of a brownish- gray color, while among the 
 European races it approximates a crimson-orange. The variations of 
 color and tint depend upon the amount and color of the pigment fill- 
 ing the cells of the choroid, and obscuring to a greater or lesser degree 
 the choroidal vessels. 
 
 In people of very light complexion, the fundus is often found to be 
 of a bright scarlet color. Such is the case in the Swede, while in the 
 Italian, or the Spaniard, the color is proportionately darker. 
 
 Examination of the fundus can hardly be regarded as complete 
 without the employment of both the direct and the indirect methods of 
 exploration. The first shows only a very limited portion at a time, 
 but this portion is highly magnified and in its true color. The second 
 shows a large field at a time, and enables the observer to note the 
 relation of the parts more accurately; but the color of the image is not 
 a true representation of the color of the object, nor is the image so 
 highly magnified as by the direct method. 
 
 The disc or papilla, is the point where the optic nerve termin- 
 ates or expands into the retina. It is usually round, or slightly oval 
 with its long diameter vertical. Its color varies, and the darker the 
 eye, the whiter the disc appears by contrast with the surrounding 
 
 2 
 
18 Diseases of the 
 
 choroid. The color is generally pink or rosy, and varies from this to 
 a steel-gray. In very dark eyes the disc appears white. 
 
 The color is derived from three sources, — the white of the con- 
 nective tissue, the red of the capillaries, and the bluish -gray of the 
 nerve tubules. The circumference of the disc is well denned; it is 
 enclosed first, by the white ring of the sclerotic, and second, by the 
 darker choroidal border. 
 
 The sclerotic ring which encloses the nerve appears as a slender 
 zone of white, usually most marked at the outer side of the disc. 
 Sometimes only a portion of this ring can be seen, or it may even be 
 entirely obscured. Outside of the sclerotic ring, the border of the 
 choroid is plainly seen. Its general color is a brownish-gray, but the 
 outer border is often of a darker hue, owing to a crescentic-shaped 
 deposit of pigment in this situation. 
 
 The central surface of the disc is depressed below the general level, 
 and of a whitish appearance. It frequently has a stippled look, caused 
 by the holes through which the bundles of nerve fibers pass. It is at 
 this point that the central artery of the retina and the accompanying 
 vein pierce the optic nerve. The white appearance of this depression 
 is due to the connective tissue enclosing the vessels. 
 
 Although the central artery of the retina usually pierces 
 the disc at its center and bifurcates as soon as it emerges, one branch 
 passing upward and the other downward, such is not always the case. 
 The artery may appear at other points of the disc, and has been ob- 
 served to emerge as several branches. After bifurcating, the branches 
 continue to divide dichotomously, continuing in all directions toward 
 the periphery of the retina. The veins enter the disc at a little dis- 
 tance apart, and correspond to the arterial branches, though the former 
 are sometimes double. The veins are tortuous in their course and 
 larger than the arteries. Sometimes a spontaneous pulsation may be 
 noticed in the central veins, and this may be augmented by gentle 
 pressure upon the eyeball. The veins are of a darker and of a more 
 uniform color than the arteries, and they usually pass under the latter. 
 The apparent caliber of the vessels will be found to differ with the 
 magnifying power used. The arteries, in contrast with the veins, are 
 straighter, of a brighter red, smaller, and the pulsation can not be 
 seen. They usually cross over the veins, and along the center of each 
 may be noticed a bright whitish line. This whitish line is scarcely 
 observable on the veins. 
 
 The color of the disc is not uniform, the inner half being of a 
 pinkish tint, and the outer half presenting more of a gray or mottled 
 
Eye and Ear. 19 
 
 appearance. The inner portion is more of a pink than the outer, 
 owing to its being more thickly covered with nerve fibers and vessels. 
 The central depression, its whitish appearance, the outer grayish 
 mottled hue, and the more decided pink of the inner half, are all 
 subject to considerable variation, but are characteristic marks in most 
 healthy eyes. 
 
 The retina is so nearly a transparent structure that it reflects 
 very little light, and is therefore generally invisible. In very dark 
 persons it may sometimes be seen lying over the choroid as a grayish 
 layer. Its appearance may well be likened to the bloom on a peach. 
 The yellow spot (macula lutea) is not easily recognized, but 
 it is situated on the axis of vision about one or two lines outward from 
 the disc. No retinal vessels cross the spot; they pass either above or 
 below. This fact helps to determine its position more readily. The 
 color generally seems to be a bright red, and in the center is a bright 
 spot known as the central pit (fovea centralis.) 
 
 The anatomy of the choroid shows it to be a vascular and pig- 
 mentary structure. An elastic lamina lies innermost, and close behind 
 this, separated from it only by the hexagonal cells, lies a dense capil- 
 lary network. The larger choroidal vessels lie next to the sclerotic, 
 and among them are distributed the most of the pigment cells. In 
 persons of dark complexion, the hexagonal cells conceal the choroid 
 from view; but in persons of a lighter hue, these cells contain no pig- 
 ment and allow light to pass to the vascular structures. This explains 
 the scarlet appearance of the fundus in the latter, and the brownish - 
 gray appearance in the former. 
 
 Opacities occurring in the cornea, lens and vitreous are readily 
 detected by the ophthalmoscope. As far back as the posterior lens 
 capsule, # as has already been noted, opacities may be seen in their true 
 colors by lateral illnmination, and even very minute ones may be de- 
 tected; but with the mirror alone it should first be ascertained whether 
 the media are clear. Once assured that an opacity exists, its depth 
 should be determined, and then, if it is within range, the lateral 
 illumination may be used. With the ophthalmoscope, opacities appear 
 as dark spots of irregular size and shape on a red background. With 
 the lateral illumioation, they generally appear as gray or light spots 
 upon a dark back-ground. With a very brilliant illumination, very 
 small opacities may be invisible; it is therefore best to employ a very 
 weak light at first. 
 
 In examining for opacities with the mirror, in order to prevent the 
 image of the fundus from obscuring or confusing them, the mirror 
 
20 Diseases of the 
 
 should be held at such a distance as will prevent the observer from 
 getting any image of the fundus. In order to do this, a lens of about 
 eight inches focal length may be used behind the mirror and the latter 
 be held at a distance of seven or eight inches from the eye under 
 observation. 
 
 To determine the depth of an opacity, it may be remembered that 
 all opacities in front of the posterior lens capsule are readily located 
 by means of the oblique illumination. The turning point of the eye, or 
 the point which remains stationary while the eye is in motion, is situ- 
 ated either at or a little behind, the posterior pole of the lens. Now 
 if the eye is moved in various directions, opacities in front of this 
 turning point, or pivot, will move in the same direction as the cornea; 
 and it is likewise obvious that opacities behind this point will move in 
 the opposite direction. An opacity situated at the turning point would 
 scarcely move at all. The reflection of the mirror upon the cornea 
 does not move with the movements of the eye. This corneal reflection 
 should therefore be taken as the fixed point by which to measure the 
 extent of movement of an opacity; and the extent aad relative direc- 
 tion will show the approximate depth. Opacities of the cornea are 
 best seen by the oblique method. The unaided eye will detect those 
 of appreciable size, and the location, size and color can be easily de- 
 termined. In opacities of the lens, spots are sometimes seen upon the 
 anterior capsule, the posterior capsule and the lens being unaffected. 
 Usually these are deposits of lymph or pigment resulting from iritic 
 or corneal inflammation. 
 
 There are several ways of determining the refraction 
 of an eye. The ways most used, however, are those of skiascopy, 
 or oftener, that of finding the lens required by the observer (any 
 ametropia of the observer being first corrected, and the accommoda- 
 tion of both the observer and the observed being fully relaxed) to 
 clearly and distinctly see the fundus of the eye under examination. 
 
 In myopia the rays converge to a focus before reaching the retina. 
 In other words, the principal focus of the dioptric media lies in front 
 of the retina. Hence rays issuing from the retina of a myopic eye 
 do not emerge from the cornea parallel, as is the case in emmetropia; 
 but coming from a point beyond the principal focus, they emerge as 
 convergent rays. They can not as convergent rays be brought to a 
 focus upon the observer's retina, but after they cross each other and 
 become divergent, the observer can obtain a distinct image. The 
 image is an inverted one, as is proven by the fact that it moves in the 
 opposite direction from the observer's head. The head of the ob- 
 
Eye and Ear. 21 
 
 server must be from twelve to sixteen inches from the eye under 
 examination. 
 
 An erect image may be seen at a short distance by interposing a 
 coQcave lens behind the mirror; but the lens should be of sufficient 
 power to render the convergent rays parallel. The focal length of 
 this lens will approximately represent the degree of the myopia exist- 
 ing in the eye under observation, and therefore the number of the 
 lens necessary to correct it. 
 
 Parallel or divergent rays of light entering the hypermetropic 
 eye converge to a focus situated behind the retina. The principal 
 focus of the dioptric media is therefore behind the retina. Kays 
 from the retina are therefore from points within the principal focus, 
 and in consequence emerge divergent. At a distance of sixteen to 
 twenty inches, these rays can be brought to a focus upon the observer's 
 retina, and form a distinct erect image. That the image is erect is 
 proven by its moving in the same direction as the observer' s head. 
 
 Kays issuing from a hypermetropic eye may be rendered parallel 
 by a suitable convex lens. The focal length of the lens which will 
 render the divergent rays parallel, enabling the observer to see a clear? 
 erect image of the eye at a distance of two or three inches, will give 
 approximately the degree of existing hypermetropia. 
 
 The size of the inverted image is directly proportionate to the 
 focal distance of the convex lens used; and other things being equal, 
 that of the myopic eye is smaller, and that of the hypermetropic eye 
 larger, than that of the emmetropic eye. But in estimating the 
 degree of either hypermetropia or myopia by these methods, one 
 source of error must be carefully guarded. It arises from the fact 
 that comparatively few observers can, in looking at near objects, pre- 
 vent the involuntary action of the ciliary muscle. To make the 
 results of value, the accommodation of both must be relaxed during 
 the examination. Repeated practice must be had until the observer 
 can accomplish this relaxation, or an allowance must be made for that 
 which can not be overcome. 
 
 To practice for this relaxation of the accommodation, emmetropes 
 and hypermetropes may look through a convex lens at objects situated 
 at the focus of the lens; and practice bringing their eyes to a parallel 
 condition by placing before one eye a prism with its base inward. It 
 may also be found advantageous to examine the inverted image through 
 a moderately strong convex lens, as a plus 3D. 
 
 In most cases of astigmatism the refraction varies slightly in the 
 different meridians of the cornea. Usually, rays entering the eye in 
 
on 
 
 Diseases of the 
 
 the vertical meridian are focused somewhat nearer the cornea than the 
 rays in the horizontal meridian. The variation is usually so slight as 
 to be unnoticed, but where the want of symmetry in the corneal curv- 
 ature is great, confused and indistinct images are formed upon the 
 retina and the condition is called astigmatism. Sometimes the crystal- 
 line lens presents irregular curvature also. By the direct method, in 
 regular astigmatism, the optic disc appears oval, and the elongation is 
 in the direction of greatest curvature. By the indirect method the re- 
 verse is true. Sometimes in normal eyes the disc is oval; hence if the 
 disc appears oval in one direction while viewing the upright image, 
 and astigmatism is present, it should appear oval in a direction at 
 right angles to the first when viewing the inverted image. 
 
 The presence of astigmatism may also be determined by observing 
 the relative distinctness with which vessels running in different direc- 
 tions are seen. For example, vessels running vertically may appear 
 clearly focused, while those running horizontally are indistinct and 
 confused. 
 
 Suppose the observer's eye is at a minimum distance and adjusted 
 for parallel rays, but upon exerting the accommodation the first set of 
 vessels becomes dim and the second set clear; manifestly it is a case of 
 simple hypermetropic astigmatism. But if under the same conditions 
 there can not be obtained by any accommodative effort a distinct image 
 of the second set of vessels, the case is one of simple myopic astigma- 
 tism. In a case of compound hypermetropic astigmatism, if the ob- 
 server's eye is at a minimum distance and adjusted for parallel rays, 
 the vessels or other details can only be seen by exerting the accommo- 
 dative power; and different degrees of accommodation will be required 
 for successively focusing vessels running in the direction of different 
 meridians. 
 
 Astigmatism may also be detected by the indirect method, for if 
 the lens is held at its principal length from the eye and then gradually 
 moved nearer, the disc appears more and more elongated in one diam- 
 eter; but if, instead, the lens is gradually withdrawn, the disc appears 
 elongated in the diameter at right angles to the first. 
 
 Skiascopy, or the shadow-test (also called retinoscopy) has two 
 ways of use: the first, where the distance between the operator and 
 patient is fixed, and the measurement determined by changing the 
 trial lenses; and the second, where this distance is varying. The first 
 way may be practiced with the ordinary concave ophthalmoscopic 
 mirror (or with a plane mirror), and will be approximative^ explained; 
 the second way always requires a plane mirror, and will not be de- 
 
Eye and Ear. 23 
 
 scribed. To make use of the first way, place the patient with the 
 back to the light, which should be about two inches higher than the 
 head, and take a station four feet in front; have the patient look 
 slightly to the left as you examine the right eye, and vice versa. 
 Looking through the hole in the ophthalmoscope, as the light is re- 
 flected into the eye, the red fundus reflex will be perceived. As the 
 instrument is now rotated very slightly, a shadow will come out from 
 behind the iris and partly cross the pupillary space. If this shadow 
 moves with the mirror, or in the same direction that the reflected light 
 on the face moves, the case is one of myopia. If the shadow is well 
 defined, and moves slowly against the mirror, hypermetropia is indi- 
 cated. If the shadow moves obliquely, or if, instead of a solid 
 shadow, dark and light lines cross the pupillary space, astigmatism 
 exists. The degree of the ametropia is measured by the strength of 
 the lens required to neutralize the ametropia disclosed. 
 
 OwiDg to the intimate relations of the structures at the fundus of 
 the eye, it must not be expected to often find marked alterations in 
 one part without more or less important changes in parts adjacent. 
 In most cases were symptoms of disease exist which, directly or indi- 
 rectly, may be referred to the fundus, it is well to explore this portion 
 of the eye in all directions, taking the optic disc as the starting point. 
 Very serious disorders may have their origin in the periphery as well 
 as in the center or in other portions of the fundus, and the situation 
 of any abnormal appearance should be carefully determined which may 
 be done by noting its distance from the optic disc, and at the same 
 time considering the direction from which the patient's eye is looked 
 into. 
 
 Thinning and increased curvature of the cornea sometimes occurs 
 while its substance remains transparent. This condition is known as 
 conical cornea. A cone-shaped prominence involves a part or the 
 whole of the cornea. Its summit is always blunt and its sides vary 
 much in height and abruptness. This can usually be seen with the 
 unaided eye. When simple inspection or the oblique illumination 
 fails to detect an elevation of this kind, the ophthalmoscope may be 
 employed. Using only the mirror and reflecting the light upon the 
 eye from different angles, the side of the cone opposite the light will 
 appear shaded or darkened. But such a test will not be needed, ex- 
 cept in slight degrees of the affection. 
 
 Elevations and depressions of the surface at any point 
 must not only be recognized, but must be distinguished from each 
 other. "With the binocular ophthalmoscope alterations in surface level 
 
24 Diseases of the 
 
 appear in their true characters, but the case is different with the mo- 
 nocular instrument. With the latter, attention must be directed to the 
 course and appearance of the vessels, for as these ascend or descend 
 from one level to another, they describe a more or less acute curve. 
 A slight alteration in surface level will cause a very slightly percepti- 
 ble curve; but on the other hand, the curve may be so abrupt and ex- 
 tensive as to hide portions of the vessels from view. 
 
 If the details of a portion of the fundus are clearly focused while 
 those of closely adjacent portions are indistinct, we may suspect a rel- 
 ative difference in surface level unless the appearance can be ac- 
 counted for by slight opacities, astigmatism or otherwise. 
 
 To ascertain whether a part is elevated or depressed, the tests for 
 hypermetropia and myopia respectively should be applied. An ele- 
 vated portion of the fundus will lie within the principal focus of the 
 dioptric media and therefore be hypermetropic. The floor of a depres- 
 sion lies beyond the principal focus of the dioptric media and is myopic. 
 By the direct method an image of each condition can be seen at a 
 distance, the first erect and the second inverted. An elevation or de- 
 pression in the base of the eye can be measured by mathematical cal- 
 culations founded upon accurate estimates of the states of refraction 
 of the summit and base of an elevation, and the margin and bottom of 
 a depression. 
 
 SECTION THREE. 
 
 The lids are subject to the same diseases as other parts of the 
 general integument, and require the same treatment. 
 
 The edges of the lids are especially liable to inflammation (bleph- 
 aritis), and the glands may also become involved (blepharaden- 
 itis). The edges of the lids are first hyperseinic, then swell and 
 become smooth and glossy. The altered secretion and discharges 
 form small yellowish scabs, which adhere to the lashes. The latter 
 fall out, and if replaced are apt to be stunted and ill-formed. When 
 the edges become hardened, the condition is called tylosis ; when the 
 lashes are shed, madarosis. 
 
 When blepharitis is due to ametropia the refraction should first 
 be corrected. When due to disease "cleanliness is an excellent rem- 
 edy, and to that end the matted lashes should ' be separated, and the 
 
Eye and Ear. 25 
 
 scabs carefully soaked and sopped away with a solution of soda (live 
 grains to the ounce of distilled water), and cold cream or simple cerate 
 applied. Should the disease be persistent, graphites ointment (three 
 or four grains to the ounce of vaseline) may be used. The other 
 troubles yield to the cure of this disease. Belladonna, silica, cal- 
 carea carbonica and graphites are among the best internal remedies. 
 
 Styes, or boils in the connective tissue, often appear singly or in 
 groups. They are generally due to some derangement of health, which 
 requires attention. If this is not the case Pulsatilla or staphysagria 
 will remove them. 
 
 A chalazion, or tarsal cyst, is caused by the obstruction of the 
 orifice of a sebaceous gland and sequent retention of the secretion, 
 forming a small tumor in the cartilage about the size of a pea. 
 If not removed, inflammation causes them to become filled with pus. 
 They may be removed by gentle evacuation or, becoming firmly seated, 
 by the knife. 
 
 Ptosis is a drooping of the upper lid; trichiasis, an inver- 
 sion of the lashes, whence they rub against the ball. Both affections 
 may be cured by removing the disease causing them, or becoming 
 severe, require the hand of the surgeon. 
 
 SECTION FOUR. 
 
 Diseases of the lachrymal apparatus, unless quickly sub- 
 dued, are likely to prove very obstinate and trying to the practitioner. 
 
 Acute inflammation of the sac (flacryo-cystitis), or an abscess 
 in the tear sac, is often associated with imperforate or misplaced 
 pun eta, nasal catarrh, and a chronic altered condition of the secretions 
 of the mucous membrane of the eye. Exposure to rough winds, or 
 a severe conjunctivitis may bring it about, or it may result from a 
 chronic inflammation of the tear passages. Its earliest symptoms are 
 tenderness, redness and a swelling over the region of the sac and lids, 
 with excruciating pain. If allowed to progress the abscess bursts 
 through the skin and intervening tissue, forming a lachrymal 
 fistula, which usually remains unless surgically closed. 
 
 Hot lotions should be applied locally if the case is well advanced 
 before seen; if not, iced compresses should be used and a thorough 
 endeavor made to abort the attack. Failing in the latter, if unable to 
 
26 Diseases of the 
 
 slit the canaliculi, it is better to open the abscess with a knife than to 
 allow it to burst. Suppuration should then be encouraged with in- 
 ternal remedies (hepar sulphur or silica) as well as local. 
 
 A chronic form of this inflammation (mucocele ) is brought about 
 by the same causes, but is much more difficult to cure. There is a 
 constant irritability of the eye, and a watery condition. This latter 
 condition i's til Heidi urn laolirymaruiin is, however, an accom 
 paniment of lachrymal troubles, and proves very annoying. Strictures 
 form in the duct, the sac varies in size according to the accumulation, 
 and on pressure, a sticky, viscid fluid exudes. Owing to the unpleas- 
 ant sensations, the patient usually presses out this exudation several 
 times a day, obscuring the vision. After a time the caruncle sympa- 
 thizes, and a very troublesome complaint is the result. 
 
 The treatment consists in allaying the irritation, opening up the 
 canaliculi and probing the duct to remove the strictures. Seemingly 
 not difficult, success is not attained easily in old cases. The channel 
 once opened, astringent and antiseptic solutions should be syringed 
 into the sac, and the membrane restored to a normal condition. Mer- 
 curic bichloride, one part to five thousand of distilled water, thus in- 
 jected, is a valuable remedy. Persistence and thoughtful care oftener 
 succeed than routine treatment. Silver probes are the best to use: of 
 varying forms and sizes, they should be gently insinuated through the 
 canals; when the strictures are obstinate and unyielding, they may be 
 forcibly dilated or cut. The bone sometimes becomes affected, com- 
 plicating the case. Inasmuch as syphilis plays an important part in 
 lachrymal troubles, the probability of its presence should be consid- 
 ered. Calcarea carbonica, hepar sulphur and silica are among the 
 best internal remedies in these affections. 
 
 SECTION FIVE. 
 
 Conjunctivitis, as its name implies, is an inflammation of the 
 conjunctiva, a mucous membrane beginning at the continuation of the 
 integument on the edges of the lids and extending over the lids, and 
 by reflection on to the eyeball to the junction with the cornea. It 
 consists of reticulated connective tissue, mainly composed of connective 
 tissue corpuscles with a fibrous intercellular substance. It is richly 
 
Eye and Ear. 27 
 
 supplied with nerves, mainly from the fifth pair, and with blood- 
 vessels. 
 
 These vessels are divided into the anterior and posterior, the for- 
 mer supplying the zone near the ocular conjunctiva, and the latter 
 the posterior zone of that tissue. The anterior zone is connected with 
 the episcleral vessels. 
 
 The arterial vessels are branches of those from the lids and lach- 
 rymal glands, and are reinforced by twigs from the angular, temporal 
 and infra-orbital arteries. The veins anastomose with the orbital 
 veins, and terminate in the vena angularis and temporal veins. The 
 posterior are connected with the anterior, and the anterior with the 
 ciliary system, thus explaning the rosy zone of vessels, with suffusion 
 of the conjunctiva, so strongly marked in iritic and ciliary inflam- 
 mations. 
 
 The classification of conjunctivitis is arbitrary, one form may run 
 into another; but for convenience it may be divided into catarrhal, 
 purulent, granular, diphtheritic and phlyctenular. In general it may be 
 said that hypersemia precedes the catarrhal form, and the catarrhal 
 form precedes the purulent. All may be infectious and contagious, 
 endemic or epidemic; the discharge from one form producing its own 
 kind or that of another. 
 
 Catarrhal Conjunctivitis is caused by contagion, exposure, 
 the exanthematous diseases, foreign bodies and injuries of all kinds,. 
 and less often by ametropia, bad hygiene and over use of the eyes. 
 
 It is not difficult to recognize. The subjective symptoms are a sen- 
 sation of sand in the eye, more or less pronounced, with smarting and 
 itching, while objectively the increased vascularity and lachrymation? 
 with sticking together of the lids, especially after sleeping, render the 
 trouble apparent. To these, when the disease has progressed a step 
 farther, are added a mucous or muco-purulent discharge, containing 
 whitish flakes of albumen and epithelial and mucous cells, chemosis 
 more or less pronounced, and red, swollen and stiffened lids. Not in- " 
 frequently numerous small infra-conjunctival hemorrhages are seen. 
 
 Under proper care it is seldom that the cornea becomes involved in 
 this variety, but in the exanthematous diseases care should be taken 
 that the conjunctiva does not become seriously implicated. Sometimes 
 it does unless watched, and hurrying into the purulent form, involves 
 the cornea, and damages or ruins the sight. This result is not infre- 
 quent in variola. 
 
 Extreme care as to cleanliness, isolation and disinfection of all 
 towels, basins, etc., should be observed, as many cases are violently 
 contagious. 
 
"28 Diseases of the 
 
 If the inflammation is due to ametropia the refraction should be cor- 
 rected by suitable glasses. If no cause is apparent, examine carefully 
 for any local irritation, as from a foreign body, any inturning lashes, 
 etc. 
 
 When the disease is fully established, insist on extreme cleanliness 
 always. Cold applications may be used in the primary stages, with 
 protection to the eyes. Mild, astringent lotions should be employed 
 when necessary, such as two grains of zinc sulphate to the ounce of 
 distilled water, or a similar solution of alum sulphate or argentum ni- 
 trate. Corneal and iritic complications may require atropine. 
 
 Tonic treatment must not be neglected if the patient is at all run 
 down in general health. The disease is usually local, however, ren- 
 dering such treatment unnecessary. 
 
 Purulent Conjunctivitis. The chief causes of the purulent 
 form of inflammation of the conjunctiva are the same as in the catarrhal 
 form, but greatly intensified. The discharge is purulent, thick and 
 highly contagious, the conjunctiva highly swollen, and often great 
 chemosis supervenes. 
 
 There is great danger of the cornea becoming involved, causing 
 ulceration, sloughing, and not infrequently the loss of the eye. The 
 corneal dangers and their treatment should be carefully considered; 
 they are- fully explained in Section Six. The gonorrhceal variety of 
 conjunctivitis is usually very severe, and shows a great tendency to 
 constitutional symptoms, which often are extremely severe, on its 
 inception. Ophthalmia neonatorum may be very mild or very severe, 
 and should be at once checked. 
 
 No eye disease requires greater judgment or a more careful course 
 of treatment than purulent conjunctivitis. Extreme cleanliness is 
 always necessary, and thorough disinfection must be accomplished and 
 maintained. Cleanliness is best accomplished by removing the dis- 
 charge with small pledgets of folded cotton cloth. It is not best to 
 allow the palpebral syringe to be used, as it is difficult to control the 
 danger of infection. 
 
 When the discharge has not set in, the conjunctiva being tense, hot 
 and dry, soothing applications should be employed, such as atropine, 
 and the way carefully felt. When the discharge is fully established, 
 an astringent lotion every few hours may be used, or it may be neces- 
 sary to paint the inner surface of the lids once or twice daily with a 
 strong astringent. A solution of ten grains of silver nitrate to the 
 ounce of distilled water is an excellent one. This should be applied 
 with a camel's hair pencil to the everted upper lid, and neutralized, 
 
Eye and Ear. 2& 
 
 when demanded, by a strong solution of common table-salt and water. 
 Its repetition should be ganged by the severity of the case, but it 
 should not be repeated usually until the discharge reappears. If the 
 cornea becomes cloudy, atropine must be used every three or four 
 hours. Canthoplasty may be performed if the lids press too closely 
 on the globe. 
 
 The non-affected eye should be carefully sealed up, if necessary; 
 in any event the greatest caution should be used that the disease is 
 not communicated to it. Cool or iced applications may be demanded 
 in severe cases. 
 
 In ophthalmia neonatorum, in addition to extreme cleanliness, one 
 drop of a one-grain solution of silver nitrate should be dropped be- 
 tween the lids, night and morning, and a powder of argentum nitricum 
 given every three hours internally. A weak solution of atropia sulph- 
 ate may be used if the cornea becomes cloudy. 
 
 As this disease often greatly drains the system, and the gonorrheal 
 variety particularly so, the strength should be kept up. The room 
 should be disinfected, and everything in use subjected to a similar 
 treatment. 
 
 Granular Conjunctivitis. — The granular form of inflam- 
 mation of the conjunctiva has been known under many names, and 
 been a great bane to the world. The chief causes are catarrhal and 
 purulent conjunctivitis, filth, impure air, and defective hygiene gener- 
 ally. Contagion, perhaps, is the greatest cause of the disease as 
 ordinarily seen. 
 
 Locally this trouble is characterized by hyperemia, swelling, and 
 a peculiar roughness of the palpebral conjunctiva. These changes 
 may be noticed as diffuse, vascular excrescences in the conjunctival 
 tissue, resembling roundish granules; or as hypertrophied papillee. 
 The former is called granular trachoma, the latter, papillary trachoma ; 
 occurring together, as they most often do, mixed trachoma. There 
 may be a discharge, at first thin and watery, gradually becoming 
 thicker and of a muco-purulent character; or the disease may steal on 
 so insidiously as to be established before really suspected. In the 
 latter case the patient generally previously complains of the lids stick- 
 ing together in the morning, with some roughness. When either 
 acute, or established, the eyes are very irritable, accompanied by a 
 sensation of sand, especially under the upper lid, and they become 
 red and watery on attempting to use them. After a short time the 
 lids become puffy, more or less flabby, and limp. All symptoms vary 
 greatly in severity according to the nature of the attack. It is conta- 
 
30 Diseases of the 
 
 gious, often highly so, and all towels, utensils, etc. , should be carefully 
 isolated to prevent the danger of contagion. 
 
 The disease shows great tendency to relapses, acute exacerbations 
 being common. It is often complicated with other diseases. The 
 greatest danger lies in the injury to the cornea. The rough, sand- 
 paper-like lids irritate the cornea, promoting vascularity and pan- 
 nus, or the cornea may ulcerate. The conjunctiva may also become 
 chronically dry (xerophthalmia), the lids be drawn inward at 
 the margin (entropion), or outward (ectropion), the lashes turn 
 in (trichiasis), or the lid or lids become firmly adherent to the 
 globe (symblepharon). 
 
 Nearly always, general complaints accompany or have originated 
 this trouble. It is particularly associated with the badly nourished ; 
 with high, free livers, who crowd their stomachs, drink hot stimulat- 
 ing drinks, remain in smoky rooms, or heated, close atmosphere, and 
 take insufficient exercise. The mind is apt to partake of the bodily 
 weakness in old, advanced cases, and the patient becomes addicted to 
 lazy, indolent habits. 
 
 The local treatment consists of the protection of the eye from 
 injurious influences and the use of a suitable irritant and stimulants. 
 If there are present large, warty granulations, they may be snipped 
 off. It should always be borne in mind that the object of the treat- 
 ment is not to burn off the hypertrophied papillse, but to cause their 
 retraction and to absorb the granulations. To accomplish this they 
 may be gently touched on the exact spot with a finely pointed pencil 
 of cuprum sulphate, or a solution of silver nitrate or other suitable 
 irritant, which must be changed from time to time. After application 
 the irritant should be washed off or neutralized at once, or after a 
 few seconds interval, as the effect desired is produced, and repeated 
 daily or less often according to the success attained. Jequirity, 
 alum, tannin and other stimulants may be useful. The application of 
 cold water is often necessary after irritants have been used. Acute 
 cases, or acute exacerbations of old cases may demand ice-bags. 
 
 It is difficult to convey by words the methods of successful local 
 treatment, but unless it is painstakingly and carefully done, it is more 
 than likely that harm will result instead of benefit. Each case must 
 be studied separately, and a consistent course carried out. 
 
 All exciting causes should be removed, general bathing with fric- 
 tion employed, and good food, air and exercise, with healthy, useful 
 employment, insisted on. 
 
Eye and Ear. 31 
 
 Diphtheritic Conjunctivitis is extremely rare in this 
 country, and only appears in a comparatively mild form. A yellow, 
 tou^h and firm product of inflammation collects in the tissue of the 
 conjunctiva, and on its surface, from which it may often be torn off, 
 like a thick lining of the lids. There are usually the symptoms of 
 intense inflammation in the first stages, with great tenderness to the 
 touch, the lids being hardened by a fibrinous infiltration. The symp- 
 toms vary much according to the case, but generally are severe at 
 first. The lids grow soft as the disease advances, and pus supervenes. 
 The greatest danger is to the cornea, which is apt to suffer severely, 
 and the lids to become cicatrized. The constitutional symptoms are 
 usually marked, and easily diagnosticated. 
 
 The treatment is not very satisfactory. Locally, iced compresses 
 may be used in the first stages, and the treatment of purulent con- 
 junctivitis employed when pus sets in. The strength should be sup- 
 ported and the case treated much as a case of diphtheria of the general 
 system, with which trouble this is usually associated. 
 
 Phlyctenular Conjunctivitis is characterized by small, 
 yellowish-red nodules on the conjunctiva, and is often associated with, 
 and in many respects similar to pustular keratitis. It requires simi- 
 lar treatment. 
 
 Pterygium, or bat' s wing, is usually caused by exposure to hot 
 winds, such as the winds of the sea, of the prairies, etc. It is often 
 sequent to chronic inflammations of the conjunctiva. It consists of a 
 triangular, vascular ridge of hyper trophied conjunctival and sub -con- 
 junctival tissue, usually on the nasal side of the eye, with the base 
 toward the canthus, and the apex adjacent to, or more or less on, the 
 cornea. It is often confounded with pingue Cilia, which may be 
 due to micro-organism parasites, or a deposit of fat, and requires no 
 treatment. 
 
 If remedies are unavailing, and the pterygium persistently en- 
 croaches on the cornea, excision, ligation or transplantation must be 
 employed to remove it. 
 
 Among the internal remedies, aconitum napellus will be found valu- 
 able in all the forms of conjunctivitis in the early stages. It is particu- 
 larly valuable in those cases which begin with much local fever and heat, 
 where it is necessary to quickly break up this condition. In the first stage 
 of catarrhal inflammation, when severe, or when there is a sensation 
 of local heat, it is always indicated. In acute exacerbation of chronic 
 granulated lids it is also indicated. It is of little value, however, 
 when once the second stages have set in, or when the boundary is 
 
32 Diseases of the 
 
 passed in the catarrhal form, and the purulent form has set in. To 
 subdue local inflammation after a hot cinder, or other foreign body, 
 has been removed, it will be of value in conjunction with local reme- 
 dies. The latter, however, will generally render it unnecessary. 
 
 Apis mellifica is a valuable remedy when the lids are swollen and 
 stinging, with a general cedematous condition. The parts have that 
 peculiar appearance as if a bee had stung them. 
 
 Argentum nitricum has long enjoyed the reputation of locally cur- 
 ing the purulent forms. It is also an excellent internal remedy in 
 these forms, but is useful in the first stages only of the granular form. 
 
 Arsenicum is useful in the first stages of the catarrhal and granu- 
 lar forms, and the various stages of the pustular form, when there 
 are burning pains especially at night. Periodicity of attack, and 
 alternate shifting from one eye to the other also indicate its use. 
 
 Belladonna is useful in the first stages of conjunctivitis, that is in 
 the precedent hyperemia and catarrhal forms, but is of no use when 
 the purulent form has set in. In the early stages it will meet such 
 symptoms as smarting and burning pains, with dryness and heat, and 
 marked photophobia. Often the face is red and swollen, with head- 
 ache. Acute attacks in chronic cases may demand this remedy. 
 
 Euphrasia finds in the conjunctival troubles an appropriate sphere 
 of action; When called for, there are profuse, acrid burning lachryma- 
 tion, and a thick, profuse yellow discharge, which run down on and ex- 
 coriate the cheek. Owing to the presence of this discharge on the 
 cornea, vision is more or less impeded, but relieved by the act of wink- 
 ing, which washes down the obstructing secretion. It must not be de- 
 pended on in the purulent form, however, as it will seldom be of suffi- 
 cient power to bring about a healthy resolution. More especially is 
 this the case if the cornea is threatening suppuration. 
 
 Graphites is not a very useful remedy in any of the conjunctival 
 forms but the pustular. When the external canthi crack and bleed 
 easily, and eczematous eruptions appear behind the ears, the dis- 
 charges being thin and excoriating, the nose participating, with a gen- 
 eral scabby condition, and dry scurfs, with a decided tendency to re- 
 cur, its use will be strongly demanded. 
 
 Hepar sulphuris must always be thought of when, in the purulent 
 form, the cornea has become implicated, and there is a strong suppu- 
 rative tendency or suppuration has actually set in. It may be useful 
 where there is a muco-purulent discharge. 
 
 Ipecacuanha is an admirable remedy for subduing the pustular 
 form. 
 
Eye and Ear. 33 
 
 Mercurius is a valuable remedy. Special indications are found in 
 the profuse, burning, muco-purulent discharges. They are thin, acrid 
 and excoriating. Syphilitic subjects particularly require its use, and 
 the well-known train of symptoms classed under this name will guide 
 in its selection. 
 
 Nitric acid may be used in gonorrheal ophthalmia, in conjunction 
 with local treatment. 
 
 Pulsatilla nigricans is a valuable remedy in almost all forms of con- 
 junctivitis. In the catarrhal form when occurring in the characteristic 
 subject, with a bland, thick discharge, it is indicated, and especially in 
 this form resulting from an attack of the measles, or from taking cold. 
 
 Rhus toxicodendron is valuable when the inflammation is caused 
 by exposure to the wet, with an cedematous swelling of the lids. 
 
 Sulphur is the remedy for certain forms of, and conditions associ- 
 ated with, phlyctenular conjunctivitis. Agglutination in the morning, 
 marked photophobia and profuse lachrymation, burning and biting in 
 the eye, with sharp lancinating pains, are indications for its use. 
 Chronic, scabby cases, occurring in scrofulous children, will be bene- 
 fited by its administration intercurrents with other remedies. 
 
 SECTION SIX. 
 
 The cornea is a horn-like substance, and supplies the anterior 
 one-sixth of the external tunic of the eyeball. It is a transparent, 
 firm, elastic, fibro-cellular membrane, and is to some extent a direct 
 continuation of the sclerotic, with which it forms the outer covering 
 of the globe, and into which it fits as a watch-glass fits into its frame. 
 Its average thickness is one millimeter, or -jV of an inch, growing thin- 
 ner from the center toward the margin. 
 
 The cornea is also a laminated membrane, consisting of five distinct 
 layers. The first, or outer layer, is composed of epithelium — the con- 
 tinuation of the epithelium of the conjunctiva, and is about 25 3 00 of an 
 inch thick. The second layer (Bowman's membrane) is a firm, elastic, 
 homogeneous membrane, -j-gVo t° toVo" °^ an mca thick. The third 
 layer (the true cornea) consists of fibrous and connective tissue in the 
 form of lamellae, and constitutes the chief bulk and strength of the 
 cornea. Its thickness is nearly -£% of an inch, and it is a modification 
 of the sclerotic, with which it is continuous. Between the lamellae 
 
34 Diseases of the 
 
 and the fibrils, of which they are composed, are spaces filled witb 
 serum and lymph, with corneal corpuscles and wandering cells. The 
 spaces anastomose, and form a system of canals, through which the 
 cornea receives its nutriment, for the cornea in health has no blood- 
 vessels (except at the extreme periphery), but derives its nourishment 
 from the numerous vessels surroundiDg its margin. These vessels are 
 derived from the episcleral branches of the anterior ciliary arteries. 
 It is exceedingly well supplied with nerves, having from thirty to forty 
 twigs entering its substance, and forming complicated plexuses be- 
 neath Bowman's layer and behind the true cornea. From these net- 
 works of nerves, numberless little fibers proceed outward to terminate 
 among the epithelial cells of the external layer. 
 
 The fourth layer (Descemet's membrane) is from a5 1 0o to 3-3V0 °f an 
 inch in thickness — an elastic, structureless membrane. The posterior 
 layer of the cornea — the fifth — is a very thin layer of epithelium cover- 
 ing Descemet's membrane. 
 
 Keratitis. In general terms, it may be said that inflammation 
 of the cornea is caused by inflammation of the adjacent parts, by con- 
 stitutional disease, by bad nutrition, by injuries and by exposure. 
 
 The most common adjacent inflammation which is liable to affect 
 the cornea, is conjunctivitis. Purulent conjunctivitis cuts off the 
 nutrient supply which the cornea needs, and not unfrequently brings 
 on destructive ulceration, and sloughing. Neglected granulations on 
 the lids, by constantly rubbing over the surface of the cornea, excite 
 roughening, cloudiness and vascularity of its surface, which, if un- 
 checked, end in ulceration. 
 
 It is owing to the great importance of the cornea as a part of the 
 organ of vision that the results of inflammation are so much to be 
 dreaded, for not only are destructive changes apt to be rapid, but the 
 changes incident to repair are necessarily slow. 
 
 Of all constitutional diseases which bring about inflammation of 
 the cornea, the most strikingly characteristic is hereditary syphilis. 
 Strumous subjects are especially liable to its ravages, and syphilitic 
 and scrofulous keratitis were formerly confounded. Poorly fed and 
 scantily clothed children, who are subject to the vicissitudes of pov- 
 erty, fall an easy prey to corneal affections, and the same is true of 
 persons suffering from great debility of any kind. Corneal incisions 
 in cataract operations ; blows and wounds of all kinds upon its surface 
 have a marked tendency to inflammation, and trivial causes should 
 never be overlooked. 
 
 Inflammations of the cornea assume various forms. Independ- 
 
Eye and Ear. 35 
 
 ently of the peculiar characteristics of each form or variety, there are 
 certain symptoms common to all varieties. These attendant symp- 
 toms are ciliary irritation, a rosy zone of vessels around the corneal 
 margin with conjunctival congestion, contraction of the pupil, pain, 
 photophobia and lachrymation, and impaired vision. 
 
 Perhaps the most characteristic of the attendant symptoms just 
 given is the contraction of the pupil. This and the pain are due to 
 ciliary irritation. The ciliary irritation also produces others of the 
 symptoms, including the zone of vessels mentioned. In many cases, 
 photophobia, with sequent lachrymation, is due to loss of the epithe- 
 lium (the outer layer), thus exposing the terminal filaments of the 
 ciliary nerves. The impaired vision may be due to corneal opacity in 
 front of the pupil, to turbidity of the aqueous humor from exudation 
 of lymph, or to the indirect influences upon the retina of the inflam- 
 matory process in the other parts. 
 
 Keratitis may involve the whole or a part of the cornea, and is 
 named according to the predominant kind of inflammation present. 
 For convenience it may be divided into vascular, pustular, suppurative 
 and interstitial. 
 
 Suppurative Keratitis is the form which forebodes the 
 greatest danger to the vision, and which unrestrained accomplishes 
 almost certain destruction of the cornea. The infiltration changing 
 into pus characterizes the form. 
 
 The chief cause of this formidable trouble is some form of purulent 
 conjunctivitis. If this is not speedily brought under control, there re- 
 sults a destruction of corneal tissue. If this is controlled before perfora- 
 tion takes place, an opacity forms of size, density and shape pro- 
 portionate to the slough, and affects vision by intercepting the rays of 
 light, in a greater or lesser degree, according to its situation in or ap- 
 proximation to the visual axis. When such opacity forms in the 
 epithelium, it is called nebula: when in Bowman's layer, albugo. 
 But should perforation take place, a prolapse of the iris results 
 (hernia iridis), and if allowed to remain, plugs up the hole and becomes 
 attached from the lymph poured out. Nourished from the highly 
 vascular supply of the iris, this prolapse may become firmly impacted 
 with the corneal tissue (leucoma adherens). 
 
 If the tendency to necrosis is not rapid, the inflammatory infiltra- 
 tion changing into pus appears as a yellowish product in the cornea, 
 forming an abscess. Should an abscess burst, it forms an ulcer. 
 But ulcers also form without precedent abscess. If the pus lie simplv 
 between the plates, the peculiar shaped appearance, which it makes 
 
36 Diseases of the 
 
 from sinking in accordance with the laws of gravity, is called onyx or 
 lunella. Perforating the plate backward, the pus escapes into the 
 aqueous chamber and forms hy popioil separately or in conjunction 
 with lunella. When the inclination to sloughing is rapid, and 
 the cornea becomes turbid, swollen and thinned, it may burst and its 
 contents prolapse, forming anterior staphyloma. Should this 
 dangerous accident happen, vision is almost sure to be damaged or 
 destroyed. A combination of causes tends to bring about this dreaded 
 result, but the most potent cause is an increase of intra-ocular tension 
 through the hypersecretion of the aqueous humor, and the latter is 
 more surely brought about if the iris becomes implicated in the disease. 
 
 When the cornea and iris have become staphylomatous, the irri- 
 tation caused by such a condition jeopardizes the companion eye, 
 while the unsound one is left in its place. The removal of such a 
 damaged eye is often advisable to protect the other from sympathetic 
 ophthalmia. Some prefer to excise the anterior portion only of the 
 globe. The contents are then evacuated, and the remnants brought 
 together form a good stump for an artificial eye, but the danger of 
 sympathetic trouble still remains to a certain extent. 
 
 A pressure bandage may be applied to overcome the intra-ocular 
 pressure and paracentesis (fully explained in Section Seven), or iri- 
 dectomy performed. The former is a palliative measure, needing fre- 
 quent repetition, but the latter once performed is usually sufficient. 
 
 For treatment one of the first indications is to support the general 
 strength, and thus indirectly the corneal tissue. Even though this 
 is successful only in part, a cornea tending to suppuration may be so 
 strengthened that it will only bulge, and the main shape of the globe, 
 though with dulled sight, on account of the changed curvature of the 
 refracting surface of the cornea, be maintained. The supporting of 
 the strength being attended to, attention may be given to the local 
 treatment. This, in the beginning, should consist of atropine, rest 
 and pressure. The two latter are attained by the use of the pressure 
 bandage. Bandaging is one of the most important things in this con- 
 nection, for by its use, cases which yield to no other remedy quickly 
 succumb to it. Occasionally eserine does better than atropine, prov- 
 ing itself of value when atropine fails. It is also at times specially 
 indicated for its myositic action, as when the perforation is near the 
 periphery, it then drawing the iris away from the wound by stimulat- 
 ing its contractility. No irritant, such as silver nitrate, or any of 
 the lead preparations, are permissible in acute keratitis. Old, chronic, 
 indolent ulcers, showing little disposition to heal, may sometimes with 
 
Eye and Ear. 37 
 
 advantage, however, be touched with weak silver nitrate to stimulate 
 them, but superficial opacities generally recover without remedial aid. 
 All local irritants hasten tissue changes. 
 
 It is not wise to allow large abscesses to burst; paracentesis 
 should be performed through their bases. ^Whenever the iris pro- 
 lapses, it is best to snip it of with the scissors unless it will draw in 
 uflder the action of a mydriatic or a myositic. 
 
 For the pain, which is sometimes very severe, hot water is usually 
 sufficient. This not only allays the pain, but promotes the efficacy of 
 the atropine and assists the process of healing. 
 
 A large opacity gives an unsightly appearance to the eye. and to 
 cover this, and thus greatly improve the personal appearance, the 
 operation of staining the cornea with India ink has been devised. 
 Staining or tattooing the cornea is not without its dangers, owing to 
 the inflammation it may set up. It is preformed by rapidly punctur- 
 ing the superficial layers of the cornea with a number of fine needle 
 points dipped in a solution of India ink, many sittings beiDg required 
 to perfect the operation. Other solutions of various tints are used, 
 and skillful hands will often give a remarkably natural appearance to 
 an eye whose unsightly appearance greatly annoys its possessor. An 
 opacity situated so as to entirely obstruct vision, may be surmounted 
 by making an artificial pupil in a remaining clear portion of the 
 cornea. 
 
 Vascular Keratitis is characterized by gray opacity of. and 
 development of vessels on, the roughened surface of the cornea. It is 
 a tedious disease, but as time goes on the vessels grow smaller, grad- 
 ually withdraw toward the palpebral margins, and slowly disappear, 
 though often failing to leave the cornea clear. The differential diag- 
 nosis between it and pannus is explained farther on. 
 
 For local treatment, protection and rest of the eyes, with hot water 
 and atropine have been found best. In cases of excessive inflamma- 
 tion, cold applications may be found useful. 
 
 The general system is always at fault, and must receive careful 
 attention. 
 
 If a case of suspected vascular keratitis is examined carefully it 
 may be found that instead of a precedent hyperemia and sequent del- 
 icate vascular loops pressing into the cornea, which are characteristic 
 of vascular keratitis, there is an hypertrophied epithelium with a super- 
 ficial, coarse and abundant supply of vessels, which, though closely 
 simulating the former at a hasty glance, are seen to be quite different 
 in the respects pointed out. This is paimu*. and the essential dif- 
 
38 Diseases of the 
 
 ference is this — that the epithelium is hypertrophied and firmly adher- 
 ent, while in the vascular form of the keratitis the epithelium is loosely 
 adherent, often shed, and when so, the cause of severe and protracted 
 pain. On the contrary, there is never any pain from pannus, for it 
 securely covers the terminal nerve filaments, rendering them inaccessi- 
 ble and free from exposure, the cause of pain. 
 
 Pannus is most frequently caused by neglected granular conjunct- 
 ivitis, or other diseases of the lids, which, by constant rubbing over the 
 surface of the cornea, promote irritation and vascularity. When fully 
 developed vision is partially or totally obscured. Successful treat- 
 ment of the granulated lids or inverted lashes which cause the pannus, 
 will generally be followed by its disapearance, but it is not always so 
 easily cured. 
 
 In cases of total pannus, after all the other remedies have failed, 
 inocculation with jequirity may be tried. 
 
 Phlyctenular Keratitis is characterized by circumscribed 
 inflammatory nodules, singly or in groups, in the superficial layers of 
 the cornea, oftenest at the margin. Its causes are obscure, but it is 
 particularly associated with the weak, nervous and badly nourished, 
 and shows a strong tendency to become epidemic. Patients who suf- 
 fer from some of the many forms of catarrh are quite likely to contract 
 it. In connection with the eruptions of herpes, eczema, etc. , it ap- 
 pears, or through any irritation of the ciliary nerves. 
 
 After these nodules have remained a short time, vesicles form on 
 them, and bursting, make ulcers. ' By reason of a nerve filament be- 
 coming implicated, these ulcers are the cause of photophobia and 
 pain seemingly wholly out of all proportion to the lesion. The lach- 
 rymation is hot and scalding, all the secretions from the eye become 
 acrid, and flowing over the delicate skin adjacent, render the parts 
 tender and excoriated. It is often combined with a similar form of 
 conjunctivitis. 
 
 The protective bandage, atropine and internal remedies are usually 
 sufficient to cure a mild case. Where the disease seems firmer seated, 
 with much photophobia, pain and lachrymation, and the patient, espe- 
 cially if a child, is inclined to bury the head in the clothes, or force it 
 down upon the chest, a compress bandage may be needed. Absolute 
 cleanliness of the lids and eye is essential, and locally a weak solution 
 of mercuric bichloride (one to five thousand), or a mild solution of 
 boracic acid, will be found useful. 
 
 Interstitial Keratitis. It is a notable fact in relation to 
 all syphilitic diseases, that it is difficult to draw from the patients, or 
 
Eye and Ear. 39 
 
 from the interested parties, a true history of the case. Sometimes a 
 full and free confession will be made at once; but more often ques- 
 tions are evaded or all knowledge of the nature of the disease is de- 
 nied. However, in any well-marked case of a hereditary nature, de- 
 nials are of little avail. The symptoms are as full of meaning, and 
 point as plainly to the nature of the affection as words of the most 
 graphic kind. 
 
 Interstitial Keratitis usually occurs between the ages of five and 
 eighteen years in children who have inherited syphilis. It is a disease 
 of slow progress, usually attacking one eye first, and in the course of 
 a few days or weeks extending to the other. 
 
 At the outset of an attack of this disease, the cornea, on close in- 
 spection, presents a faint, cloudy appearance in one or more spots, 
 or numerous little dots of a hazy appearance are scattered through its 
 structure. Before these have become clearly visible, the patient has 
 usually been annoyed by some slight photophobia and lachrymation. 
 As the disease advances, the whole cornea becomes more or less 
 opaque, assuming somewhat the appearance of ground glass. The 
 opacity of the cornea, from the beginning to its height, is due to the 
 progressive infiltration of its structure with a grayish or yellowish - 
 white product. ' This infiltration shows very little tendency to break 
 down and usually remains collected more densely in some regions than 
 in others. By the time the disease is well advanced in one eye the 
 other generally begins to be affected. Six to eight weeks is usually 
 sufficient to develop a well-marked case, though the disease may reach 
 its height in much less time. Cases may be mild or severe; rarely the 
 cornea becomes almost completely covered with vessels. Under proper 
 treatment, most cases recover, but the disease may recur, and the 
 vision remain much damaged. 
 
 The features to which attention is drawn, are peculiar accompani- 
 ments of the inherited syphilitic taint. These are the scarred and 
 flabby skin usually present in these patients, with the flattened bridge 
 of the nose, and the small, irregular teeth with the peculiar vertical 
 notch of the upper central incisors. 
 
 If a case appears to be at all doubtful, or if while the cornea shows 
 unmistakable evidence of changes similar to those described, the usual 
 accompanying characteristics of the disease are absent or obscure, 
 careful investigation may reveal other conditions equally conclusive. 
 
 The history of specific disease in the parents may be sought out. 
 The forms of disease to which the patient has been subjected should 
 be ascertained, and if these correspond to any of the many affections 
 
40 Diseases of the 
 
 due to hereditary syphilis, the evidence is more complete. Chronic 
 enlargement of glands, ulcers in the throat, psoriasis, exostoses, etc. , 
 are all manifestations of the true nature of the difficulty; some of 
 these are usually present, or have been. But the most constant, 
 peculiar and reliable symptom is to be found in the malformation of 
 the teeth. The permanant set, upper central incisors, are the ones 
 which require particular notice, though the others often are small, 
 dark-colored and misshapen. The various forms should be familiar- 
 ized, and not all notched teeth declared due to syphilis, even though 
 the upper central incisors are the ones affected. 
 
 After the malformations of the teeth, the next most reliable indica- 
 tions are in the condition of the patient's skin, and the shape and 
 structure of the nose and forehead. The skin has a dull, heavy ap- 
 pearance, is usually thicker than ordinary, and covered with seams and 
 scars, the result of previous eruptions. The mouth often shows at the 
 corners seams extending out into the cheeks; these are not constant, 
 however. The frontal eminences are large and prominent; the bridge 
 of the nose is often broad and sunken. The state of the finger-nails 
 is sometimes charasteristic, being broken and split, but not so constant 
 as that of the hair, it being dry and scanty. 
 
 If the case is one which has passed through the eye troubles pecu- 
 liar to the affection, a hazy state of the cornese may be seen, and a 
 lusterless condition of the irides behind them. But there is no devia- 
 tion from the normal appearance in eyes which have not thus suffered, 
 they retaining their natural brilliancy, sometimes seemingly bright- 
 ened by the appearance of the surrounding skin. 
 
 Statistics show that a very large percentage of cases of interstitial 
 keratitis occurs between the ages of eight and fifteen years. Enlarge- 
 ment of the glands, so common in strumous subjects, are nearly always 
 absent. Numerous special affections are accompaniments of the dis- 
 ease. Among these are deafness, tinea tarsi, cicatrices in the soft 
 palate and pharynx, enlarged joints, etc. Another marked point is 
 that the patient is generally the eldest of the family. Failing in this, 
 the next in numerical order is usually the one afflicted. 
 
 It is extremely seldom that one eye only is affected. Both partici- 
 pate in the process of the disease, but seldom is the attack simultane- 
 ous, but at the interval of a few days or a few weeks. Iritis is not a 
 frequent accompaniment, and when present it is not of that violent 
 type noticed when the syphilis is acquired, and it is rare to find the 
 pupil occluded as the result. 
 
 The subjects of this disease are also usually members of a family 
 
Eye and Ear. 41 
 
 in which infantile mortality has been well marked. When such has 
 not been the case, the subjects have presented the usual infantile 
 accompaniment (rash, anal ulcers, prolonged snuffles or sore mouth), 
 or been "exceedingly difficult to raise," being delicate and sickly in 
 infancy, and often puny in childhood. 
 
 If seen early, and before the cornea has become involved to a great 
 extent, a favorable prognosis may be given. In the severest cases, if 
 the eyes are extremely intolerant of light, a much more guarded 
 opinion must be expressed. Changes take place in the structure of 
 the cornea, and often on recovery from the photophobia sufficient to 
 permit, it will be discovered that the cornea is misshapen. Some- 
 times it breaks down completely, though more often it will rally from 
 the severest form of apparent destruction. The co- existence of inflam- 
 mation of the deeper structures, especially the choroid and retina, 
 may \)Q suspected, and the influence of their damaged condition taken 
 into account in making an estimate of the probable condition of the 
 sight. 
 
 But little can be expected in the way of prophylaxis. The rem- 
 edies so powerful in acquired syphilis are impotent in the hereditary 
 form. The patient should enjoy, when possible, the advantages of 
 change of air and scene, a liberal diet, etc., for even though these do 
 not really accomplish anything in a prophylactic way, they conduce 
 to a healthy condition and tone of the general system. 
 
 The treatment should embrace a good supporting diet and a care- 
 fully selected internal remedy. Locally, many cases need nothing more 
 than protection by blue glasses and rest; in severe cases, without 
 atropine and a supporting bandage, blindness might result. The 
 various mydriatics and myositics must be thoroughly studied, and 
 used or changed as good judgment and experience shall dictate. 
 Where there are severe photophobia, blepharospasm, lachrymation 
 and intense pain, it may be necessary for an attendant to open the 
 eyes occasionally and keep them open. When atropine affords no 
 relief by reason of its not being absorbed even after the most care- 
 ful attempts with hot water or steam, iced water dropped on the 
 cornea for a few minutes, and repeated often daring the twenty-four 
 hours, will relieve. Such treatment should be used carefully, how- 
 ever, for fear of other troubles resulting. 
 
 Among internal remedies, aconite will be found useful in ulceration 
 of the cornea, when the characteristic symptoms are present, and the 
 patient is restless, thirsty and feverish. A dry condition of the con- 
 junctiva is an indication for its employment. Ulcers due to injury 
 also call for this remedy. 
 
42 Diseases of the 
 
 Apis is indicated when there are stinging pains, with a swollen, 
 cedematous condition of the lids. A tendency to swelling of all the 
 adjacent parts is well marked in the condition referred to, accompa- 
 nied by the characteristic pains. Chemosis is often well met by this 
 remedy. 
 
 Argentum nitricum is a standard remedy in the ulceration of the 
 cornea, often attendant on the form of conjunctivitis known as oph- 
 thalmia neonatorum. 
 
 Arsenicum has been used to great advantage in those forms in 
 which the ulceration is accompanied by profuse and burning lach- 
 rymation with intense photophobia. The pains are worse at night, 
 and are burning and sticking. The lids are often spasmodically 
 closed, excoriated by the acrid lachrymation, and swollen. 
 
 Calcarea carbonica has been found one of the most useful of 
 remedies. It is especially adapted to the form of keratitis occurring 
 in fat, unhealthy children, who are extremely liable to take cold. 
 The scrofulous diathesis particularly calls for this remedy. 
 
 Cimicifuga has been found very useful in wandering, shooting, 
 pains, in connection with deep ulceration. 
 
 Conium maculatum has the power of relieving the marked photo- 
 phobia in superficial ulceration of the cornea, whereby the terminal 
 filaments of the nerves in Bowman's layer become exposed. This 
 trouble is one of the commonest and severest in apparently slight 
 ulceration, for on casual inspection there seems to be but little cause 
 for the intense pain, there being little or no redness of the conjunct- 
 iva. The lids are usually closed spasmodically, and on being opened 
 the tears gush forth. The body is bent upon itself, and the head 
 often held down firmly upon the body. . 
 
 Graphites is an excellent remedy, and when prescribed according 
 to its indications, gives good results. It is specially valuable in 
 corneal ulcerations which occur in scrofulous children with eczematous 
 eruptions, especially when these eruptions are found behind the ears. 
 An acrid discharge from the nose, which is often covered with scabs, 
 is frequently present. Bleeding and cracking of the external canthus 
 usually accompany the other troubles when this remedy is indicated. 
 
 Hepar sulphuris is invaluable in the suppurative form. Evacua- 
 tion of pus from the anterior chamber is rendered unnecessary by the 
 use of this remedy. Abscesses of the cornea frequently require no 
 other internal remedy. 
 
 In superficial ulceration, mercurius finds its sphere of action; in 
 the deep, sloughing forms it is not so reliable. It is often called for 
 in the vascular form, and not infrequently in the phlyctenular. 
 
Eye and Ear. 43 
 
 Superficial ulcers are benefited by the administration of nux vom- 
 ica. It is also an excellent remedy in the neuro-paralytic forms. Its 
 well-known power after drugging is not to be forgotten. 
 
 Pulsatilla is one of the mainstays in the pustular form, when occur- 
 ring in the characteristic subject. 
 
 Rhus toxicodendron does good service in the superficial forms when 
 produced by getting the feet wet, or as the result of wet clothing. 
 Chemosis yields to its administration. 
 
 Spigelia is useful in the sharp, shooting pains which pierce in deep 
 ulceration. The eyeballs hurt on moving them, and seem as if too 
 large for the orbits. 
 
 Sulphur is said to have an immediate effect on the sharp, sticking 
 pain — pains as if a needle were thrust into the eye. 
 
 SECTION SEVEN. 
 
 The iris is a circular curtain or diaphragm stretched across the 
 anterior portion of the eyeball just behind the cornea, and perforated 
 a little to the nasal side of its center by a circular opening called the 
 pupil. It divides the anterior portion of the eyeball into two cham- 
 bers, the anterior and posterior, which are occupied by the aqueous 
 humor, in which fluid the iris is suspended. The pupillary margin 
 rests upon the anterior capsule of the crystalline lens. Upon this 
 surface it glides smoothly in the movements of contraction and dila- 
 tation. 
 
 Through the pupil the anterior and posterior chambers communi- 
 cate, and through the same aperture all of the rays of light pass to 
 the retina. Until the seventh month of foetal life there is no pupil, 
 its place being covered by the pupillary membrane. 
 
 The iris is to a great extent continuous with the ciliary muscle 
 which lies at its circumference; it also is firmly attached to the pos- 
 terior layer of the cornea by the suspensory ligament (ligamentum 
 pectinatum). The continuation of these fibers into the iris gives the 
 latter its fibrous element. The stroma is composed of connective tissue 
 continuous with that of the ciliary body and choroid; and within its 
 meshes lie numerous blood-vessels, nerves, lymphatics, and a great 
 number of pigment cells, which make up the parenchyma. 
 
 The arteries are derived from the ciliary, and form the greater 
 
44 Diseases of the 
 
 arterial circle of the iris. This lies in the ciliary muscle, and from it 
 numerous branches are given which run toward the pupil, near the 
 margin of which the lesser arterial circle is formed. The veins pass 
 backward and empty into those of the choroid. 
 
 The nerves are derived from three sources — the third, the fifth and 
 the sympathetic. The muscular fibers, chiefly involuntary, consist of 
 two sets, the circular and the radiating. The former surround the 
 pupil, forming the sphincter of the pupil, the latter converge from the 
 ciliary border toward the pupil, uniting with the sphincter. The 
 action of the third nerve is manifested by contraction of the pupil 
 through its influence on the sphincter muscle of the pupil; the action 
 of the sympathetic is manifest by dilatation of the pupil through its 
 influence upon the dilator muscle of the pupil. 
 
 The movements of the iris are reflex through the action of light 
 upon the retina, and accommodative, depending upon the action of 
 the ciliary muscle in accommodation. 
 
 The iris is a very highly organized structure, exceedingly delicate, 
 and therefore nature has well provided for its protection. Behind 
 the firm and protecting cornea, suspended in a fluid which affords 
 equal pressure in all directions, it appears very unlike the frail mem- 
 brane that it is. Removed from its aqueous chamber, it often has 
 scarcely more consistence than a spider-web. Yet its nervous and 
 vascular supplies are so abundant, its relations to adjacent organs so 
 close, and the part it plays in the visual act so important, that not 
 only is it peculiarly susceptible to take on inflammation from slight 
 causes, but the changes wrought by inflammation, neglected or im- 
 properly treated, are especially to be dreaded. 
 
 The causes which produce iritis are numerous, but the chief ones 
 are exposure, rheumatism, syphilis, injuries, and the extension of in- 
 flammation from adjacent parts. It also forms an important part of 
 those serious diseases known as sympathetic ophthalmia and glaucoma. 
 
 Any classification of iritis is arbitrary; nevertheless it has dis- 
 tinctive characters, so for convenience it may be divided into three 
 forms: The plastic, characterized by plastic exudation; the se- 
 rous, characterized by hyper-secretion of the aqueous humor; the 
 parenchymatous or suppurative, characterized by well-defined 
 nodular masses, which are reddish- brown at first, then yellowish and 
 tend to suppuration. Each form, however, may run into or be com- 
 bined with another. It may also be either acute or chronic, and may 
 present all degrees of severity. There are symptoms more or less 
 attendant on all varieties. These are changes in color and texture of 
 
Eye and Ear. 45 
 
 the iris (a light iris becomes greenish, a dark iris brownish -red); alter- 
 ation in form and mobility of the pupil (the iris being sluggish) ; suf- 
 fusion of the conjunctiva, with a zone of vessels around the corneo- 
 scleral junction, which zone may be red, blue or brown; pain, which 
 is variable and maybe absent; photophobia and lachrymation; and 
 the vision always impaired. 
 
 The symptoms which mark a case of iritis are but the manifestation 
 of other changes as well; for seldom, if ever, does the iris take on 
 inflammation without the parts in close anatomical relations sharing 
 in the disturbance. The iris is a continuation of the ciliary body and 
 of the choroid, and these always suffer to a greater or less extent 
 when the iris is diseased. 
 
 Pain is a symptom of iritis which is more or less constant. It may 
 be slight, amounting to only to an uneasy feeling about the eye and 
 corresponding side of the head, or it may be an intense, unbearable 
 pain, shooting, throbbing, sticking in character. Its favorite seat is 
 usually over the brow or along the side of the head or down the side of 
 the nose. It intermits at times, and is usually much worse at night. 
 ' Until iritis is fully established many of the symptoms simulate 
 those of keratitis and other diseases; so, as would naturally be ex- 
 pected, the most reliable diagnostic symptoms are the changes which 
 may be seen to take place in the iris itself. The changes in the color 
 and texture of the iris are always observable features of the disease, 
 and need not be mistaken in any case where the patient has two eyes 
 and only one is diseased. The iris loses its brilliant color; its texture 
 and hue become coarse and confused and muddy. Often the aqueous 
 humor is turbid, and this apparently adds to the abnormal appear- 
 ances in the iris itself. The iris is also very sluggish, and reacts but 
 slowly to the influence of light. The application of atropine to the 
 affected eye may be followed by slow dilatation of the pupil, or the 
 pupil may dilate irregularly, showing partial adhesions of the iris to 
 the lens, or it may not dilate at all, owing to its whole circumference 
 being adherent to the lens capsule. Synecliise are adhesions of 
 the iris to either the cornea or anterior lens capsule, and these condi- 
 tions are • called anterior and posterior, respectively. When the area 
 of the pupil is encroached upon by exudation, the condition is called 
 occlusion of the pupil ; when the pupillary margin is entirely adherent 
 to the anterior lens capsule, exclusion of the pupil. 
 
 The rosy zone of vessels around the corneal margin is always pres- 
 ent in this disease; it is due to congestion of the sub -conjunctival ves- 
 sels around the cornea, these vessels anastomosing with those of the 
 
46 Diseases of the 
 
 iris and choroid. The conjunctiva maybe so reddened and swollen as 
 to obscure this symptom altogether, and the amount of the subcon- 
 junctival congestion differs much with the severity of the disease. 
 
 Photophobia and lachrymation are very common symptoms of acute 
 iritis, and give the patient much inconvenience and pain upon expos- 
 ure of the eyes to light. 
 
 The impairment of vision in ordinary cases of iritis is due to the 
 turbid condition of the aqueous humor. If the vision is much impaired 
 it is often due to the ciliary body and vitreous humor being consider- 
 ably involved. Tenderness on pressure over the ciliary body is a suf- 
 ficient indication of its implication. 
 
 The essential point in the treatment of iritis is to attack it w 7 ith 
 remedies promptly. Inefficient dilatory treatment allows synechise to 
 become firmly organized and set up much internal trouble. 
 
 Perfect rest for both eyes, the shutting out of bright light, and 
 protection from injurious changes of temperature should be assured. 
 These are best accomplished in all extreme cases by keeping the pa- 
 tient in bed in a darkened room until the active symptoms are over. 
 Except in the very worst cases this is unnecessary though often de- 
 sirable; but where this is impracticable and the patient must go about, 
 or in milder cases, a pad and light bandage to the affected eye to pre- 
 vent movements of the lids, as well as to shut out the light, and a 
 shade, or a flat blue glass to the sound eye, will be the next best plan. 
 The latter precaution may often be wisely omitted. As soon as ex- 
 pedient, however, if it has been found necessary to confine the patient 
 in bed, or a darkened room, send him out of doors. 
 
 It is also essential to secure complete rest for the inflamed iris. 
 For this purpose a solution of atropia sulphate is best, and full dilata- 
 tion of the pupil is the guide, and in most cases is essential to success. 
 Atropia should be continued some days after all inflammation has 
 apparently subsided. In serous iritis, a paracentesis of the cornea is 
 demanded, unless atropine and hot applications relieve early. Par- 
 acentesis is done by thrusting through the cornea at its periphery 
 and parallel to the plane of the iris, a paracentesis needle, thus allow- 
 ing the aqueous humor to escape. Great harm is often done to the 
 delicate parts of the eye by dilatory treatment. Hypopion is well 
 met by remedies, and seldom requires to be evacuated. In the par- 
 enchymatous form, anterior synechise may form and require to be 
 broken up. Iridectomy is often required in serous iritis of a severe 
 type, and may be required in severe parenchymatous iritis due to 
 syphilis. When there is great intra-ocular pressure, atropine will not 
 
Eye and Ear. 47 
 
 always work until the pressure is relieved by paracentesis or other- 
 wise. 
 
 In those cases only in which there are no synechia likely to form, 
 can a mydriatic ever be dispensed with. It is better not to omit it, as 
 even the experienced might err. 
 
 The reason is plain. If there is exudation from the iris, and it is 
 not drawn away from its resting place, the anterior lens capsule, syne- 
 chia must form, and more or less firmly tie down the iris. Neglect of 
 the instillation of a mydriatic for this purpose alone (laying aside for 
 the moment all the other advantages enumerated for it in Section One) y 
 in cases of exudative iritis, will bring about complications not only 
 highly injurious to, but often destructive of, the integrity of the globe., 
 entire loss of sight being a not infrequent result. 
 
 "It is much to be wished that all persons who may, by any possi- 
 bility, be tempted to prescribe for eye disease without knowing any- 
 thing about it, would at least lay to heart the cardinal truth that a. 
 solution of atropine, although it may fail to do good, will in many 
 cases be very serviceable and can scarcely ever do any harm. Astrin- 
 gents, on the other hand, although highly conducive to the cure of con- 
 junctival affections, may be productive of irreparable mischief when 
 either the cornea or iris is inflamed. A commencing iritis treated by 
 a nitrate of silver lotion is apt to be stimulated into a state of inten- 
 sity which is hardly ever seen under other circumstances. ' ' 
 
 The use of cocaine to allay pain in iritis, though usually success- 
 ful in this respect, is attended with danger. To be effective it must 
 be used strong and often, and the effect on the cornea is often disas- 
 trous. 
 
 Pain is best subdued with water as hot as can be comfortably 
 borne. Cloths folded to a size suitable to cover the eye and adjacent 
 regions are to be wrung out dry enough to prevent running and then 
 quickly placed upon the parts, and gently pressed down. They should 
 be allowed to remain but a few seconds, when they should be replaced. 
 Success is brought about by careful attention to the details of this 
 simple affair. Bits of hot wool or similar contrivances may be used, 
 but are not usually successful in severe cases. 
 
 Complications with the neighboring tissues should be kept down. 
 Nothing is more beneficial to iritis than plenty of sleep. Owing to 
 the pain and a general restlessness, this is sometimes difficult to ob- 
 tain, and its accomplishment should receive careful attention. 
 
 The fundus of every eye is colored by the pigment of the 
 choroid and the choroidal blood vessels. The amount, distribution 
 
48 Diseases of the 
 
 and color of the former, and the amount and quality of the blood in 
 the latter, modify the color of the fundus in individual cases. The 
 more pigment the fundus contains, the darker its hue. This is owing 
 to the obscuration of its blood vessels, and the sclerotic. When any 
 part of the fundus becomes destitute of pigment, the white sclerotic 
 is seen shining through. 
 
 In an ophthalmoscopic examination the abnormal conditions of the 
 choroid show these features of importance, viz., hyperemia, inflamma- 
 tion, tumors, coloboma, tubercles, rupture, changes in, or causing my- 
 opia, hemorrhages and detachment. 
 
 Unless one eye only is involved hyperemia is not easily deter- 
 mined. Even then, the varying conditions of pigmentation may mis- 
 lead. However, increased caliber and redness of the choroidal vessels 
 at any point should be regarded as partial evidence; and if, added to 
 this, the optic disc is hypersemic and its outline indistinct, the evi- 
 dence is still more complete. 
 
 Inflammation of the choroid as in retinitis presents 
 several distinct forms, but the exudative presents the most marked 
 ophthalmoscopic appearances. In the other forms the appearances 
 are less definite. 
 
 Exudative choroiditis, or choroiditis disseminata, is a form 
 of choroidal inflammation in which plastic deposits take place. These 
 deposits may take place at any portion of the fundus, but most often 
 they appear first near the periphery and thence extend toward the 
 posterior pole. Their color is yellowish -white or gray, and often quite 
 dull, and their size and shape are subject to many variations. They 
 may be very small at first, not larger than a mustard seed, but as the 
 disease advances they are apt to increase in size and to finally coa- 
 lesce, forming larger and more irregular patches. 
 
 A syphilitic form of the disease begins most often by spots of exu- 
 dation at or near the posterior pole, thence extending by increase of 
 size and number toward the periphery. The spots do not coalesce, 
 and are surrounded by a pale red border. But unless the patient's 
 history confirm the diagnosis, the syphilitic nature of any case can not 
 be fully determined. 
 
 In later stages, the absorption of the exudations begins and pro- 
 gresses until not only they have disappeared, but until the choroidal 
 structure in which they were lodged becomes atrophied and patches 
 of the glistening white surface of the sclerotic are seen. Around 
 these white patches a dense border of pigment is collected, and the 
 retinal vessels are seen crossing the patches themselves. 
 
Eye and Ear. 49 
 
 That the exudations are not in the retina is made evident by the 
 fact that the retinal vessels can be seen clearly and uninterruptedly 
 passing over them, and furthermore, in the intervals between the spots 
 the retina appears perfectly normal. But, although this disease is 
 described separately, it is scarcely necessary to observe that if it is at 
 all severe, the retina and iris both become implicated, and atrophy of 
 the retina and optic nerve are the result. Opacities of the vitreous, 
 either fixed or floating, are not an infrequent accompaniment of the 
 disease. 
 
 The tumors of the choroid are sarcoma and carcinoma, but 
 the ophthalmoscope does not aid in distinguishing between them. At 
 the outset of the disease a small spot or elevation may be seen in the 
 choroid. This gradually increases in size, and advances toward the 
 vitreous, causing changes in the retinal structure. Soon an effusion 
 of serum takes place behind the affected portion of the retina, causing 
 detachment of the latter. The detached portion of the retina can be 
 seen in its wave-like folds, trembling with each motion of the eye. 
 This usually obscures the tumor from view, and the ophthalmoscope 
 does not disclose it again until it has considerably increased in size. 
 Often the lens or the vitreous humor becomes hazy or opaque, early in 
 the disease, and this prevents any clear observation. 
 
 Colohoma, or fissure of the choroid, is often accompanied by 
 fissure of the ciliary body and of the iris, and sometimes even of the 
 lids: but it may exist independently of all these. The optic disc may 
 also be included in the fissure. 
 
 Together with the fissure of the choroid there exists a bulging 
 backward, or staphyloma of the sclerotic. The fissure is at 
 the lower part of the fundus, and is of congenital origin. It appears 
 as a gray or whitish figure of varying width, extending from the optic 
 disc to the ciliary body, and its color is due to the partial exposure of 
 the sclerotic. 'Its size, shape and color are dependent upon the extent 
 to which the choroid is deficient. The margins of the figure are clearly 
 defined and usually pigmented, and the course of the retinal vessels, 
 as they cross, is curved or twisted. More or less of the attenuated 
 choroidal structure is usually present between the margins of the 
 fissure, and can be detected. 
 
 THhercles of the choroid may be observed in the eyes of 
 tuberculous patients. They are situated in the region of the optic 
 disc, and appear as pale yellow or pale rose-colored spots from three 
 millimeters to five millimeters in diameter. The larger ones are 
 somewhat elevated above the level of the choroid. They have a 
 
50 Diseases of the 
 
 slightly reddish tinge about their margins, but do not present a very 
 marked contrast to the surrounding normal color. Their slight eleva- 
 tion causes the vessels to curve in passing over them. Very excep- 
 tionally they are slightly pigmented around their borders. The retina 
 remains normally transparent. 
 
 Rupture of the choroid follows injuries to the eye or to 
 the head, such as blows. Hemorrhage and cloudiness of the vitreous 
 usually follow; but after these are sufficiently absorbed, the presence 
 of one or more whitish streaks may be detected in the choroid, and 
 generally at or near the outer side of the optic disc. The edges of 
 the streaks are clear and sharp, and usually bordered with pigment. 
 The retina often passes intact over the rupture, as shown by the unin- 
 terrupted course of its vessels. The course of the rupture is usually 
 vertical, and it may be straight or curved. It is more common to find 
 it consisting of two or more lines of separation than of only one. 
 
 The choroidal coat undergoes some very marked changes in 
 myopia, especially in myopia of a high degree. In the vicinity of 
 the optic disc, generally at its outer side, the choroid becomes atro- 
 phied in the form of a crescent. This is called the myopic cres- 
 cent, and is frequently accompanied by thinning and bulging back- 
 ward of the sclerotic. The crescent is a white, reflecting surface, and 
 is caused by the sclerotic shining through the atrophied portion of 
 the choroid. Its size may vary much; it may be a very small white 
 arc, or may extend entirely around the disc in the form of a broad 
 white girdle. In the latter case, the term crescent does not apply. 
 Small patches of pigment sometimes dot its expanse. The whiteness 
 of the crescent, or girdle, causes the optic disc to appear abnormally 
 pink by contrast. 
 
 But instead of a sharply denned crescent at the outer side of the 
 optic disc, or a girdle encircling it, the atrophy of the choroid may 
 take very irregular forms. It may shade off into the surrounding 
 healthy choroid so as to have no distinct outline, or it may have 
 branches. 
 
 Hemorrhagic effusions may be wholly confined to the 
 choroid, or they may escape through the retina into the vitreous. 
 Thev may pass backward between the choroid and the sclerotic. 
 Hemorrhages into the choroid may usually be recognized as dark, 
 irregularly shaped, red spots, over which the retinal vessels pass 
 uninterruptedly. Sometimes if the blood spots are very dark, it 
 is impossible to determine if the vessels really pass over them or 
 beneath. They are apt to persist a long time, and some pigment 
 
Eye and Ear. 51 
 
 may become deposited about them: but during the process of absorp- 
 tion they become paler and of a yellowish hue: and. if small, may 
 leave no trace behind. 
 
 Detachment of the choroid from the sclerotic is some- 
 what analogous to detachment of the retina, in its appearance; but it 
 may be distinguished from it by the fact that it does not tremble with 
 the motions of the eye. The retinal vessels may also be distinctly 
 traced over its surface. The protrusion is ovoid in form, and dis- 
 tinctly seen in the erect image. Its surface is smooth and the cho- 
 roidal vessels can be seen close beneath it. 
 
 If the detachment is caused by an effusion of blood, the color of 
 tumor is dark red: but if caused by serum it is of a yellowish 
 The retina covering the surface of the protrusion may also 
 become partially detached and complicate the appearance. 
 
 The ciliary hocly may be regarded as the central portion of 
 the uveal tract and is a continuation of the choroid. It is chieflv 
 concerned by its muscle in the act of accommodation, and is mentioned 
 in this connection on account of its complication in the iritic and 
 choroidal diseases 
 
 Irido-cyclitis. or inrlammation of the iris and ciliary body, is 
 caused often primarily by cyclitis. but generally springs up in connec- 
 tion with iritis, or with choroiditis. It frequently arises from injuries, 
 such as wounds in the ciliary region, a dislocated lens, or a foreign 
 
 ly in the eye. 
 
 It may also be symj^athetic from the other eye: when so arising its 
 principal symptoms are great tenderness on pressure over the ciliary 
 region, with pain. This tenderness on pressure is not present in 
 iritis. It is accompanied by turbidity of the aqueous and vitreous 
 humors, loss of accommodation, photophobia and lachrymation. im- 
 pairment of vision, a zone of vessels around the cornea, and an in- 
 crease of tension. 
 
 It is an extremely dangerous and insidious disease, much resem- 
 bling iritis, and often steals on quietly without marked snbjective 
 warning, and hence is unnoticed until beyond hope. Of all the in- 
 flammations of the eye. there is none over which the surgeon has less 
 control with materia medica. A comprehensive knowledge of the sub- 
 ject is all-essential: an error in diagnosis or a vacillating delay reaps 
 a terrible punishment. 
 
 As to the method by which this inflammation is transmitted from 
 a companion eye. pathology reveals little that is practical. It is 
 enough to know that the nervous relationship existing between the eyes 
 
52 Diseases of the 
 
 is sufficient to transmit to a previously sound companion eye an in- 
 flammation originating in an injured eye, this transmission being ef- 
 fected so incomprehensibly as often to be unrecognized until the injury 
 is hopelessly done. These effects, known interchangeably by the 
 terms sympathetic irido-cyclitis, sympathetic irido -choroiditis, sym- 
 pathetic ophthalmitis, and sympathetic ophthalmia, consti- 
 tute an extremely dangerous disease. Its pathology, as far as knowD. 
 is simple, consisting of an irritation causing an exudation of plastic 
 lymph capable of speedy organization, and in such process gluing to- 
 gether the delicate mechanism of the eye; or the exudation may as- 
 sume a serous or purulent form, and the eye totally break down. 
 There are generally prodromal symptoms giving warning. When 
 present these are known as symptoms of sympathetic irrita- 
 tion, and may be embraced as irritation and slight injection of the 
 previously sound eye, neuralgic pain, slight photophobia and lachry- 
 mation, with speedy fatigue of the eye when used at near or fine work. 
 An ophthalmoscopic examination of Descemet's membrane, especially 
 to note if there are any fine deposits thereon, and to detect any fleet- 
 ing cloudiness of the aqueous humor, should not be omitted at this 
 stage of the disease. When fully developed in a typical case, the 
 globe has. a pinkish appearance from the sclerotic injection, with a 
 well-marked rosy zone of vessels, indicating internal congestion, and 
 is tender to the touch. The iris is adherent to the anterior lens cap- 
 sule throughout the pupillary margin, causing an infundibuliform ap- 
 pearance peculiar to this trouble. The disease extends back to the 
 fundus, the lens becomes opaque, the tension of the globe changes 
 and vision is lost. 
 
 There is no warning by which the approach of this trouble may be 
 declared with certainty, but the causes most likely to produce it in a 
 companion eye may be found in injuries involving the ciliary region, 
 penetrating wounds from blunt points being especially dangerous ; in 
 foreign bodies penetrating the globe and passing from the sight, or if 
 remaining in view, can not be removed; wounds near the cornea or in 
 it, involving the ciliary region, and especially when in the process of 
 repair of such wound a portion of the iris, of the ciliary processes, or 
 of the anterior lens capsule, becomes entangled in the cicatrix; and in 
 degenerative changes which have taken place in an eye in which vision 
 is already lost from some cause other than suppuration, eyes lost by 
 suppuration being least likely to cause this trouble. 
 
 It avails nothing to report " cures " of eyes so injured as to be em- 
 braced in the above classes, for so far as can be seen such cases are 
 
Eye and Ear. 53 
 
 cured; no one can authoritatively say they are not cured, and yet after 
 months or years, without the least disturbance in the injured eye, or 
 any manifest sign of any morbid change whatever, vision in the com- 
 panion eye may slowly fail, or with consuming inflammation quickly 
 go out forever. Neither does it avail anything that any physician of 
 any school of therapeutics "cures " a case of this kind after another 
 physician of any school has declared it " incurable," because the lat- 
 ler has no knowledge entitling him to such a dictum, and the former 
 does not know if the disease is forever quieted by his medicine, or 
 only lies dormant from its peculiar nature. All that one is warranted 
 at the present time in saying is, that the experience of oculists per- 
 mits the assertion that it is almost certain that sympathetic irritation 
 or ophthalmia will not arise after all nervous connection has been sev- 
 ered by the removal of an irritating globe or remnant, provided there 
 have been no sympathetic symptoms already manifest; and if there has 
 been sympathetic irritation, sympathetic ophthalmia will, most likely, 
 be prevented by such removal. 
 
 Several operations have been proposed to obviate this removal 
 and sequent disfiguration, and variously named. That any one of 
 them would be eagerly seized upon were it efficient, admits of no dis- 
 cussion. But inasmuch as all fail to permanently sever all nervous 
 connection between the two globes, they have proved uncertain, and 
 their consideration is unnecessary. 
 
 The danger of the supervention of sympathetic ophthalmia is gen- 
 erally considered at the minimum after injury up to the seventh or 
 eighth day; after that period until about the thirty-eighth or fiftieth 
 day at the maximum. But there is no set time, and it may appear 
 soon after an injury, or delay weeks, months or years. 
 
 It is evident that the judgment and skill of a surgeon is severely 
 tried to determine whether or not to leave an injured eye, especially 
 when it retains any sight. Hence in a case of threatened or possible 
 sympathetic irritation (the stage preceding sympathetic ophthalmia), 
 when the practitioner can have the immediate supervision of a patient 
 so that the first approach of sympathetic ophthalmia may be noted, or 
 when the patient is of sufficient intelligence to appreciate the nature 
 and danger of the trouble, which should be fully explained, the in- 
 jured eye may be allowed to remain if there is still vision present; 
 but where the reverse is the case, and all sight in the injured eye is 
 lost, the danger to the uninjured eye of entire loss of sight from the 
 presence of the irritable eye should outweigh all other considerations, 
 and the injured eye be at once removed. It should ever be borne in 
 
54 Diseases of the 
 
 mind, however, that risks are taken, varying in degree, in permitting 
 the injured eye to remain, and the first symptoms of irritation should 
 warn that they must be met without delay. 
 
 For local treatment, when the disease is primary, complete rest, 
 protection, cold or heat as is best borne, atropine, and the remedies 
 seemingly indicated, may be tried, a careful watch being kept on the 
 companion eye for the first symptoms of irritation. Fortunately the 
 idiopathic form is not as dangerous as that arising from injury. 
 
 Hyosis. Contraction of the pupil is associated with diseases of 
 the globe, and frequently calls attention to a more serious lesion of 
 the deeper structures. This symptom often demands for its solution 
 an intimate acquaintance with the higher branches of ojmthalmology, 
 and diseases in which it occurs should not be lightly regarded. Un- 
 connected with the more serious classes of disease, contraction of the 
 pupil is comparatively seldom seen. 
 
 Mydriasis.. Dilatation of the pupil accompanies lesions of the 
 brain or spine, and is often a guide to ravel hidden and remote dis- 
 eases. Like myosis, a thorough familiarity with eye troubles is essen- 
 tial to comprehend its monitions. Unlike myosis, it is associated 
 with minor complaints at times. As it is often associated with serious 
 organic defect, however, watchful care should be exercised until a 
 conclusion as to its danger can be formed. 
 
 Iri do -choroiditis. Inflammation of the iris and choroid is 
 caused by an extension of inflammation from the iris, and the reverse. 
 
 The symptoms are those of iritis mainly, but exaggerated in 
 degree. The vitreous becomes clouded, and there is a contraction of 
 the field of vision not explained by iritis. The disease is most fre- 
 quently the result of a previous oft-recurring iritis, where the chambers 
 of the eye have become separated by exclusion or occlusion of the 
 pupil, or the iris is being dragged on by synechia. Eyes are often 
 lost by the disease, and sympathetic ophthalmia may result and the 
 companion eye be endangered or lost. 
 
 When occurring with iritis, it requires the same treatment. Iri- 
 dectomy is the most valuable remedy for severe cases. 
 
 The remedies most suited to diseases of the uveal tract are as fol- 
 lows: In the first stages, whenjihere is heat and dryness of the eyes, 
 aconite will be found useful. It is particularly valuable after surgical 
 operations, when there is restlessness with constant turnings of the 
 patient; seeming tendency to an inflammation. All the symptoms of 
 the patient are -accompanied by much general febrile excitement, 
 denoted by quick pulse, dry, hot skin, thirst, etc. There is also a 
 
Eye and Ear. 55 
 
 direct indication for its use when there is marked ciliary congestion, 
 with contracted pupils, and severe throbbing pains. 
 
 Alium cepa is a valuable remedy when pains produce intense suf- 
 fering or restlessness. The mother tincture should be given in five- 
 drop doses. 
 
 Arsenicum is called for by burning pains. The parts burn like fire. 
 Great anguish and restlessness are present; the patient has intense 
 thirst, drinking little and often. All the pains are worse at night and 
 after midnight; better from warm applications. The pains are aggra- 
 vated by light and by moving the eyes. There is photophobia, lach- 
 rymation, and great prostration of mind and body. 
 
 Arnica is called for where there is hemorrhage and ecchymosis 
 from blows and wounds of any description. 
 
 Asafcetida for severe boring pains above the eyebrows. The pains 
 are also throbbing, beating, boring, or burning in character in the 
 eye, over or around it. Highly useful in syphilitic iritis, and after 
 the abuse of mercury. The pains are usually from within outward, 
 and are relieved by rest and pressure. It is also particularly adapted 
 to nervous, hysterical persons with hypersensitiveness of the whole 
 system. 
 
 Aurum has been successfully used in syphilitic iritis, and after the 
 abuse of mercury and potash. / The pains indicating its use are dull 
 or burning in character, compelling one to close the lids occasionally. 
 They are worse in the morning, and ameliorated by the application of 
 cold water. 
 
 It will also be found a valuable remedy in cases of syphilitic iritis, 
 where thereis great depression of spirits, with tearing, pressing pains, 
 seemingly deep in the bones surrounding the eye, and aggravated by 
 touching. 
 
 In the early stages belladonna will sometimes be useful. It is 
 particularly suited to plethoric persons, and those of a stout, full 
 habit. 
 
 Indications for its use are as follows : Photophobia ; sharp pains in 
 the orbits, extending to the brain; the pains appear suddenly, and 
 cease as suddenly; there is dimness of the vision; the eyes are red 
 with much congestion; bright redness of the vessels. 
 
 Throbbing pain in the head and eye, and flushed face, things look- 
 ing red, sparks of fire passing before the eyes, are symptoms also 
 relieved by this remedy. 
 
 In inflammation due to rheumatism, and in the serous forms gen- 
 erally, bryonia is a useful remedy. The symptoms controlled by it 
 
56 Diseases of the 
 
 are a sensation of pressure from within outward in the globe of the 
 eye. Sensation of soreness and aching in the ball and around it. 
 Sharp, shooting pains in the eyes, extending into the head and down 
 into the face; or pain as if the eye were being forced out of the socket. 
 All the pains are aggravated by moving the eyes in their sockets. The 
 eye symptoms are aggravated by warmth, and are generally worse at 
 night. Patient is exceedingly irritable at night, not so much so during 
 the day. The head aches as if it would split open. 
 
 In periodical supraorbital neuralgia, cedron is indicated. The 
 pains are sharp and shooting, starting over the eye and extending 
 along the branches of the supraorbital nerve. 
 
 Calendula is valuable in a class of cases somewhat similar to those 
 where arnica is usually prescribed. 
 
 Chamomilla relieves severe ciliary neuralgia in scrofulous children. 
 
 When dependent upon or continued by loss of vital fluids or ma 
 laria, china will afford much benefit. The pains are variable, but show 
 a marked periodicity. 
 
 Cimicifuga is indicated under these conditions: Eheumatic iritis, 
 with intraocular tension and much pain; intense and persistent pains 
 in the eyeballs, of a dull, aching, sore nature; pain in the center of the 
 eyeballs. 
 
 Cinnabaris has been used very successfully in condylomatous excres- 
 cences on the iris, edge of the pupil, or edge of the lids. Particularly 
 valuable in syphilitic iritis. 
 
 Colchicum is well adapted to rheumatic cases, with great soreness 
 of the eyeballs. Violent, sharp, tearing pains in the eye, around the 
 orbit. 
 
 Cutting pains around the eye have been controlled by colocynthis. 
 Pains relieved by it are quieted by pressure. 
 
 Conium is well suited to the debility of old people. Burning heat 
 in the eye is well met by it also. 
 
 Euphrasia has been used in rheumatic iritis, with constant aching, 
 and occasional shooting pain in the eye. The lachrymation is profuse, 
 the tears acrid and excoriating. 
 
 Gelsemium acts well in serous diseases of the uveal tract. 
 
 Hamamelis is a valuable local application in traumatic iritis, and 
 may be used internally at the same time. Hemorrhage into the an- 
 terior chamber may be hastened in its absorption by its use also. 
 
 Hepar sulphuris is one of our most valuable remedies. In all cases 
 where suppuration has taken place, or is inevitable, as in kerato-iritis, 
 or suppurative iritis, its administration is called for. The pains are 
 
Eye and Ear. , 57 
 
 throbbing, pressing, or aching in character, aggravated by cold and 
 relieved by warmth. Much photophobia, with swollen and sensitive 
 lids. Absorbs pus in the anterior chamber. Adapted to scrofulous 
 persons with enlarged glands, every cut or wound suppurating: also 
 to the system after the abuse of mercury. 
 
 Kali iodatum is a valuable remedy in choroiditis, or in acute 
 or chronic irido- choroiditis. It also follows well in syphilitic iritis 
 after the patient has been drugged with mercury, or when secondary 
 symptoms accompany the eye inflammation. 
 
 Lachesis is indicated when there is much pain in the eye, with 
 sharp pains in the upper jaw and teeth, with complaints of suffocative 
 feelings. Stitches as from knives in the eye, the sensation coming 
 from the head. The eye complaints are worse after sleeping. Pains 
 rapidly change from the eye to other parts of the body and back again. 
 
 The preparations of mercury have long and successfully been used. 
 They are all valuable,, especially in the syphilitic forms. The symp- 
 toms comprise a great variety, and the choice of a particular form will 
 depend upon the general characteristics. 
 
 In the syphilitic and choroidal forms of these troubles mercurius 
 corrosivus and the iodides are the most effectual. 
 
 After exudations have taken place from the iris, which appears dis- 
 colored, or the area of a pupil is covered by a film with a tendency to 
 posterior synechia, no remedy is better to promote absorption. Hy- 
 popyon or condylomata yield to its influence. 
 
 While the eye symptoms may call for this remedy, we oftener find 
 general characteristic symptoms in connection with them. These are 
 such as diseases of the glands, acute or chronic ; cold clammy sweat on 
 the thighs and legs at night; salivary glands greatly swollen, with 
 excessive secretion of saliva and fetid breath; greyish ulcers on the 
 inner surface of the lips, cheeks, gums, tongue and soft palate; erup- 
 tions on the skin; nightly pains in various parts of the body. Aggra- 
 vations are from warmth, at night, from rest, and in damp weather. 
 
 Nitric acid is especially useful in treating^syphilitic or gonorrhoeal 
 troubles. It also follows well after the abuse of mercury. While not 
 strictly applicable to many eye diseases, it is adapted to the treatment 
 of affections arising from suppressed syphilis, and to secondary affec- 
 tions of syphilis in broken or cachetic constitutions. 
 
 Nux vomica is an auxiliary remedy, especially adapted to people of 
 a malicious, irritable temperament, and to those who make great men- 
 tal exertions. 
 
 Pulsatilla relieves in characteristic subjects. 
 
58 Diseases of the 
 
 The symptoms are all worse toward evening; relieved in the open 
 air, worse on returning to a warm, close room. The form of symp- 
 toms is very changeable; worse one moment, better the next, or at 
 longer intervals. Sluggish circulation manifested by constant chilli- 
 ness, coldness and paleness of the skin; disorders of digestion and men- 
 struation. 
 
 Rhus toxicodendron is a remedy especially valuable in suppurative 
 inflammation of the iris, the latter involving, or showing a strong dis- 
 position to extend backward and involve the rest of the uveal tract. 
 
 Iritis occurring in rheumatic subjects, or arising from exposure to 
 cold is well met. The pains are worse at night, and relieved by warm 
 applications; also worse before a storm and in damp weather. Rheu- 
 matic pains that affect any part of the body, aggravated by rest, and 
 relieved by motion. 
 
 Silica promotes a tendency to absorption, and will be found to 
 exercise control wherever this point is desirable. 
 
 Spigelia is useful where the pains are sharp and shooting, or 
 severe, pressing and jerking, and radiate from points around or in the 
 eye. The pain is much worse from moving the eye in any direction. 
 
 Iritis in scrofulous subjects will often be benefited from the use of 
 sulphur. It is useful in chronic cases, and when the pains are sharp 
 and sticking, like pins sticking in the eyes. Useful after suppressed 
 eruptions. 
 
 Thuja is indicated in syphilitic iritis with condylomatous excres- 
 cences upon the iris. The pains are ameliorated by warmth. 
 
 SECTION EIGHT. 
 
 Glaucoma is one of the most dangerous of eye diseases. The 
 causes are probably oftenest from heredity, mental emotions, such as 
 prolonged grief, or any influence on the fifth nerve, and direct irrita- 
 tion of the ciliary nerves. Retinal hemorrhage is an indirect cause. 
 It is also secondary to other diseases. 
 
 The almost certainty that badly or neglectfully treated, hopeless 
 blindness will ensue, has stimulated ophthalmologists to its thorough 
 study. Hypermetropic eyes- are most liable to its inroads, and females 
 at and about the menopause are highly susceptible, an attack on either 
 eye almost certainly extending to its companion. 
 
Eye and Ear. 59 
 
 A fully declared glaucoma is a rare form of the disease, and may 
 be confounded with a severe bilious attack, or a brain trouble until too 
 late for advantageous aid. In this form its onset is so furious and of 
 such an acute type of inflammation that it should not be overlooked. 
 In the chronic form prodromal symptoms may be shown, such as a 
 rapid increase of any existing presbyopia; colored rings around a 
 light, the latter appearing as when seen in a foggy atmosphere; in- 
 termittent obscurations of sight, the intervals or periods of remission 
 lasting days or months; more or less neuralgia, combined with the 
 ciliary form; a variable slight increase of the intra-ocular tension, 
 and a contraction or narrowing of the visual field, with dimness of 
 vision. 
 
 Immediately before an acute attack these symptoms are intensified; 
 it then bursts forth with the addition of severe headaches and terrible 
 ciliary neuralgia, cloudiness of the aqueous and vitreous humors, 
 dilatation and sluggishness of the pupil, which may be filled with a 
 greenish reflex (whence the name of the disease) photophobia, lachry- 
 mation, and conjunctival congestion, fever and vomiting, and clouded 
 cornea, the iris being jammed down against the cornea until the an- 
 terior chamber is obliterated. The distinguishing symptom is never 
 lacking, the increased tension. Should a view of the fundus be 
 obtainable, an unusual thing owing to the turbid condition of the 
 humors and media generally, there will be found pulsation of the 
 arteries, a swollen beaded appearance of the veins, slight retinal 
 hemorrhage, and most likely the cupping of the optic disc fully de 
 scribed in Section Ten. 
 
 But the acute attack is rare compared with the chronic form in 
 which the disease generally invades the eye. A rarer form still is the 
 lightning glaucoma (glaucoma fulminans), which is an intensified 
 acute attack, concentrating its energy into a few hours. Under the 
 chronic form the prodromal symptoms are usually mild, nearly always 
 overlooked, and the disease crawls on, becoming hopelessly incurable, 
 or bursting into the acute form. The narrowing of the visual field 
 may be the only symptom noted by the patient, or perchance an in- 
 crease of an existing presbyopia, necessitating frequent visits to the 
 optician to change glasses. Any one of the symptoms should be 
 regarded as suspicious. No case of eye disease, of a nature not 
 thoroughly disclosed, should be dismissed without ascertaining the 
 eye-tension, with a searching glance for this subtle trouble. A nebu- 
 lous cornea, a dilated pupil, any uncertain symptom, and above all, a 
 staphylomatous globe, may conceal this disease in ever-shifting form, 
 
60 Diseases of the 
 
 which hurrying on to the absolute form, renders the globe as hard as 
 stone, the pupil dilated, the lens opaque and green, the cornea dull 
 and insensitive, and the anterior chamber shallow or obliterated. 
 
 It is not surprising that a physician hastily summoned to a patient 
 who is vomiting and loudly complaining of terrible hemicrania, and 
 who shows no more injection of the eye than emesis produces, should 
 think of many diseases before this one, especially as the patient may 
 lay light stress on his disordered vision. 
 
 The age at which glaucoma is found, it being almost always a dis- 
 ease of middle life, may assist in the diagnosis, though cases are not 
 infrequent at an earlier age. 
 
 Care should always be used in the instillation of atropine into the 
 eyes of patients over forty years of age; great care if there is detected 
 the slightest tendency to glaucoma. A solution similar in strength of 
 eserine or of pilocarpine may be used. Cases of an acute nature may 
 do well under local remedies, but they avail little in chronic cases. 
 
 The general health should be enquired into, and suitable instruc- 
 tions given, moderate use of the eyes enjoined in recurrent attacks, 
 cheerful surroundings, and the tonics of air, sunshine and cheerful 
 company not neglected. 
 
 Among internal remedies used at the outset and as aids to other 
 treatment, belladonna has been found of use in relieving the flushed face 
 and throbbing headache with sharp pains. The pupils are dilated, 
 conjunctiva congested, with a general dry feeling, and much photo- 
 phobia. 
 
 Bryonia alba may be given when the eyes feel sore to the touch, 
 and are generally worse on motion. Sharp, shooting pains through 
 the globe may also demand this remedy. 
 
 Cimicifuga is valuable for the wandering pains which often change 
 into other portions of the body. 
 
 Colocynthis has been used where the pains are better on pressure, 
 but of a sharp, stitching nature. 
 
 Gelsemium is one of the most valuable of the remedies in this 
 trouble, being often palliative of the severe pains, and seemingly ex- 
 ercising a curative influence on the neurotic character of the disease. 
 
 Phosphorus is useful in clearing up the vision after an iridectomy 
 has been performed. 
 
 Spigelia has been found more valuable than any other one internal 
 remedy for the alleviation of the sharp, shooting, and sticking pains 
 which accompany this disease. These pains are worse on motion and 
 at night. 
 
Eye and Ear. 61 
 
 Others will be suggested by their concomitant symptoms. Reli- 
 ance, however, should not be placed on internal remedies alone, for in 
 nearly all forms an iridectomy is sooner or later indicated, and is then 
 the only remedy known. 
 
 SECTION NINE. 
 
 The leilS has diseases of only one character to be considered. 
 Strictly speaking, the term cataract should be limited to an opacity 
 of the lens, though the term is applied to opacities of the lens capsule 
 as well. There are therefore two general classes of cataract, the cap- 
 sular and the lenticular. 
 
 Capsular cataract is an opacity of the lens capsule, which 
 generally encroaches on the area of the pupil. It has a whitish ap- 
 pearance and seldom occurs without the lens itself having been previ- 
 ously involved. 
 
 The anterior capsule is more frequently affected than the posterior. 
 The trouble is not so much in the capsule itself as on its inner surface, 
 where, with the oblique illumination, crystals of cholesterine or chalky 
 concretions may be seen. 
 
 Lenticular cataract may be divided into four varieties: the 
 soft, the cortical, the hard and the zonular. 
 
 Soft cataract occurs among infants and young children and is 
 often congenital. Dilate the pupil with atropine; the lens shows a 
 bluish-white opacity which is usually uniform and free from striae. 
 With the ophthalmoscope the opacity will be found to reach from the 
 center of the lens to its circumference and no portion of the fundus 
 will be visible. Occasionally, opaque whitish spots are noticed be- 
 neath the capsule. 
 
 Under the head of soft cataract, traumatic cataract may be 
 mentioned as sometimes analogous in appearance. If an injury to 
 the lens is extensive the aqueous humor prevades its whole substance 
 and renders it opaque. In slight injuries only a small and irregular 
 portion of the cortical substance is involved. The history of the case 
 will almost preclude the possibility of a mistake in the diagnosis. 
 
 Before fully formed, the cortical cataract appears as a series of 
 striae running from the circumference of the lens toward its center. 
 These striae are often situated in the posterior substance of the lens, 
 but as the cataract advances, they become white, increase in breadth 
 
62 Diseases of the 
 
 and finally occupy the whole lens. Dilate the pupil with atropiue, 
 and the opacity will appear quite uniform but marked with pearl- like 
 bands, and perhaps of a yellowish tint at the center. But with the 
 ophthalmoscope, it will be noticed that the margin of the lens allows 
 a few rays of light to pass from the fundus, the red reflection being 
 seen. The central portion of the lens appears opaque and dense, 
 surrounded by a dim reflection from the fundus. In the soft cataract, 
 no striae or colored reflection are seen. 
 
 Senile or hard cataract seldom affects a person under forty 
 years of age. It first appears as an amber- colored opacity, most 
 marked at the nucleus, the cortical substance remaining comparatively 
 unaffected. The amber- colored center is the characteristic feature 
 throughout the course of its formation. In the earlier stages, if the 
 pupil is dilated with atropine, small opalescent striae may be seen 
 extending inward from the circumference, and as the cataract ad- 
 vances, these become more apparent. The ophthalmoscope shows the 
 circumference more transparent than the center even in the latter 
 stages. Spots of fatty epithelium are often observed beneath the 
 inner surface of the capsule. 
 
 Zonular cataract is usually congenital, and most often occupies 
 layers of the posterior cortical substance of the lens, and is most dense 
 at the axis. Dilate the pupil with atropine, and unless the case is far 
 advanced, the ophthalmoscope clearly reveals a portion of the fundus 
 through the circumference of the lens. Even a dim reflection of the 
 fundus may be seen through the denser portions. The opacity appears, 
 by oblique illumination, as a whitish -gray film apparently upon the 
 posterior lens capsule. Sometimes striae radiate from the central por- 
 tion, but the circumference of the lens is often completely transparent. 
 This form of cataract may be progressive or may remain stationary for 
 many years. 
 
 The lens may be either partially or completely displaced, and in 
 almost any direction. In partial dislocation, if the pupil is well 
 dilated with atropine, the change in the position of the lens may be 
 noted by either oblique illumination or by the ophthalmoscope. 
 Using the ophthalmoscope by the direct method, the edge of the lens 
 maybe seen as a distinct, dark, curved line lying over the back-ground 
 of the fundus. Not only this, but if the lens is so far dislocated 
 laterally, as to leave a portion of the pupil unoccupied, a distinct 
 erect image of the fundus can be seen through that portion of the 
 pupil, and the part of the fundus thus seen will be very hyperme- 
 tropic. 
 
Eye and Ear. 63 
 
 Complete dislocation of the lens into the anterior chamber can 
 scarcely be mistaken even when the lens is quite transparent. If the 
 dislocation is backward into the vitreous, with the ophthalmoscope 
 its location can readily be ascertained. It will appear nearly natural 
 in outline, darker in color, occupying the lower portion of the vitreous 
 while the head is erect. Using the oblique illumination, no reflection 
 from the anterior capsule is apparent. When the lens lies partially 
 across the pupil, it acts as a prism, and a double image of the fundus 
 may appear; but when it is entirely without the axis of vision, the eye 
 becomes intensely hypermetropic, and the details of the fundus appear 
 very small. 
 
 Success in the medication of the lens is as yet problematical, 
 though to various remedies are attributed powers in effecting changes. 
 At present the subject lies almost wholly within the domain of oper- 
 ative surgery. 
 
 SECTION TEN. 
 
 The optic disc, or papilla, is frequently the seat of pathologi- 
 cal changes, and its appearance differs much in the various affections. 
 
 Hyperemia of the disc accompanies hyperemia of the optic 
 nerve, and if confined to one eye, an advantage may be gained by 
 comparison with the healthy eye. 
 
 The disc becomes much reddened, its vessels are fuller and its 
 margins not clearly defined owing to a haziness which extends over 
 into the retina. The vessels of the retina are generally more or less 
 enlarged, and often the whole fundus, including the disc, is of a 
 uniform red or scarlet hue. In the latter case, the position of the 
 center of the disc can be determined only by the position of the cen- 
 tral vessels. 
 
 In optic neuritis, or inflammation of the nerve, the phenomena 
 in the disc differ with the origin of the disease, and its successive 
 stages, but in the earlier stages the following symptoms generally 
 present themselves: The disc appears larger than in health, and is 
 red, swollen and somewhat cedematous. Its surface is convex instead 
 of concave, its margin hazy and dimly defined. The appearance of 
 the surface and margin of the disc is often described as woolly, and 
 is due to hypertrophy of its connective tissue. The vessels from the 
 
*U Diseases of the 
 
 retina can not be traced beyond its margin, and their exit from the 
 eye is frequently lost to view. New vessels often become developed 
 upon the surface of the papilla, and not unfrequently its surface and 
 vicinity are the seat of numerous blood extravasations: both of which 
 causes render it very red and vascular. The disc is prominently 
 elevated and can be seen at some distance from the eye in the erect 
 image. Owing to the firm and unyielding nature of the scleral riDg 
 which encloses the nerve's extremity, the swollen and infiltrated nerve 
 presses upon its own vessels and obstructs the circulation. As a 
 result the retinal veins are more or less engorged, dark and tortuous, 
 while the arteries are much contracted and at times scarcely distin- 
 guishable. 
 
 Severe cases of optic neuritis are usually followed by more or less 
 complete atrophy of the papilla and nerve, and this constitutes the 
 later stages. 
 
 In ailcemia both eyes are equally affected, each disc being un- 
 naturally white. The retina and choroid are also wanting in color. 
 The eyes do not light up well. The. general state of health in which 
 the patient is found helps to explain the anaemic state of the eyes. 
 
 The paleness of anaemia of the disc may be distinguished from 
 the paleness of atrophy by observing that in anaemia the fundus also 
 is pale, but in atrophy it remains red because the choroidal vessels 
 are normal in color. Neither is the paleness of the anaemic disc so 
 striking as that of the atrophic, owing to 'its lack of contrast with the 
 surrounding fundus. In all stages of anaemia, although the amount 
 of blood is small in both the central arteries and veins, these vessels 
 can be distinguished from each other. In the earlier weeks of atrophy 
 the central veins are dilated and the arteries small; but later, both 
 sets of vessels are reduced in size and number and finally become 
 undistinguishable from each other. It not unfrequently happens 
 that no vessels can be traced over the white expanse of an atrophied 
 disc. Perhaps a single artery or vein may remain, though it is gen- 
 erally destitute of branches. 
 
 There are two classes of atrophy of the optic papilla, the 
 primary or progressive, and the consecutive. The appearances of the 
 disc in atrophy may be enumerated as unnatural whiteness, decrease 
 in calibre of the retinal vessels, the veins diminishing in size some- 
 what later than the arteries, and a peculiar excavation of the disc 
 itself. Sometimes the whiteness is very great, and in other cases the 
 color is bluish-white. The small nutrient vessels upon the surface 
 have generally disappeared, and this aids in producing its unnatural 
 
Eye and Ear. 65 
 
 whiteness. The latter is especially marked in cases of primary atrophy 
 in which the outlines of the disc though sometimes irregular, are clearly 
 denned. 
 
 Atrophy consecutive upon optic neuritis is usually for a long time 
 distinguishable from other kinds. The papilla remains swollen, and 
 its outline indistinct. Its color is of rather a dull grayish- white; but 
 after a time distinctions become lost, and it assumes the same appear- 
 ance as the other varieties. In most cases of atrophy of the disc both 
 eyes are affected, but not always to an equal extent. 
 
 Cupping or excavation occurs in three varieties, known as the 
 physiological, the atrophic, and the glaucomatous. 
 
 The first or physiological cup, is a congenital excavation. 
 It never involves the whole disc, is usually very small and shallow and 
 generally confined to the central 'portion, though quite often displaced. 
 The walls are in most cases slightly inclined from the center to a 
 higher level. Exceptionally they are steep or irregular, or the cup 
 may be funnel-shaped. As the retinal vessels enter the disc, they 
 curve more or less acutely as they pass the margins of the cup. The 
 whole fundus moreover looks healthy and cheerful, and there are none 
 of the symptoms accompanying the other diseases. 
 
 In the atrophic cup there is loss of nerve fibers, blood vessels, 
 and sometimes connective tissue. The blood vessels are not usually 
 all lost, but those which remain are altered in size and appearance. 
 The excavation is shallow, but involves the whole surface of the disc. 
 It is also deepest at the center. In the beginning of atrophy the 
 whiteness is very bright, and occupies a portion of the disc near its 
 center. Later, this whiteness extends and occupies the whole surface 
 of the disc quite up to the sclerotic ring, and the latter stands out 
 very distinctly. The ultimate color of the disc is apt to be bluish or 
 grayish white. The shallowness of the excavation and its gradual in- 
 clination from center to edge cause no very marked curve or displace- 
 ment of those vessels which remain. They pass over its edge with 
 little or no appreciable curve, and no part of them is lost to view. 
 
 The glaucomatous cup is usually very deep, and occupies the 
 whole surface of the disc. In its early stages the walls may be steep, 
 straight and only moderately deep, but as the disease progresses the 
 cavity deepens and the edges of the disc overhang its sides. In the 
 first case the continuity of the central vessels may be traced, though 
 they necessarily describe a very sharp curve on passing the edge; but 
 when the sides become excavated laterally, parts of these vessels are 
 lost to view. Vessels from the retina upon reaching the margin seem 
 
66 Diseases of the 
 
 to abruptly break of, but remnants of them may again be dimly seen 
 near the center of the floor of the excavation. 
 
 A shadow surrounds the scleral entrance of the central retinal 
 artery (porus opticus) in the form of a ring, and changes with the 
 movements of the ophthalmoscope. This shadow is cast by the walls 
 of the excavation, and was formerly the cause of an optical illusion, 
 and cupped discs were regarded as prominent ones. Deeply cupped 
 discs have a mottled appearance, the result of atrophic changes and 
 the manner in which the light falls upon them; the usual color is gray 
 or grayish -white; it may be greenish or even very white. 
 
 Another characteristic appearance in the glaucomatous cup is the 
 so-called parallax of glaucoma. This is apparent while using 
 the indirect method of examination and slightly moving the objective 
 from side to side. As the objective is moved, both the floor and the 
 margin of the excavation move too, but the latter much more rapidly 
 than the former; and it requires no great movement of the lens to 
 cause the margin to move some distance across the bottom of the 
 excavation. Arterial pulsation, so often noticeable in glaucoma, is 
 another distinguishing point, but the characteristic displacement of 
 the vessels, the abrupt sides of the cavity, and the other points already 
 described, can hardly fail to show the nature of the glaucomatous cup. 
 Partial cupping of the disc has been sometimes observed in glaucoma. 
 It is recognized by the same marks as the other forms. 
 
 It is not unusual to find quite a deposit of pigment along the 
 edge of the optic disc, but very rarely does pigment become deposited 
 within the limits of the disc itself. Cases have been reported, how- 
 ever, in which marked pigmentation of the disc occurred. This abnor- 
 mal change has usually followed some severe accident to the eye, and 
 is due to the escape of coloring matter from the blood. 
 
 In most cases of retinitis the disc is inflamed also, and in all cases 
 of optic neuritis of any extent, the retina is involved. The concur- 
 rence of inflammation in both of these structures is known as neuro- 
 retinitis. 
 
 Acnte parenchymatous retinitis presents these ophthal- 
 moscopic appearaDces: The fundus of the eye is uniformly scarlet and 
 the outside of the optic disc lost. The central artery may remain 
 normal, but the veins are enlarged and unusually tortuous. Blood 
 extravasations, of varying form and extent, are usually scattered over 
 the expanse of the retina. An effusion of serum or lymph renders the 
 retina more or less swollen and cedematous. There is a hazy look 
 about the fundus, in most cases, owing to the retinal infiltration. 
 
Eye and Ear. 67 
 
 If the disease assumes a more chronic form, the inflammatory 
 exudation causes the disc, as well as the surrounding fundus, to look 
 opaque, and the character of the exudation determines the color of the 
 opacity. An opacity resulting from serous effusion is pale and of a 
 grayish or grayish- pink color. An exudation of lymph causes an 
 opacity which is nearly white. If the exudation occupies the external 
 retinal layers, the retinal vessels will not be obscured; if the internal 
 retinal layers are involved, the vessels will be hidden to an extent de- 
 pending upon the nature and size of the exudation. 
 
 Inflammation of the vitreous body, with sequent haz- 
 iness, is an accompaniment of acute retinitis, especially if the internal 
 layers are affected; this may obscure to a considerable extent the real 
 appearance of the retina. The spots of blood extravasation vary in 
 color, size and appearance with the depth at which they are situated, 
 the length of time they have existed, and whether they originated from 
 the arteries or from the veins. These will be further described under 
 retinitis apoplectica. Inflammatory exudations may occupy the whole 
 or a part of the retina, and may be scattered about in spots or in clus- 
 ters of spots. 
 
 Serous retinitis is not easily recognizable with the ophthal- 
 moscope. It is characterized by a delicate, uniform, bluish-gray or 
 greenish opacity, which appears like a cloud over the surface of the 
 retina. The infiltration of serum is usually most observable about the 
 disc, and gradually shades off toward the periphery of the retina. The 
 periphery may be entirely free from any infiltration. 
 
 On account of the thinness of the retina at the yellow spot the 
 opacity at this place is less marked; as a result there is an apparent 
 increase of redness at this point, owing to the reflection from the 
 choroidal vessels. The retinal arteries are normal while the veins are 
 usually congested, dark and twisted in their course. 
 
 Retinitis albuminurica or nephritic retinitis oc- 
 curs during the progress of Bright' s diseases of the kidneys, or pre- 
 cedes and is recognized before any of the other symptoms of the latter 
 malady are apparent. The pathological appearances of the retina are 
 thought by some to be constant and peculiar; but before the disease is 
 fully developed the changes which are observable may all be included 
 under the forms of inflammation already described. The disc is 
 hypersemic and its outline indistinct. There is serous infiltration in 
 the vicinity of the disc and this occupies quite a portion of the sur- 
 rounding retina. The arteries are normal at first, and the veins 
 larger, darker, and more tortuous than usual. As the disease ad- 
 
68 Diseases of the 
 
 vances the above symptoms become more marked and the optic disc 
 may even become swollen and prominent. Now the characteristics of 
 the disease begin to appear. Hemorrhages are the first and these 
 occur early in many cases. Sometimes they are about the first thing 
 noticed and the most usual position is in the vicinity of the disc and 
 macula lutea. Small spots, usually whitish though sometimes yellow 
 or gray, begin to form in the retina around the disc. These develop 
 in size and number, and finally coalesce into one large patch, or, as is 
 more usual, form a broad white belt around the disc. This belt is 
 usually separated from the disc by a space which is occupied by gray- 
 ish infiltration. At the same time whitish dots, or small starlike fig- 
 ures, are noticed in the region of the macula lutea. These also may 
 run together and perhaps join the belt. 
 
 These spots around the macula lutea, together with the whitish 
 belt surrounding the disc, are the most characteristic symptoms of 
 this form of retinitis. 
 
 It is often possible to discover Bright' s disease before much evi- 
 dence of it can be gathered from the urine. In cases where it is least 
 expected, the observer has sometimes to announce to the patient the 
 true nature of his malady, and confirm his diagnosis by an examina- 
 tion of the urine. 
 
 The spots' which appear in the region of the optic disc and the 
 yellow spot are due to fatty degeneration of blood and of connective 
 tissue. All of the symptoms enumerated differ much in character and 
 degree in individual cases. Similar spots and marks are sometimes 
 present in other forms of retinitis, especially in that form due to con- 
 stitutional syphilis; but the spots are much paler in the other forms, 
 and those in the region of the macula lutea are never star-like as in 
 the nephritic variety. The general history of the case should confirm 
 the diagnosis. 
 
 In retinitis pigmentosa not only the retina but often the 
 choroid suffers in a peculiar manner, so that a well developed case can 
 not well be mistaken for anything else. The disease is due to con-* 
 genital predisposition. Physiological pigmentation around the optic 
 disc and pathological pigmentation of the disc itself have been men- 
 tioned. In exceptional cases pigment may be deposited in the retina 
 in the course of .optic neuritis; but none of these constitute the disease 
 in question. 
 
 Retinitis pigmentosa usually makes its beginning in the periphery 
 of the fundus upon the nasal side and then extends gradually around, 
 all the while advancing toward the posterior pole. It is characterized 
 
Eye and Ear. 69 
 
 by variously shaped black spots of pigment irregularly disposed or 
 gathered into clusters. Some of these spots are round or oval, some 
 have rough jagged edges and others, usually the larger ones, have long 
 narrow processes radiating from them. Often the spots seem disposed 
 to follow the course of the blood vessels which at times have black 
 streaks or lines side by side with them. The last stages of the dis- 
 ease are characterized by atrophy of the retina and optic nerve, to- 
 gether with changes in the choroid. The latter consist in loss of 
 epithelium in places, exposing the vessels and thus forming light 
 patches which are usually fringed with dark pigment. If the cho- 
 roidal structure becomes atrophied, the white sclerotic is seen shining 
 through in whitish patches. The vitreous seldom becomes affected. 
 The disease is generally binocular. 
 
 Syphilitic retinitis occurs in the course of constitutional 
 syphilis. It so frequently closely resembles other forms of retinitis 
 that the patient's history must aid largely in deciding its nature. 
 Spots and opacities resembling those described under albuminuric 
 retinitis form in the region of the yellow spot and optic disc, but 
 they are of a duller hue and less persistent. They come and go, and 
 require only a few days for new ones to appear and old ones to disap- 
 pear. 
 
 The choroid and iris are apt to become implicated in this inflamma- 
 tion, and if atrophy of the choroid follows, changes similar to those 
 described under retinitis pigmentosa take place. 
 
 Retinitis leucaemia is a very rare disease which sometimes 
 accompanies a disease of the spleen and lymphatic glands. The fundus 
 has a pale orange -red color if examined by diffuse daylight received 
 through a hole in the closed window shutter. The papilla is pale and 
 the retina about it clouded. The retinal vessels, notably the veins, are 
 peculiarly pale. The cloudiness of the retina is striated. Small, irreg- 
 ular whitish spots are seen in the region of the yellow spot, and these 
 are more numerous toward the periphery of the retina. Sometimes 
 these spots are large and round and fringed with red. Effusions of 
 blood are scattered over the fundus irregularly. 
 
 Hemorrhages into the retina are not often absent in any 
 marked case of retinitis, but where the tendency to extravasation of 
 blood is very great and the patient is one in whom some disturbance 
 of the general circulation is known to exist, the term retinitis ap- 
 oplectica is applicable. Hemorrhages in the retina seem governed 
 by no rule as to extent, location or number. They may occur in the 
 outer or in the inner layers. They may lie between the retina and 
 
70 Diseases of the 
 
 the choroid or may extend inward and burst through into the vitreous 
 humor. Their location may be such as to partially or completely 
 obscure the retinal vessels from view or they may lie directly behind 
 these vessels, the latter being seen to pass directly over them. In this 
 form of disease there is usually very little destructive change in the 
 retina itself, owing to the slight nature of the infiltration, but the 
 recurrence of the trouble is to be expected and it may lead to degen- 
 eration of the retina and optic nerve. The appearance of an effusion of 
 blood into the retina, if seen early, is bright red. In all cases hemor- 
 rhages appear much darker than the surrounding fundus, and they retain 
 their color a long time. If absorption takes place the spots gradually 
 assume a brighter color, break up and disappear. If, as sometimes 
 happens, they undergo fatty or pigmentary changes, black spots are 
 the result, and these are more or less permanent. 
 
 Atrophy of the retina is a sequel to many inflammations of 
 the inner parts of the eye. It may involve the whole or only a part of 
 the retinal structure. Atrophy of the retina and atrophy of the optic 
 nerve always go together. The central blood vessels are much atten- 
 uated and reduced in number or else quite lost. The increased thin- 
 ness of the retina with its loss of reflection renders it very little obstruc- 
 tion to a distinct view of the choroid. Spots of exudation sometimes 
 remain a long time in the retinal tissue, or pigment may become 
 deposited along the course of some of the remaining bloodvessels. 
 
 Detachment of the retina means a separation of the retina 
 from the choroid, and may begin at any point; it may remain small or 
 extend in all directions. The lower half is most often the seat of a 
 detachment. The appearances of a detached portion, if large, are those 
 of a loose folding surface bulging more or less forward into the vitre- 
 ous humor, and trembling with each movement of the eye. Its vessels 
 are usually darker that those of the surrounding fundus and there is 
 more or less cloudiness in the part. Sometimes the vessels can be 
 traced in their tortuous course over the folds; but more often their 
 continuity seems broken. 
 
 Small detachments are more difficult to see than large ones; their 
 presence may be suspected if slight opacities are noticed at any point, 
 together with a curving of the vessels passing over them. 
 
 Tnniors of the retina demand a brief allusion. They are 
 either glioma or glio-sarcoma, and present, if seen very early 
 in their course, a small protrusion from the surface of the retina at 
 some point, with some effusion about it, and perhaps some enlarge- 
 ment of the surrounding vessels. 
 
Eye and Ear. 71 
 
 As this is a disease of childhood, it is seldom seen until a later 
 stage than above described, and the first thing usually noticed is a 
 bright shining yellowish reflection from the fundus of the eye, seen 
 by the unaided eye in a favorable light, or by the oblique illumination. 
 With the ophthalmoscope the growth can be accurately examined so 
 long as the media remain clear. It usually appears nodular and vas- 
 cular upon its surface, and in color it is either orange, yellow or whit- 
 ish. The reflection from such an eye is usually similar to that from a 
 cat's eye seen in the darkened room. The further development of the 
 tumor is that of increased growth and protrusion until it occupies the 
 whole surface of the retina, and finally the whole eye. 
 
 Embolism of the central artery of the retina dif- 
 fers in ophthalmoscopic symptoms according to the position in which 
 the embolus is lodged. If in the trunk of the main artery, before it 
 divides, the arterial branches are reduced in size, and are nearly or 
 quite bloodless. The optic disc is pale and transparent, and its ves- 
 sels ansemic. The veins are either empty or irregularly filled, clots 
 appearing to have formed at various points. The retina soon becomes 
 cloudy, especially at its central portions, and in the region of the mac- 
 ula lutea, and the latter assumes the appearance already mentioned 
 under serous retinitis, that is, it looks like a bright spot of effused 
 blood owing to the surrounding retinal infiltration. If the obstruction 
 continues in the artery, atrophy of the retina and disc will be the re- 
 sult. If it becomes gradually absorbed, the circulation may again be 
 restored and the retinal opacity disappear. It is of very rare occur- 
 rence. 
 
 In inflammation of the vitreons hnmor (hyalitis) 
 it is diffusely clouded with a grayish mist, which partially or com- 
 pletely obscures the fundus. 
 
 Besides diffuse opacity, there often exist opaque bodies varying 
 much in shape and size. If the vitreous is in a fluid condition, these 
 move about with the motions of the eye, and can readily be detected 
 with the ophthalmoscope. Opacities from hemorrhage appear bright 
 red, unless very extensive, when they may cause the whole fundus to 
 appear dark. The location and amount of hemorrhage is subject to 
 no rule. After absorption has begun, the color and form of the blood 
 spots change to various irregular, fibrinous or filamentous shreds, 
 either fixed or floating. 
 
 In a softened, fluid condition of the vitreous, a large number of 
 small bodies are to be seen suspended in its substance; in fact, unless 
 these bodies are present it can not be said positively that a fluid con- 
 
72 Diseases of the 
 
 dition of the humor exists. They are often in the form of fibrinous 
 threads, interspersed with crystals of cholesterine. 
 
 An abundance of cholesterine crystals generally is present when 
 the vitreous is in a fluid state, presenting a beautiful appearance. 
 "While the eye is at rest these crystals subside more or less completely 
 toward the bottom of the chamber, but with every movement of the 
 eye they become diffused through the fluid, and appear like particles 
 of sparkling gold-dust. The term sparkling synchisis is ap- 
 plied to such a condition. 
 
 When a foreign body has entered the vitreous, if the media 
 remain clear, the use of the ophthalmoscope will reveal its character 
 and position. After some days have elapsed, the body is likely to 
 become gradually covered with the products of inflammatory exuda- 
 tion, concealing it from view. 
 
 The treatment for diseases of the fundus demands experience* 
 But in general it may be said that the treatment of optic neuritis, 
 retinitis, or atrophy, varies with the cause, and is sometimes very pro- 
 tracted. • Blue glasses and rest are always proper. Hyalitis requires 
 the treatment of the primary affection. 
 
 The internal remedies must also be selected after a careful ascer- 
 tainment of the cause of the trouble, due reference being had to 
 special indications. 
 
 SECTION ELEVEN. 
 
 The eye is placed in such a position as to avoid many accidents. 
 The overhanging brow shields it, and it rests in the orbit on tissues 
 which are soft and yielding. But that which best protects it is the 
 inherent sense of approaching danger, this sense so quickened that 
 one eye warns the other, and causes the head to turn or bow instan- 
 taneously, the lids to close, and the globe to roll up and back. 
 
 It is also well-known that those who have lost an eye, not infre- 
 quently receive an injury to the remaining eye which might have been 
 avoided by a person possessed of both eyes. This can best be accounted 
 for by the supposition of one eye warning the other. 
 
 It is not a difficult proceeding to remove a bit of coal or other 
 foreign substance from the eye, provided the patient is not nervous, 
 unless the particle is imbedded in some one of the tissues. Nearly 
 
Eye and Ear. 73 
 
 all particles might be removed by the patient, if he would remember 
 to draw the upper lid away from the globe and down over the under 
 lid, with a few shaking motions. This maneuvre frees the foreign 
 body from the contact, and the tears from the lachrymal gland sud- 
 denly acting on the stimulus given its branch of the fifth nerve, washes 
 the body out or down into the inner canthus, where it may be found. 
 But so few are able to accomplish this little maneuvre that turning 
 back of the upper lid is generally demanded (explained in Section 
 One). 
 
 Strong sulphuric or nitric acids are often splashed or thrown 
 into the eyes by peculiar accidents, by design, etc. , and require im- 
 mediate attention. They act chemically on the tissues of the eye, 
 and if in sufficiently large quantities disorganize the parts and pro 
 duce sloughs more or less serious. There is great danger of sym- 
 blepharon resulting. The cornea is also liable to suppurate if the 
 epithelium is destroyed. Copious, deluging quantities of water should 
 be used at once, as a little will do harm. The eyes should be syringed 
 out with a weak alkaline solution, olive oil dropped between the lids, 
 an oiled linen placed on the closed lids and a roller bandage and pad 
 applied. The after-treatment is the same as that for quicklime. 
 
 Injuries to the eye from the contact of quicklime, mortar, 
 lime-planter, etc. , are very common, and cause partial or complete 
 destruction of the eye. The space of one or two minutes is some- 
 times sufficient for this, their effect being most disastrous on the cor- 
 nea, producing acute keratitis, subacute keratitis, slough, panophthal- 
 mitis, with resultant leucoma or nebulous condition. The treatment 
 should be to remove at once the foreign substance, being extremely 
 particular that all is taken out, after which freely syringe with warm 
 water. A spasm of the lids often makes this very difficult. If seen 
 very early, dilute acetic acid (one drachm to one and a half ounces of 
 water), or vinegar and water should at once be put into the eye. 
 This will form acetate of lime, which is innocuous. At the time it is 
 likely to be seen by the physician, however, this stage is past, and a 
 little sweet oil may be dropped between the lids. 
 
 The great tendency is for the lids to adhere to the globe (sym- 
 blepliaron) or together (ancbyloblepharon) owing to the 
 raw surface made by the burn. These adhesions must be broken up 
 by a probe dipped in sweet oil, and every attempt made to prevent 
 their reforming. A mild, muco-purulent discharge may set in; this 
 is to be treated as is that form of conjunctivitis. The resultant cor- 
 neal opacity is usually indelible; if deep, no treatment will remove it. 
 
74 Diseases of the 
 
 When there is a slough, a lotion of an ounce of glycerine to six or 
 seven ounces of distilled water will be found very soothing. 
 
 Burns and scalds affect the eye in a manner similar to other 
 parts of the body, but that which would be a slight scald elsewhere 
 becomes serious here. A scald whitens the surface, vesicates the 
 epithelium and produces general redness of the lids and eye. 
 
 For treatment, use that which at first excludes the air best; then 
 use soothing lotions until the sloughing stage is past, and when the 
 sloughs have separated and healthy granulations spring up, stimulat- 
 ing applications must be used. At first it is best to put in a few drops 
 of olive oil, cleanse the discharges from the eye with a glycerine lotion, 
 and cover the eye with a little cotton wool held in place by a turn of 
 a roller bandage. If the lids are severely burned, before applying 
 the cotton wool put on lint soaked in carron-oil (about equal parts of 
 linseed oil and lime water). If the burns are severe and the sloughs 
 separating, it is better to leave off the bandage and apply soothing 
 applications. Frequently bathe with a glycerine lotion; if very pain- 
 ful foment with decoctions; or, if there is no granulating wound of 
 the external surface, apply a cloth repeatedly wetted with belladonna 
 lotion. When the sloughs have separated from the eye or the mucous 
 surfaces of the lids, or if conjunctivitis is present with a muco-purulent 
 discharge, the injury should be treated as though it were this latter 
 disease primarily. 
 
 The treatment of the resulting cicatrices from accidents and injuries, 
 as well as the direct injury, often involves delicate parts so seriously 
 as to require very skillful aid to save sight. The chances for a favor- 
 able operation afterward depend much on the care given at the time of 
 injury. 
 
 For the treatment of injuries of an unknown or serious nature, it 
 is impossible to outline a successful course of treatment; but it may 
 be said that cold applications should be used in the beginning of an 
 injury, a few drops of a weak atropine solution instilled at short inter- 
 vals, and a protective bandage adjusted. 
 
Eye and Ear. 75 
 
 SECTION TWELVE. 
 
 By refraction is understood the faculty the eye possesses of 
 focusing certain rays of light upon the retina; this is due to the 
 shape of the globe and the refracting media, and is independent of the 
 accommodative apparatus. By accommodation is understood 
 the voluntary action whereby the eye becomes adjusted for vision of 
 points nearer than is possible under refraction alone. 
 
 In viewing any point beyond about eighteen feet, the refraction 
 alone is used, and the accommodation (or the eye sometimes) is said 
 to be at rest; points nearer require the aid of the accommodation. 
 Any object situated more than eighteen feet distant from the eye is 
 said to be at an infinite distance; nearer, at a finite distance. 
 
 Emmetropia is a term for perfect refraction, that state in 
 which parallel rays are brought to a focus upon the retina when the 
 accommodation is at rest. Ametropia is a term for imperfect re- 
 fraction, and embraces astigmatism, myopia, bypermetropia and pres- 
 byopia. 
 
 Astigmatism is that state of refraction, when the accommoda- 
 tion being at rest, rays of light emanating from a point are not reunited 
 at a point. It is caused by asymmetry of the refracting surfaces, whence 
 no image is correctly formed on the retina. It may be congenital or 
 not, but generally is; when not, it is due to the results of inflamma- 
 tion of the cornea, defective union of the cornea after cataract oper- 
 ations, etc. 
 
 Its symptoms subjectively are generally that the eye sees more 
 than one image, and these distorted in shape and position. Object- 
 ively, with the ophthalmoscope, distortion of the fundus is seen; and, 
 with oblique illumination, irregular corneal reflections and changes of 
 curvature are easily noted. The principal meridians are those of 
 greatest and least curvature. Different focal lengths of the principal 
 meridians, which are at right angles and generally vertical and hori- 
 zontal, cause regular astigmatism; differences of refraction in the same 
 meridian cause irregular astigmatism, which is incurable by glasses, 
 though occasionally improved by stenopaic apparatus (metal discs 
 pierced with small holes or slits). Regular astigmatism is called simple 
 when one principal meridian is emmetropic and the other ametropic, 
 as simple myopic astigmatism, or simple hypermetropic astigmatism: 
 compound when both are hypermetropic or myopic, but the defect is 
 
76 Diseases of the 
 
 greater in one than the other, as compound myopic astigmatism, or 
 compound hypermetropic astigmatism; mixed, when one principal 
 meridian is hypermetropic, the other myopic, as mixed astigmatism 
 with predominant myopia, or mixed astigmatism with predominant 
 hypermetropia. 
 
 When the accommodation is at rest, and parallel rays of light 
 entering the eye are focused in front of the retina, the condition is 
 called myopia, divergent rays being focused upon the retina. The 
 cause is that the optic axis is too long, a too high refractive power. 
 It is often hereditary. Anything that favors congestion of the globe, 
 as straining the eyes at fine work, reading by too dim a light, or read- 
 ing in a recumbent posture; stooping over at the desk, etc., may 
 cause it. 
 
 In myopia the far point lies nearer the eye than in emmetropia. A 
 myopic eye is often considered as necessarily of strong sight, and 
 hence not regarded as unsound. This is erroneous. While a stationary 
 myopia of low degree may not necessarily be a serious matter, it must 
 always be regarded as liable at any time to become progressive; a pro- 
 gressive myopia of high or low degree is a serious matter. One of 
 high degree, accompanied by staphyloma, is dangerous to vision in 
 advanced life, always affecting the sight more or less; one of high 
 degree, accompanied by posterior staphyloma and attendant atrophy^ 
 of the optic nerve, not infrequently ends in blindness. The latter 
 grades are nearly always attended by asthenopia, much irritation and 
 amblyopia. 
 
 Myopia is often confounded with spasm of the ciliary muscle, and 
 the latter diagnosticated as myopia. Spasm of the ciliary muscle is cur- 
 able by medicine, myopia is seldom, if ever. The two may be associ- 
 ated, and the spasm being overlooked, an improvement of the myopia 
 is supposed to be accomplished by medicines, whereas it is the spasm 
 that is relieved. 
 
 Myopia may be diagnosticated by the ophthalmoscope, in which 
 case the details of the fundus can be seen by the direct method a 
 short distance away; carrying the ophthalmoscope to one side, the 
 fundus is seen to move in the opposite direction. On a nearer 
 approach, a concave glass will be required to get a clear, erect image. 
 By the indirect method the details of the fundus seem smaller than in 
 an emmetropic eye. 
 
 The distance of the far point determines the degree of the my- 
 opia. A patient who does not clearly see beyond thirty-two inches is 
 said- to have myopia equal to g\ ; beyond twelve inches, myopia equal 
 to y 1 ^-, etc. 
 
Eye and Ear. 77 
 
 A stationary myopia through youth has a compensation in that the 
 necessity for lenses for old sight does not exist until the error due to 
 myopia is overcome by the senile change. Sometimes this never hap- 
 pens, hence lenses are not required. Much in the way of medical relief 
 can now be accomplished, and internal remedies should be tried before 
 any lenses are ordered. 
 
 When the accommodation is at rest, and parallel rays of light are 
 focused behind the retina, the condition is called hypermetropia. 
 Convergent rays are focused upon the retina. The cause is that the 
 optic axis is too short; when caused by senile changes in the eye, 
 aphakia or absence of the lens, there is low refractive power. It may 
 be hereditary. 
 
 In hypermetropia the eye cannot see distant objects without using 
 a certain amount of the accommodation, or what optically amounts to 
 the same thing, a convex lens; in emmetropia no accommodation 
 is used for distant objects, the refraction alone sufficing. This ab- 
 normal use of the accommodation overtasks the eye, causing spasm of 
 the ciliary muscle, strabismus, etc. Latent hypermetropia is that 
 which is habitually concealed, and only revealed by the use of a strong 
 mydriatic; manifest hypermetropia is that which is present without 
 the use of a mydriatic. The latter is represented by the strongest 
 convex lens through which the patient sees distant objects most acutely; 
 the total hypermetropia by the strongest convex lens through which 
 the patient sees distant objects most acutely after a strong mydriatic 
 has acted; the difference between the two represents the latent. 
 
 Hypermetropia is divided into three kinds: facultative, that in 
 which the patient sees near and far objects clearly with or without 
 convex lenses; relative, in which the patient sees near and far objects 
 clearly, but only by converging the visual lines to points nearer than 
 the objects, giving the eyes a periodic squint; absolute, in which 
 neither near nor far objects can be seen clearly without convex lenses. 
 
 In examining patients, it should be borne in mind that the two 
 e yes will often be found to differ greatly, either in grade or kind of 
 defect. One eye may be myopic and the other hypermetropic, or one 
 eye emmetropic and the other hypermetropic or myopic, forming ani- 
 sometropia myopia ; or similarly hypermetropic, causing anisometropic 
 hypermetropia, etc. 
 
 Hypermetropia may be diagnosticated by the ophthalmoscope, with 
 which the details of the fundus may be seen some distance away; car- 
 rying the ophthalmoscope to one side, the image of the fundus moves 
 in the same direction. On a nearer approach, a convex glass will be 
 
78 Diseases of the 
 
 required to get a clear, erect image. By the indirect method, the 
 details of the fundus look larger than in an emmetropic eye. 
 
 Asthenopia is a very common trouble, and is caused by a lack 
 of strength. Frequently it is due to some error in the refraction or the 
 accommodation. It is also due to such a multiplicity of other causes, 
 however, principal among which are muscular debility from any cause, 
 as diphtheria, typhoid or other fevers, uterine diseases and other con- 
 stitutional troubles, that a thorough knowledge of general medicine 
 and surgery is essential to rinding and removing the cause. Many 
 such cases, as well as the severer diseases of the eye generally, are the 
 results of fundamental changes in the structure of the body, or 
 deterioration of important organs, and are not merely functional 
 disorders, as is commonly supposed. 
 
 When once a case has settled into a chronic one, it is often difficult 
 to cure, hence the importance of an early recognition and suitable 
 treatment of this trouble. 
 
 Aphoria is a term used to indicate troubles arising from mus- 
 cular errors due to weakness or insufficiency of the ocular muscles, 
 whence the visual axes of the two eyes are not harmonious or in the 
 same plane. Hyperphoria implies a dissociated upward movement of 
 one visual axis from the horizontal plane; hypophoria a similar one 
 downward; ^xophoria one outward from the vertical plane; and eso- 
 phoria a similar one inward. The unfolding of the subjects of 
 ametropia, asthenopia and aplioria, affords a solution of 
 the causes of headache, neuralgia and similar troubles heretofore un- 
 solved. While it is impossible to briefly elucidate these complicated 
 processes, in a general way the present knowledge may be epitomized 
 as follows: Refractive are more common causes than muscular errors 
 in the production of headache, though the latter are more certain to 
 produce it; and of refractive errors, astigmatism and hypermetropia 
 are relatively the most frequent causes of this complaint. Hyperme- 
 tropia most frequently is the cause of strabismus and perhaps ble- 
 pharitis. Insufficiency of the inferior and superior recti muscles, either 
 alone or complicated with the lateral muscles, is a common muscular 
 error. * Vertical muscular error is more apt than any other muscular 
 error to produce headache; combined with astigmatism, it is almost 
 certain to do so. Sometimes these errors produce chorea, and possibly 
 epilepsy, as both may be alleviated, when such errors are present, by 
 lenses. The revelations of aphoria in connection with ametropia and 
 asthenopia, and their mastery by lenses, local or internal medication, 
 and the delicate operations so successfully performed, are the later 
 triumphs of modern surgery. 
 
Eye and Ear. 79 
 
 SECTION THIRTEEN. 
 
 For many years after their discovery, no special advancement was 
 made, and the use of lenses remained confined to supplying the 
 deficiences of the eye consequent on age. During the past half cen- 
 tury, however, and especially during the last quarter, the subject has 
 been carefully studied by men eminent in the known sciences. That 
 use which was based on a simple accidental discovery, has been sup- 
 planted by one controlled by unvarying laws solved by the higher 
 mathematics. Opinions based on the knowledge of past years should 
 be discarded. No age is now necessarily implied by their use. They 
 may be worn by any one at some period of life, for one or more of 
 the many affections to which they give relief. 
 
 These researches have also shown that a large class of troubles, 
 hitherto numbered among the incurable, are readily amenable to treat- 
 ment by lenses alone; and diseases formerly allowed to go on for the 
 want of a remedy, are now by their use promptly arrested. Many 
 who are totally unconscious that their sight is defective, are relieved 
 of troubles and made to see in a manner they never deemed possible. 
 Others who have been obliged to abandon occupations on account of 
 supposed failing sight, can now return to them. 
 
 It was but comparatively recently that the inheritance of an optical 
 defect was one of the most unfortunate hereditary calamities. This 
 thorough study of the laws governing the use of lenses, however, has 
 wrought one of the pleasantest of changes. By it, members of the 
 same family may be placed upon widely different planes of life; for 
 occupations closed to the older members by reason of such inheritance, 
 are open to the younger. Inability to use the eyes for near work 
 from inherited refractive defects, has become almost a thing of the 
 past. 
 
 It is as useless to expect to do away with lenses for eyes requiring 
 them as it is foolish to attempt it. The value of lenses to every one 
 at some period of life, and their absolute necessity to many at all 
 times, should do away with all prejudices against their use, and lead 
 to its study. Such study will not only remove erroneous notions, but 
 by awakening interest in newly discovered optical laws, stop the im- 
 positions of prowling pretenders. 
 
 Nearly all persons are familiar with the fact that lenses have been 
 worn as aids to sight; but many have confused notions regarding 
 
80 Diseases of the 
 
 their functions. Indeed, it will not be far out of the way to say that 
 a large proportion of the laity know almost nothing of their uses be- 
 yond that they help the aged and weak-sighted. So strong have 
 these notions become implanted, that it is not infrequent to find em- 
 ployers declining to engage an applicant wearing glasses; or those 
 needing them going without them, because of the idea that they im- 
 part a tinge of age or indicate a lack of capacity. In the hands of a 
 skillful person there is no remedy at this day which will in their vary- 
 ing combinations so frequently assist the sight, as suitable lenses. 
 
 Causes for the use of lenses may also be found in headaches, neu- 
 ralgia of the eye and general system, cross-eye, spinal irritation, 
 nervous prostration, choreic spasms, sleeplessness, depression of 
 spirits, irritability of temper, inability to concentrate the attention and 
 apply the mind, and other oculo-nerval reflexes, produced or sustained 
 by a faulty shape of the eye and weakness of the ocular muscles. 
 
 Focal glasses. To overcome myopia, concave spherical lenses 
 are used, because they render parallel rays of light sufficiently diver- 
 gent to impinge sharply on the retina; to overcome hypermetropia, 
 convex spherical lenses are used, because they produce the opposite 
 effect optically; presbyopia is corrected by convex spherical lenses, 
 because they supply the deficiencies of accommodation and refraction; 
 and astigmatism is corrected by concave or convex cylindrical glasses, 
 with or without a combination with the other kinds as may be indicated, 
 by restoring the symmetry of the different meridians of the refract- 
 ing surfaces. 
 
 Xon-focal glass may be recognized by holding it up to the 
 light and noting if a perpendicular line moves with the glass when it 
 is slowly moved from right to left, or the reverse. If it does, or moves 
 in an opposite direction, or if images are distorted, the glass does not 
 belong to this class. The common, cheap coquilles, and by these are 
 meant the common curved blue glasses so generally worn (but not what 
 are known as goggles, which never should be habitually worn in eye 
 disease, and not at all unless by order of a physician), are made of 
 pressed or molded glass, and it is quite rare to find such without 
 focus, nearly all presenting a negative meniscus. This defect can be 
 obviated, however, by a pair which have been ground, not molded. 
 
 The colors proper for these glasses, and their correct adaptation 
 should be considered, for it is extremely rare to find anyone who has 
 any suspicion that such glasses are in any manner injurious to the eye 
 or sight. It is not at all uncommon, however, to find cases where the 
 deeper portions of the eye are kept in a state of chronic irritation from 
 
Eye and Ear. 81 
 
 their use, by which other parts of the eye from reflex action are. sym- 
 pathetically disturbed. 
 
 The ordinary double-convex or double- concave lenses are alike on 
 both sides, the convex lenses being convex on both sides, the concave 
 lenses concave on both sides. Periscopic lenses are concave on 
 one side and convex on the other, the concavo-convex having a shorter 
 radius of the convex surface; the convexo-concave a longer. Could it 
 be done, all lenses should be put into the eye, so that they would 
 become an integral part of the globe. Such not being possible, they 
 are placed directly in front of the eye. Unfortunately they cannot 
 move with the eye, and hence when the axis of vision, owing to the 
 turning of the eyes, is no longer directly in front through the centers, 
 as is often the case, they prevent free vision in a greater or less de- 
 gree, according as they are stronger or weaker in power. To over- 
 come this trouble, one must turn the head rather than the eye. With 
 periscopic lenses, less of this trouble is noticed, for there is a freer 
 range of the eye behind the glass, thus permitting a clearer view of 
 objects lying in an oblique field of vision. 
 
 The question of material for the composition of lenses 
 must be decided by the use to which the glasses are to be put. All 
 lenses are made from two materials, glass and rock crystal, the latter 
 being the material generally known as pebble, the distinctive adjec- 
 tive usually being taken from some remote district of high-sounding 
 name. 
 
 The great object is to select that material which disperses light the 
 least in proportion to its refractive power . The preference for pebbles is 
 often claimed on the ground that the polish on their surfaces is higher, 
 and hence they do not scratch as easily; and that the material is per- 
 fectly white and transmits a pure light, while even the best glass has 
 a greenish tint. This remark about the non-transparency of glass 
 was true, but a transparent glass is now readily and cheaply available 
 to all opticians, and transmits a pure, clear light. In this preference the 
 greater object should overcome the lesser one; hence for glasses of 
 high power, and especially concave ones, crown glass should be 
 selected; for weak ones, and especially weak convex ones, any preju- 
 dice for pebbles may be safely indulged. By the use of the pebble- 
 tester, however, supposed pebbles may be found to consist of glass, 
 and ideas of the relative value of the different kinds changed. 
 
 This test consists of two plates of tourmaline, between which the 
 lens is placed, and then held up to the window. If the lens is pebble, 
 the light is polarized, and colored rings appear; if it is glass no effect 
 
82 Diseases of the 
 
 is produced. Pebble is also a better conductor of heat than glass, 
 hence a lens made from it will seem colder to the tip of the tongue 
 than one made from glass. In order that the pebble lens may be of 
 its greatest value, it is essential that its axis be at an exact right angle 
 to the axis of the double refraction, this double refraction being: a 
 peculiarity of pebble in one direction. But if care is taken in this 
 respect, not so many lenses can be cut out of one piece of crystal, hence 
 it is sometimes disregarded, and in consequence the image seen 
 through them is more or less blurred and fuzzy on its edge. Re- 
 source being again had to the pebble-tester, the defect can be easily 
 detected; for if the lens is rightly cut the rings of colored light will be 
 circular ; if not they will be more or less irregular or eliptical in shape, 
 or as opticians usually say, prismatic colors will be abundant. 
 
 Unprincipled dealers often seek reputation by pretending to have 
 superior glasses under the names of "clearers," "restorers/' etc. 
 Too strong glasses for a time seem to make the sight better also, but 
 they quickly fail to be valuable and cause the eyes to ache. 
 
 The proper kind of glass having been determined upon, it is im- 
 portant that the correct frame is selected. It is not enough that 
 the lens is correct, its erroneous adaptation to the eye may defeat 
 much gained by its use. The distance between the eyes should be 
 considered, in connection with the shape and style of the nose, and an 
 adaptation made of some one of the kinds. The material for the con- 
 struction of the frames, is usually a matter of taste. 
 
 When glasses are to be worn for seeing at a distance, the connect- 
 ing bridge should be longer than when they are to be worn for near 
 vision, because the visual lines are practically parallel; if for both near 
 and far, a medium may be sought. In addition, the lenses of the first 
 should be set high, in order that they may correspond to the plane of 
 the pupils. To see near objects, however, the lenses should be set 
 low, and the lower edge of the lenses inclined backward. 
 
 Sometimes when a person has old sight supervening on over- 
 sight, or has absolute over-sight, it is convenient to have two pairs 
 of lenses in one frame, the lower half of the lens stronger than 
 the upper; or if short-sighted, with diminished range of accommoda- 
 tion, the upper half concave and the lower half convex. Such glasses 
 are known as Franklin glasses, or glasses of double focus, and 
 may be mounted in the same frame. If suitably adjusted, they are 
 very convenient, and often greatly liked by the wearer, but in the 
 hands of some require such careful adjustment, that they weary and 
 annov. 
 
Eye and Ear. 83 
 
 The natural stimulant to the special nervous elements of the retina is 
 sunlight which is reflected by objects in their different colors. If blue 
 glasses are ordered, certain colors are changed or shut out. This is 
 often desirable for very nervous persons, or when traveling on lakes, 
 where the reflection from the water is strong, or in morbid states of the 
 retina. Formerly green glasses were almost universally used, but 
 they have been generally displaced by blue; for while reflected green 
 light is agreeable, transmitted often is not. But if it is not desirable to so 
 shut out or change certain colors it is necessary to order the lenses in 
 a neutral tint known as London smoke, for these glasses exclude 
 each color of the solar spectrum in equal proportions, and so simply 
 soften the light. 
 
 Up to about the year 1860, when the present system of meas- 
 urement of lenses in inches was practically introduced, there 
 was no generally accepted way of numbering lenses. A manuf acturer 
 might make twenty powers of lenses and number them from 1 to 20 ; 
 another might make only twelve powers of lenses embracing the same 
 range, and number them from 1 to 20, and so on, so that the number 
 10 of one manufacturer might be the number 7 of another, and the 
 number 13 of another, etc. To overcome this, it gradually came to be 
 understood that the number of the glasses indicated their focal length 
 in inches. But the refracting power of a lens also depends on the 
 index of refraction of the glass, varying with the kind of which it 
 is composed. The Parisian inch is the equivalent of 27.07 milli- 
 metres, the English of 25. 30, the Austrian of 26. 34. and the Prussian 
 of 26. 15, while the index of refraction of the glass of which lenses are 
 constructed varies all the way from 1.526 to 1.534. Hence there were 
 sources of error in all calculations, for even though the country was 
 known where the lenses were made, and presumably they were made on 
 the standard of that country, the refracting power could never 
 be told unless the index of' refraction of the glass was known. In order 
 to simplify the latter, a common index of refraction of 1. 5 was accepted, 
 but even with that wrong basis, only part of the trouble was removed, 
 so that as a compromise it became generally accepted that the number 
 of a lens indicated both the focal distance and the refracting power. 
 Thus a lens numbered 9 had a focal distance of nine inches, and a 
 refracting power of \. But it was known all the time that it had 
 not, and it in no wise made an intelligent person feel that a prac- 
 tical matter was solved by feigning to believe what was known to 
 be wrong. A sensible system of notation would indicate either the 
 power of refraction or the focal distance of a lens. This old system 
 
84 Diseases of the 
 
 did neither, and by making the unit too strong necessitated the con- 
 stant use of fractions in all calculations. Practically there is much 
 more to do with the refracting power of a lens than with its focal 
 distance. The refracting power is always the inverse of the focal 
 distance. The numbers of the old system give the focal distance of the 
 lens in inches, the unit being a lens of one inch with a refracting 
 power of \-. There is seldom need of this lens in practice, and it 
 is not put in trial cases. 
 
 To obviate these difficulties many oculists offered plaDs and intro- 
 duced them at different conventions. As a result, at the International 
 Congress of Ophthalmology in 1867, a new system of number- 
 ing all lenses according to the refracting power was proposed. After 
 a short delay, that which is known as the new or the metrical 
 system was adopted. A lens of one metre focal distance, instead of 
 one inch as in the old system, was selected as the unit, called a diop- 
 try, and numbered 1. This dioptry, a metre, is the equivalent of 100 
 centimetres, 1,000 millimetres, or 39.33 English inches. Thus by 
 following the cardinal numbers, there is a series of lenses with an 
 interval of one dioptry, as No. 2 is twice as strong as No. 1 ; No. 20 
 twenty times as strong as No. 1. Unfortunately there is need of 
 lenses weaker than one dioptry, and at intervals between dioptries, 
 so that this system does not after all remove the need of fractions, 
 and there are lenses of .25 and .50 dioptry, 1.75 and 2.50 dioptries, 
 etc. 
 
 To adjust lenses to refractive anomalies, trial cases are used, 
 and are indispensable for one who is not skilled in that branch of oph- 
 thalmoscopic optometry which treats of measuring the refraction of 
 the eye with the ophthalmoscope. Even then it is usual to make use 
 of them, though advantage is derived from being able to confirm their 
 estimate of the refraction by the latter method. These trial- cases, 
 when complete, are composed of glasses of the various kinds known, 
 with which the applicant for glasses tries or tests the eyes under the 
 guidance of the physician, the examination being subjective. When 
 the correct lenses are thus found by trial, duplicates of such lenses 
 are ordered for the patient to wear, they being ground and set in a 
 suitable frame. It is essential to test the eyes separately, for it is not 
 at all uncommon to find them differing in their refractive power. 
 Lenses being designated by the metric system, as well as the old 
 inches, in ordering lenses, if the new system is used, the numbers 
 should be designated by a " D " (Dioptry) following each number 
 thus: .5D., ID., etc. 
 
Eye and Ear. 85 
 
 At first glance it will seem that there is no objection to giving a 
 glass suitable for the correct measurement of the refractive power of 
 each eye. But the eyes do not see, they act simply as an optical box; 
 sight lies in the brain. Convex lenses enlarge the image of an object, 
 and concave ones diminish it. If there is placed before one eye an 
 enlarged image, as would be brought about by the use of a convex 
 glass essential in the case of a hypermetropic eye, and a diminished 
 image before the other eye, as would be produced by a concave lens 
 essential in the case of a companion myopic eye, the effect would be 
 the same as in endeavoring to see two overlapping objects with one 
 eye. Neither would be seen well. There are exceptions to this rule, 
 as to all others, but the general principle holds good. The practical 
 difference found to exist, if it does not exceed one-forty- eighth or one- 
 sixtieth of an inch may be neutralized in both eyes by correctly fitting 
 glasses ; when it exceeds this, it will be found the better rule to fit the 
 eye with the better sight, and give a correspoDding glass for the other 
 eye. It by no means is always true that the eye with the better re- 
 fraction is the better one for vision, for it may be amblyopic, and 
 hence not be as useful as the other which has the poorer refractive 
 power. 
 
 If, however, such eyes are to be used for any purpose requiring 
 accuracy of fixation, as in rifle- shooting, or the determination of lines, 
 as in surveying, etc., it will generally be found that the right eye 
 must be the one to be fitted; for on trial it will be found that the 
 preference to the right eye is usually given in such matters. 
 
 SECTION FOURTEEN. 
 
 In order to lit lenses for refractive troubles, it is essential to 
 have a set of test-types in addition to the trial case. For a num- 
 ber of years much confusion resulted from there being no uniform 
 way of testing vision. To overcome this, it was agreed by commoL 
 consent to make use of a set of letters drawn upon a given scale. • 
 Snellen and Jaeger both devised such sets, and as each has merits 
 peculiar to itself, each is used; the former being considered better for 
 the determination of the acuity of vision, and the latter for the ease 
 of reading. Snellen' s letters are square and their size increases in a 
 definite ratio, so that each kind is seen at an angle of five minutes, 
 
86 Diseases of the 
 
 No. 3 being seen at a distance of three feet, No. 2 at a distance of 
 two feet, and so on. As a rule, these letters can not be seen distinctly 
 beyond these distances. 
 
 The standard of measurement of lenses having been changed from 
 inches into dioptries, so as to have a uniform standard, the same unit 
 of measurement was taken for the measurement of the dis- 
 tance of the test-types. Thus a person who has normal sight reads 
 the test-types at the distances corresponding to the numbers marked 
 thereon. If in feet, No. 200 is read at 200 feet, No. 20 at 20 feet, 
 and so on. But if the new system is used, No. 60 is read at 60 diop- 
 tries, No. 6 at 6 dioptries, and so on. 
 
 An eye suffering from diminished acuity of vision, in order to gain 
 large retinal images, will demand a larger retinal angle than five min- 
 utes to see the letters, and hence No. 1 can not be seen at one foot, 
 but for example, only at a distance of six inches, and so on. 
 
 If, then, the card of Snellen's types is placed at a distance of 
 twenty feet, or, according to the new nomenclature, at a distance of 
 six dioptries, and the observer see No. 20 of the first, or 6 of the sec- 
 ond, plainly, the vision is perfect, 20-20ths or 6-6ths. If, however, 
 that which should be seen at 70 feet, can only be seen, the vision is 
 20-70ths of what it would be were it normal. In practice the, frac- 
 tions should never be reduced, but the denominator allowed to remain 
 the distance at which the test-types should be seen, and the numerator 
 the distance at which they are placed. For the eye in a state of rest 
 depends on the refraction alone, but when viewing any object nearer 
 than about eighteen feet, the accommodation is used, so that practi- 
 cally 2-7ths is not 20-70ths. In the former case the expression would 
 mean that the types used should be seen at 7 feet, and were only seen 
 at 2 feet, the accommodation being used, or in a condition where it 
 might be used if not diseased. In the latter case the expression 
 would mean that the types should be seen at 70 feet, but were only 
 seen at 20 feet, the refraction alone being used, as the distance at 
 which the types were placed was such as to preclude the use of the 
 accommodation, for it must be at rest at a distance of 20 feet. More- 
 over, there is some advantage in using the scale of tens when fractions 
 are involved, as will be seen when the adjustment of lenses is attempted. 
 
 Jaeger's types are not square, but similar to those in ordinary use. 
 Already familiar in ordinary reading, they are the more readily seen 
 and recognized. 
 
 Short-sighted lenses should be worn near the eyes; over-sighted 
 ones not necessarily so. Astigmatic glasses should be carefully kept 
 
Eye and Ear. 87 
 
 in the exact position designated, otherwise they impede rather than 
 benefit vision. 
 
 Inasmuch as no one sees with the eye, but with the brain, the eye 
 maybe perfectly fitted as to its refraction, the image perfectly formed, 
 and yet there be no vision, the sensorium taking no cognizance of the 
 image present. This will afford a solution to many otherwise unsolved 
 and seemingly incomprehensible, optical problems. 
 
 To make a practical application of lenses, a person 
 whose vision is suspected to be imperfect should be seated at twenty 
 feet from No. 20. If every letter seems black and the outlines of the 
 letters clearly defined, there is apparently normal vision for dis- 
 tance, but the eye may still be hypermetropic. In order to determine 
 this, place in front of the eye a plus 72 inches lens, and let it look at 
 No. 20. If the letters are slightly dimmed, or less distinctly seen, the 
 eyes are normal for distant sight. If, however, with such a lens the 
 sight continues as good as before, try a plus 36 inches lens : if it still 
 sees as well, try a stronger, and so on until the letters are getting 
 dimmed. The manifest hypermetropia is now overcome, but most 
 likely there is some latent. The strongest lens with which sight is as 
 good as it is without it, represents the manifest hypermetropia. With 
 this trouble, however, as with myopia, there is danger of confounding 
 spasm of the ciliary muscle. A more complete description of the lat- 
 ter affection will be given; it requires care to detect it. 
 
 The total hypermetropia is determined by paralyzing the accom- 
 modation with atropine and then selecting a lens of sufficient strength 
 to render distant objects clearly visible. This lens represents the total 
 hypermetropia. 
 
 It is often well, though not necessary always, to completely par- 
 alyze the accommodation in cases which require examination. This 
 is effectually done by instilling into each eye three times a day, for 
 one or two days, a drop of a solution containing four grains of pure 
 neutral atropia sulphate to an ounce of distilled water. 
 
 Generally it will be found in practice, that the strength of the 
 lenses to be prescribed for individual cases should not be sufficient to 
 correct the total hypermetropia. Correction of the manifest hyper- 
 metropia with a small amount of the latent, is often sufficient at first, 
 and relieves any asthenopia due to the affection. Lenses sufficient to 
 do this may be worn until an additional amount of the latent hyper- 
 metropia becomes manifest, and then be replaced by stronger ones. 
 As a rule, young persons who see as well, or better, with their 
 mother's or grandmother's glasses, are hypermetropic. 
 
88 Diseases of the 
 
 The correction, at first, of the total hypermetropia, is often found 
 practically to be attended with more or less discomfort to the patient; 
 for it is seldom that a patient can at once wholly dispose of the habit 
 of accommodating. The involuntary accommodation added to glasses 
 of full strength, renders the refraction in effect myopic. One must, 
 therefore, by easy stages, be educated to the use of stronger and 
 stronger glasses, until accustomed to the use of those which are 
 equal to the total hypermetropia. 
 
 For children affected only in a slight degree, and in whom the 
 accommodative apparatus is in full vigor, glasses which overcome 
 the hypermetropia for distance are all that may be required for many 
 years. For old people, in whom the power of accommodation is 
 nearly lost, glasses equal to the total hypermetropia may generally be 
 prescribed at once. 
 
 In regard to the use of lenses for hypermetropia, it is 
 best that it should be constant. If the glasses are laid aside at inter- 
 vals, a return of the old symptoms is apt to follow, and no progress 
 will have been made in overcoming the disorder of the accommoda- 
 tion. However, in young persons who experience no inconvenience 
 except while engaged in near and fine work, the lenses may meet all 
 requirements if worn only while engaged in such work. 
 
 In advanced life, after presbyopia has set in, hypermetropes often 
 require two pairs of glasses, the strong for near, and the weaker for 
 distant vision. These may be combined in one frame if desired. 
 
 When lenses of a high power are required, as in near vision in 
 hypermetropia of high degree, the centering and adjusting 
 the lenses properly is a very important matter. By centering is 
 meant that the lenses should be so adjusted as to allow the visual lines 
 to pass through their axes, for when light passes too near the edge of 
 either a convex or a concave lens, the lens acts as a prism. 
 
 So close is the association between the functions of accommodation 
 and convergence, that a slight disturbance in their equilibrium, as by 
 the action of improperly centered lenses, may be attended with very 
 painful nervous symptoms. Notwithstanding the lenses may be prop- 
 erly centered, they cannot change with the movements of the eye. If 
 the visual lines always remained in the same relation to the centers of 
 the lenses, or, in other words, if the eyes always maintained the same 
 degree of convergence, and only moved in exact conjunction with the 
 movements of the head, lenses could be so centered and adjusted as to 
 be always a fixed and reliable factor in the visual apparatus. But not 
 only does the angle which the visual lines make with each other change, 
 
Eye and Ear. 89 
 
 according as near or distant objects are observed, but also when the 
 eyes are turned outward, upward or downward, the visual lines pass 
 near and even beyond the edges of the glasses, thus causing confusion 
 and indistinctness of vision. 
 
 The distance and size of objects is estimated in part by the amount 
 of effort required in the accommodation and the convergence of the 
 eyes while viewing such objects. The association between the func- 
 tions of accommodation and convergence is constant. Convex glasses 
 placed in front of hypermetropic eyes cause the accommodation to 
 relax ; a certain degree of convergence has always been associated with 
 some given degree of accommodation, hence the patient at once asso- 
 ciates with the relaxed state ef accommodation, a certain increase in 
 the size and distance of objects. Objects often seem to recede, and in 
 walking, the floor or pavement seems farther away than natural, and 
 the patient feels as though constantly stepping to a lower level. 
 
 The eyes that are unused to the wearing of convex glasses must 
 often become accustomed to them in more respects than one, before 
 the effects of the new conditions, consequent upon their use, will seem 
 real and agreeable. 
 
 It has already been mentioned that late in life all eyes become 
 presbyopic, and usually to that degree that they cannot exert the ac- 
 commodation necessary for reading and fine work; therefore stronger 
 glasses are required for such purposes, while those glasses to which 
 the patient has already become accustomed remain good for distance. 
 A patient with hypermetropia of two dioptries, and wearing . lenses of 
 sufficient strength to correct it, would, in the ordinary course of events, 
 at the age of forty-five, have presbyopia amounting to about one 
 dioptry. The addition of one dioptry to the strength of the lenses, 
 making the lenses three instead of two dioptries, would therefore be 
 required for near vision. 
 
 One of the most common results of hypernietropia is con- 
 vergent squint, or cross-eye. At about the age of five or six years, 
 children are usually put to school and there required to read and 
 write, and to otherwise use their eyes for fixing small objects more or 
 less distinctly and continuously. This is the time when convergent 
 squint most often makes its appearance, and the timely use of con- 
 vex lenses will, in many cases, prevent this condition. 
 
 To adjust lenses for myopia, the patient should be seated 
 as directed for hypermetropia, that is, at twenty feet from No. 20. 
 If now the letters are not distinctly seen according to their numbers, 
 nor do convex glasses of any power improve the vision, myopia may 
 
90 Diseases of the 
 
 be suspected to be present. Place in front of the eye a minus 36 
 inches lens; if this improves the vision and brings to view a smaller 
 set of letters than could before be seen, change to a stronger concave 
 lens, and so on until No. 20 is read. The weakest lens with which 
 No. 20 can be easily read, will be the measure of the myopia, if no 
 spasm of the ciliary muscle is present. But if no glass is found which 
 permits of this, the eye may be amblyopic or astigmatic and require 
 other aid. But owing to complications which may exist and render 
 vision otherwise defective, it must not be expected that all cases of 
 myopia can be brought to a normal standard of vision for all dis- 
 tances. 
 
 In the choice of lenses, many complications are met in indi- 
 vidual cases. In high degrees, weaker glasses for near and stronger 
 for far vision are usually given. In moderate cases, those of three 
 dioptries or less, one pair of lenses will often subserve both purposes, 
 and may be constantly worn. 
 
 For far vision in any case, the glasses chosen should be the weak- 
 est which render distant objects most distinctly visible. These same 
 glasses would answer for near vision, as for reading, etc., were it not 
 for the diminished power of accommodation, so common in myopic 
 eyes. This is the result of disuse of the accommodative apparatus, 
 and consequent weakness. Therefore when either one or two pairs of 
 glasses are required, those which fully correct the myopia, and no 
 stronger ones, should be given for distant vision. 
 
 The Strength of the glasses to be used for near vision in 
 any given case, must depend much upon the state of the patient' s 
 accommodation. If the accommodation is good and the myopia does not 
 exceed five or six dioptries, a patient can sometimes, without incon- 
 venience, wear lenses which nearly but do not quite correct the defect. 
 But the stronger the lenses used the smaller will be the retinal images, 
 and the greater the strain upon the accommodation. 
 
 The treatment of myopia, by the use of concave lenses, depends 
 upon the principle that carrying objects farther from the eye does 
 away with an excessive amount of convergence which overtasks the 
 eyes, and increases and perpetuates the trouble. This fact should be 
 impressed upon the minds of patients, or the most carefully adapted 
 glasses will often fail to accomplish their purpose; for habits once 
 formed are hard to overcome, and the habit of bringing the work very 
 near the eye, unless due care is exercised by the patient, will often be 
 persisted in after the glasses are given. This matter needs especial 
 attention in the case of children; for in them the disease is especially 
 apt to increase. 
 
Eye and Ear. 91 
 
 The object usually in using lenses for near vision, is to remove the 
 far point to a convenient distance for reading and line work, thus 
 preventing straining of the eyes by unnecessary convergence. 
 
 Suppose a patient has a myopia of five dioptries, the far point is 
 at about eight inches. It is desired to remove it to a convenient dis- 
 tance for reading. A myopia of three dioptries has the far point at 
 about thirteen inches; a myopia of two and one-half dioptries has the 
 far point at about sixteen inches, and either distance is convenient for 
 reading. Lenses are therefore given which reduce the myopia to 
 either 3 or 2. 5 dioptries. A lens of 2 dioptries will accomplish the 
 first, a lens of 2. 5 dioptries will accomplish the second. 
 
 In slight cases of myopia, 1. 5 dioptries or less, the only inconven- 
 ience experienced is not seeing distant objects distinctly; so if the 
 patient does not ud consciously, or through ignorance of the effect, 
 bring work too near the eyes, very little inconvenience will be experi- 
 enced, and no glasses desired. Children need especial care in regard 
 to this matter of holding the work too near, for the defect is not only 
 aggravated by it, but may be created in perfectly normal eyes. Until 
 the vision has been properly tested, a child should never be corrected 
 for holding work too near. 
 
 The remarks concerning the centering' of the lenses under 
 hypermetropia, are quite as applicable to myopia. The visual lines 
 should pass through the axes of the lenses, and, for this reason, the 
 lenses for near vision, owing to the convergence of the visual lines, 
 should have their axes nearer together than those used for far vision. 
 
 Spasm of the ciliary muscle occurs in hypermetropia or 
 myopia. When due to hypermetropia it occurs in young people most 
 frequently. While their eyes appear myopic and concave glasses im- 
 prove vision, the use of the ophthalmoscope, or paralysis of the ac- 
 commodation with atropine, reveals hypermetropia. The state of the 
 refraction in such eyes is also variable, causing one power of lenses to 
 fit at one time and another power at another. But the strength of the 
 lenses which render vision normal at any time, is much less than the 
 apparent degree of the myopia would seem to indicate. Such cases 
 require medical treatment. 
 
 Cases of myopia which increase rapidly, should excite suspicion of 
 spasm of the ciliary muscle, especially if they are accompanied by 
 marked symptoms of asthenopia on using the eyes for reading, or for 
 near work. 
 
 One of the various complications, which often accompanies and is 
 dependent upon myopia, is insufficiency of the internal recti 
 
92 Diseases of the 
 
 muscle*, whose function it is to draw the eye inward. This affec- 
 tion is most common in myopia of high degree, though it may be 
 present in almost any grade. The cause is to be found in the over- 
 work of the internal recti muscles while producing the excessive con- 
 vergence of the visual lines necessary for near vision. The muscles 
 become fatigued after continued exercise in reading, and one eye finally 
 rolls outward. 
 
 The subjective symptoms of which the patient complains, are heat, 
 pain, fullness and pressure in and about the eyes, with dimness and 
 confusion of vision. These disappear after resting the eyes awhile, 
 only to be renewed as work is resumed. 
 
 On examination of the eyes in a case of suspected insufficiency, they 
 appear normal. But hold a pencil, or some similar object, vertically 
 in front of the patient's eyes, and while they continue to look steadily 
 at the object, gradually carry it toward the eyes. When the object is 
 within five or six inches of the patient, one eye will become unsteady 
 and roll outward. This outward deviation may be gradual or sudden. 
 
 But a better test is to place a prism of ten degrees, base down, be- 
 fore the right eye, and have the patient look at a dot on a vertical 
 line. Two dots will be seen, one above the other. If both are on the 
 line, there is no insufficiency present; but if the upper dot is to the 
 right, the internal recti are deficient; if to the left, the external recti 
 have been overcome. In the normal, or emmetropic eye, the prism 
 simply has the effect to cause the images to appear double, one image 
 being directly above but not to one side of the other. The strength 
 of the prism required to fuse the two images, is the measure of the 
 insufficiency. When they are to be worn, these, prisms should be 
 placed in frames, bases inward, and the proper convex lenses ground 
 into the prisms. 
 
 The action of prisms is to deflect rays of light inward toward 
 their bases; therefore, rays from near points, on passing through them, 
 enter the eyes as though they came from greater distances. This dis- 
 poses of the excessive convergence of the optic axis. The proper con- 
 cave lenses relieve the accommodation, the proper prisms, bases in- 
 ward, relieve the convergence. 
 
 With the best possible adaptation of glasses, the vision of some 
 myopic eyes is but little improved, especially for distant objects. 
 This fact is susceptible of explanation in various ways; but perhaps 
 the most constant and potent cause is to be found in the fact that the 
 perceptive elements of the retina are spread over a larger space in the 
 myopic than in the emmetropic eye. Concave glasses, while they 
 
Eye and Ear. 93 
 
 bring parallel rays to a focus at their proper place upon the retina, 
 and thus make the image distinct, also diminish the size of the images 
 so much that sometimes little advantage is gained. 
 
 Many persons affected with myopia, refuse to wear glasses in the 
 hope that with the advance of age, they may have no need of them. 
 Such a course is not to be commended, for not only is the affection 
 more apt to increase thereby, but these persons constantly undergo 
 much unnecessary discomfort, and not infrequently produce a systemic 
 disturbance. 
 
 "When two pairs of glasses are given to one person, explicit direc- 
 tions should be given regarding their use, and the patient should be 
 especially warned against attempting to use the stronger glasses for 
 near vision. It is a question whether considerable harm is not caused 
 by the thoughtless observation of near objects while the stronger 
 glasses are in use. The stronger glasses are simply intended to con- 
 tribute to the comfort of persons wearing them, permitting them to 
 see at a distance; the weaker glasses are intended to prevent the pro- 
 gress of the affection, and should not be laid aside while engaged in 
 reading or near work. 
 
 Lenses of any power, however, may often be more serviceable of 
 a blue, green, or neutral tint, as may be necessary or desirable in dif- 
 ferent forms of trouble. It is usually better not to order them ground 
 in tinted glass, for the glass being of varied thickness, the shade is 
 unequally distributed over the field of vision, especially in the stronger 
 glasses, but preferable to attach to one of the surfaces a colored plain 
 glass by means of Canada balsam, which is transparent. 
 
 The methods of testing and measuring astigmatism are 
 very numerous, and as in the other forms of ametropia, may be either 
 subjective or objective. All subjective tests depend upon the fact 
 that if the astigmatic eye looks at a number of lines of uniform 
 width, drawn in different directions, some will appear clear, and 
 others more or less indistinct. The lines used for this purpose should 
 be clear, sharply denned, and not too narrow. Diagrams for this 
 purpose may be obtained at any medical bookseller's. The normal 
 eye is slightly astigmatic, but if the difference is less than one-fortieth 
 of an inch, it causes no appreciable disturbance of vision. 
 
 All lenses for the correction of ordinary errors of refraction are 
 segments of spheres; those for astigmatism often combine two kinds, 
 the spherical and the cylindrical, though sometimes the latter is suf- 
 ficient. A cylindrical lens is the longitudinal section of a cylinder, 
 and may be either convex or concave according to the portion of the 
 
94 Diseases of the 
 
 cylinder it is taken from. It may also be either plano-convex or 
 plano-concave, bi-convex or bi-concave, a positive or negative menis- 
 cus. When a cylindrical lens is combined with a spherical lens, the 
 resulting lens is termed sphero-cylindrical. This lens is made with 
 one side ground spherical, and the other cylindrical. 
 
 Kays of light falling on the plane of the meridian passing through 
 the axis of a cylindrical lens, do not change their direction, there 
 being no refraction in this meridian. In all other meridians, how- 
 ever, the light is refracted, but in degrees, increasing as the meridian 
 is more nearly perpendicular to the axis of the cylinder. In the per- 
 pendicular meridian, the highest degree of refraction is obtained. 
 
 Similar differences of refractive power taking place in the astig- 
 matic eye between the least and the greatest deviating, or the princi- 
 pal, meridians, it follows mechanically that if a glass of the cylindri- 
 cal form compensating for the deviation in any meridian, is placed in 
 front of such meridian, the eye will be in a correct state of refraction. 
 
 Simple astigmatism is corrected by a cylindrical lens, 
 while compound astigmatism requires a combination of two kinds. 
 Success in treating astigmatism lies in removing the difference between 
 the two meridians by a cylindrical lens appropriate to such difference; 
 the spherical lens equaling the ametropia still remaining will then 
 enable the rays of light to impinge sharply on the retina, and the 
 anomaly will be corrected. A little reflection will show that it is some- 
 times a question of judgment as to whether it is better to correct the 
 anomaly as apparent, or by a suitable cylindrical lens, create the oppo- 
 site one, and then relieve that by its suitable lens. Success will be 
 easiest attained by bringing up the best meridian to normal with a 
 spherical lens; then allowing this glass to remain in the trial frame, 
 take opposite lines, holding the axis of the cylindrical glass now used 
 in the direction of these lines, and bring up the remaining meridian 
 to normal. 
 
 Changes take place in the eye as age comes on, the practical 
 results of which are, decrease in the refraction of the eye and short- 
 ening of the range of the accommodation. The recession of the near 
 point beyond eight inches in emmetropic eyes may be regarded 
 as the beginning of presbyopia. By means of convex lenses, the 
 near point is restored to its normal distance and the overtasked accom- 
 modation relieved. In uncomplicated presbyopia, the patient can 
 generally read No. 20 of the test-types at twenty feet, but he cannot 
 see small objects well. Ordinary fine print cannot be distinguished 
 at the former distance of eight inches and less, but it must be carried 
 
Eye and Ear. 95 
 
 farther from the eye. The accommodation is at fault, and rays from 
 near objects are not focused upon the retina. 
 
 In the beginning of presbyopia, when the near point has not 
 receded beyond nine or ten inches, very weak convex lenses will supply 
 the deficiency in the accommodation, and will need to be worn only in 
 the evening and by artificial light. If the near point has receded to 
 nine inches, and it is desired to restore it to its original distance of 
 eight inches or less, the lens 'necessary to do this may be" found *as 
 follows: 1-8 — 1-9=1-72, which shows that a lens of 72 inches focal 
 length, about a plus . 5 dipotry, is required to supply the deficiency 
 in accommodation. If the near point is at twelve inches, then 1-8 — 
 1-12=1-24. If the near point is at sixteen inches, then 1-8 — 1-16=1-16, 
 and so on: or in other words, a 24 inches convex lens (about a plus 
 1.5 dioptries), will supply the first case, and a sixteen inches convex 
 lens (about a plus 2. 5 dioptries) will supply the second. The weakest 
 convex lenses which will enable a patient without fatigue to read No. 
 1 of Snellen's test-types at from twelve to sixteen inches from the eye, 
 are the correct ones. In the greatest number of cases, plus 36 to plus 
 40 will be quite strong enough in the beginning; an increased power 
 will be required as age comes on. In some cases it will be better to 
 begin with the weaker ones. 
 
 If in addition to the presbyopia, the patient is amblyopic, lenses 
 will not improve the vision much, if at all. The perceptive power of 
 the retina diminishes as age increases, at times causing a defect in the 
 visual apparatus which lenses cannot remedy. The patient should 
 have abundant aid. Many endeavor to conceal the full degree of 
 presbyopia through false motives of pride, hoping thus to retain a 
 baseless reputation for juvenility. Myopes may often weaken their 
 concave glasses or lay them aside altogether when presbyopia super- 
 venes. Cataract and glaucoma may find their cause in the strain put 
 upon aged eyes by improperly fitting lenses. A rapid increase of this 
 trouble is one of the premonitory symptoms of glaucoma; hence in 
 fitting lenses, glaucomatous symptoms should not be overlooked. 
 
 The general principles on which to treat presbyopia are to recog- 
 nize it early, and to supply abundant optical aid. If the lenses pre- 
 scribed fail to relieve, a careful consideration of the convergent 
 muscles must be made. 
 
THE OTIC DISEASES. 
 
 SECTION ONE. 
 
 In all ear diseases open to ocular examination, it is essen- 
 tial to have a clear view of the innermost parts of the auditory canal. 
 To obtain this it is necessary to place the patient in a position favor- 
 able to receiving a good reflected light. Daylight is better than arti- 
 ficial light, but it is desirable to be able to use either. 
 
 Having placed the patient in such position, then, an otoscope 
 should be taken in the right hand, and, sitting or standing, the edge 
 placed against the forehead to steady the instrument, and the concen- 
 trated light turned directly into the canal. 
 
 The otoscope consists of a concave mirror of about three 
 inches focal distance. Its use is greatly facilitated by a head band to 
 hold it on the forehead, freeing the hand for other purposes. 
 
 The outer portions of the auricle may be quickly examined, a spec- 
 ulum taken between the thumb and forefinger of the left hand, the 
 upper and outer portion of the auricle seized with the disengaged 
 fingers of the same hand and gently lifted upward and backward, 
 straightening the canal. The speculum then should be introduced, 
 and gradually pushed inward, as successive portions of the canal are 
 viewed until the drum-head (membrana tympani) is clearly exposed. 
 
 The form of speculum now in general use is made preferably of 
 hard rubber or german silver. Too much stress is often laid upon its 
 shape; any one of them is suitable. 
 
 A cotton-holder consisting of a simple flexible wire, with a 
 serrated end, with which to use absorbent cotton as a swab, is a valu- 
 able adjunct. 
 
 It is much to be regretted that there is no efficient way of testing 
 and recording the hearing power artificially. The reason of this lies 
 in the fact that but one way exists — by the human voice — and as that 
 is not possible of successful imitation, many attempts have been made 
 to utilize the ticking of the watch. With this the hearing power may 
 be recorded as a fraction, the numerator of which is the distance at 
 
Eye and Ear. 97 
 
 which the ticking is heard, the denominator the distance at which it 
 should be heard by an ear of good average hearing power. This de- 
 nominator must vary according to the watch used, and should gener- 
 ally be expressed in inches. 
 
 Among the methods of diagnosticating and treating ear disease, 
 there are none which are so constantly the subject of misuse as the 
 various methods of inflating the middle portion of the ear. 
 Nearly all cases of ear disease are subjected to some one or more of 
 the different ways, and the ear "blown out," without much seeming 
 regard to the ultimate results. Much damage is thus done, until it 
 has been questioned whether there is not more damage than benefit 
 produced by any of the methods known. 
 
 That of Politzer is the best and the one most often abused. It is 
 based on two well-known anatomical facts; that the pharyngeal orifices 
 of the Eustachian tubes open, while the uvula rests upon the pharyn- 
 geal wall during the process of swallowing, thus separating the upper 
 from the lower pharyngeal space. In order to make use of this 
 method, the patient takes a little water into his mouth, which is swal- 
 lowed at a given signal. At this moment air is blown from a rubber 
 bag- syringe into the upper pharyngeal space through the nostrils, 
 and thence into the opened mouths of the tubes, and through the lat- 
 ter into the tympanic cavity, thus freeing those parts from obstruction 
 or proving their permeability. Frequently this method will be suffi- 
 cient for the purpose, but oftentimes a resort must be had to other 
 devices. 
 
 As auxiliary to the method thus described and the catheter, it was 
 proposed to auscultate these parts at the moment of their inflation by 
 means of an instrument called a diagnostic tube. This consists 
 of a flexible rubber tube, about two or three feet long, suitably tipped 
 at both ends so as tightly to fit the external ear. One end is placed 
 in the surgeon' s ear and the other in the patient' s. On forcing the 
 air into the upper pharyngeal space as described, the surgeon listens 
 to the sounds produced, and from them judges of the condition of the 
 parts. At first much importance was attached to the sounds so heard, 
 and a compendium of them arranged similar to that for exploration of 
 the thorax, showing what might be diagnosticated from a ' ' dry 
 sound," a "crackling sound," etc., which was extended largely; but 
 practice has shown them to be often wrong. In consequence this 
 instrument has not proven as useful as was anticipated, though still 
 used within its range. 
 
 That of Valsalva has a limited range, and is but little used. It 
 
98 Diseases of the 
 
 consists of simply holding the nostrils tightly closed with the thumb 
 and finger, and making forcible attempts at expiration. It has become 
 well known to the laity, and many cases coming to the aurist have 
 *' blown themselves up " so frequently as to seriously injure, and prej- 
 udice their chances of recovery. 
 
 Valuable practical information may also often be obtained in con- 
 nection with inflation, by watching the cone of light on the drum- 
 head. This method takes advantage of the fact that in its normal 
 position a cone of light is formed on the drum-head, which changes 
 into a square, divided or irregular shape with altered position, when- 
 ever the curvature of the membrane is changed. The latter being 
 largely under the control of pathological changes within, this method 
 becomes a valuable diagnostic aid. 
 
 But when these methods are not sufficient, a resort to other ways 
 must be had. There is a tube leading directly from the pharnyx into 
 the tympanic cavity. Desiring to reach this cavity with atmospheric 
 air, and the methods mentioned having proved insufficient, the sim 
 plest way is to prolong this tube, by artificial means, from its open- 
 ing into the pharnyx to an accessible point outside the head. The 
 tube once so prolonged — that is, the Eustachian catheter 
 passed, there is attached directly to the appropriately made and 
 exposed end • such apparatus as may be necessary to introduce the 
 air. 
 
 Two ways have been suggested of prolonging this tube, one by 
 passing a catheter through the nostril and inserting the distal end 
 in the mouth of the tube, leaving the other end without the nostril; 
 the other by passing the catheter through the mouth, and in substan- 
 tially the same manner accomplishing a like result. The former only 
 is used. 
 
 Familiar with the anatomy and possessed of a steady hand, it is 
 a very simple matter to introduce the instrument. In a healthy con- 
 dition of the parts it always should, and, if properly done, always 
 will be painless, though oftentimes somewhat distasteful. But some- 
 times the inroads of disease have so affected the membrane, and pro- 
 duced such pathological changes, that some pain will result. ^Yhen 
 once in position, however, it should occasion little inconvenience. 
 
 Hard rubber catheters are necessary for steam or hot medication; 
 german silver ones may be used at other times if preferred. The 
 proper one having been selected, pour hot water over and through it, 
 and let the patient blow the nose and be seated. 
 
 Holding the catheter perpendicularly with the thumb and forefinger 
 
Eye and Ear. 99 
 
 of the right hand near its funnel-shaped end, the ring on the instru- 
 ment pointing to the mesial line of the body, slightly draw down the 
 upper lip of the patient with the forefinger of the left hand, and intro- 
 duce the catheter into the nostril. This being done, at once turn the 
 instrument into a nearly horizontal position, with its concavity down- 
 ward. 
 
 If it does not enter readily slightly withdraw the catheter, turn it 
 a little, and on again advancing it will enter. Gradually raising it 
 until it is in a completely horizontal position, urge it onward until it 
 touches the posterior wall of the pharnyx. Then raise the funnel- 
 shaped end, withdraw a little, generally from three- eighths to half an 
 inch, and turn the catheter from within outward (guiding by the ring 
 near the exposed end of the catheter) about one-quarter of a circle, or 
 ninety degrees. This movement will lift the beak of the catheter into 
 the mouth of the Eustachian tube if the catheter has been withdrawn 
 exactly enough. Sometimes it will be found that the instrument seems 
 to engage the mouth of the tube, and yet does not open into the tube. 
 In such case it has not been withdrawn enough, and, in consequence, 
 the beak has been lifted into the pit just behind the mouth of the tube. 
 Once in position it is grasped tightly by the muscles, and the Eusta- 
 chian tube is prolonged as desired, and there is a continuous channel 
 from the funnel-shaped end of the catheter through it into the Eus- 
 tachian tube and thence into the tympanic cavity of the middle ear. 
 Proof of this is made by blowing a little air into the tympanic cavity 
 with the bag-syringe, using a moderate degree of force only. 
 
 There are a few accidents liable to occur: Laceration of the mem- 
 brane is the most serious, as on inflation by any method, emphysema 
 of the submucous tissue may result, and be accompanied by serious 
 symptoms; the mouth of the Eustachian tube may be missed, and the 
 cicatrix of some old ulcer, or an ulcer itself, engaged; some hemor- 
 rhage may result from rough manipulation. 
 
 But the first and third will not happen with careful manipulation, 
 and the second can be avoided by a pharyngeo-rliinoscopic 
 examination, which should always be made whenever there is 
 occasion to suspect any old cicatrix, any existing ulcer, or any disease 
 involving extensive or deep-seated pathological changes. 
 
 With the catheter successfully in place, it will develop a very 
 unpleasant tendency to slip out. Numerous bands, clasps, etc. , have 
 been devised to retain it, but it is better controlled by a gentle touch. 
 
 It may be unnecessary to force any air through the catheter, the 
 simple introduction and consequent opening of the mouths of the 
 
100 Diseases of the 
 
 tubes, being all that is necessary. But some diseases of these parts 
 will require the use of air as a preliminary step if it does not suffice 
 for the entire treatment. 
 
 One advantage of the simple introduction of the catheter is that in 
 many cases where it could not be previously used advantageously, after 
 the mouths of the tubes have been simply opened, Politzer' s manner 
 of inflation can be successfully used. 
 
 The various ways of using air are: 
 
 By the rubber air-syringe. The nozzle of the air-syringe should 
 be supplied with a rubber tube about eighteen iuches long, tipped 
 with a nozzle to fit into the catheter, and the bag- syringe should be 
 made with a valve allowing immediate inflation after an expiration, 
 thus rendering unnecessary the removal of the nozzle from the 
 catheter until the operation is completed. With such arrangements 
 the syringe can be freely compressed without jarring the catheter in 
 the least. 
 
 By means of a condensing pump and metallic receiver. This ap- 
 paratus consists of a large metal reservoir, into which for some minutes 
 air is condensed by a pump. To this is attached a flexible tube from 
 which the air is shut off by a valve. When it is desired to remove 
 some obstruction or adhesion, the tube is attached to the catheter and 
 the compressed air turned on. 
 
 By attaching the pump to a tube connecting with the catheter and 
 forcing air directly into it. 
 
 Quite a number of accidents have resulted from the last two- 
 ways. A glance at the anatomy of the middle and internal ears shows 
 that in the tympanic cavity are the three ossicles of the ear, one of 
 which is attached to the drum-head; one presses against the oval 
 window (fenestrum ovalis) in such a manner that it will compress the 
 contents of the unyielding bony walls of the labyrinth and squeeze 
 the delicate filaments of the auditory nerve (the third forming the 
 connection between the other two) ; that the mastoid cells open directly 
 into the tympanic cavity; that the delicate drum-head forms the only 
 barrier between this cavity and the external ear; and that all these, as 
 well as other delicate parts of the auditory apparatus, are exposed to 
 the shock of a blast of air driven through the catheter. It is clear, 
 therefore, that no operator should in any manner force air into the 
 tympanic cavity with unyielding power ; and it is reasonable to believe 
 that any so doing will have accidents of a serious nature. 
 
 Pharyngeal disease is so closely allied to otic disease that 
 the former must be suspected as the cause of much trouble in the ear. 
 
Eye and Ear. 101 
 
 SECTION TWO. 
 
 All descriptions of foreign bodies are found in the external 
 
 auditory canal, such as pins and needles, beans, peas, etc. 
 They are usually quickly removed by thorough syringing, but much 
 damage may result from blindly probing. 
 
 It should be an imperative rule never to do anything until a thor- 
 ough inspection with an otoscope has been made. Proper, patient 
 syringing will remove almost every kind of body. When instruments 
 are necessary, cautiously dislodge the body and syringe it out. 
 
 The auditory canal is frequently the seat of a class of parasites 
 which materially aggravate or cause inflammations of the part. Most 
 commonly they are secondary to eczema. They can be distinctively 
 seen only by the microscope. The symptoms are a sensation of full- 
 ness, deafness, vertigo, heavy dull pain, blackish or whitish flakes 
 blocking up the canal and adhering to its walls. 
 
 The treatment consists in removing all traces of them and subdu- 
 ing the inflammation. The forceps and hot water usually meet these 
 indications. 
 
 The auricle is the seat of few troubles not associated with the 
 canal, or. other adjacent parts. Frost-bites are common; after ex- 
 tracting the frost, exclude the air by emollient cerates or collodion. 
 Diffuse inflammation and abscesses should be carefully treated, as 
 they are liable to produce great deformity. 
 
 Psoriasis, ichthyosis, comedo, acne, and other dermatological, as 
 well as syphilitic diseases, attack the auricle, but malformations and 
 malignant diseases are rare. Deposits of urate of soda are often 
 noticed in gouty subjects, and may cause some pain. 
 
 Inspissated Cerumen, or dried and hardened ear-wax, is 
 frequently found in the auditory canal, and should be removed on the 
 same principle as any other foreign body. Its presence must be 
 regarded as a symptom of disease, and its removal but the precursor 
 of other treatment. 
 
 The symptoms of its presence are ringing in the ears, deafness, 
 sense of fullness, more or less pain, and in the severest forms, reeling 
 and staggering. It is easily seen with the otoscope. 
 
 It may not be advisable to remove it all at one operation, unless 
 .small in amount and easily loosened. When intensely hard, as it often 
 
102 Diseases of the 
 
 is, some solvent (glycerine and oils are useless), such as ten to twelve 
 grains bicarbonate of soda to an ounce of hot water, may be instilled 
 several times shortly before its removal is attempted. No force should 
 ever be used to wrench out this substance, as the canal is too delicate 
 to bear violent treatment. After all is removed, a little cotton to 
 deaden the shock of the now increased sounds may be used. 
 
 A good artificial membraiia tympani can often be worn, 
 greatly improving the hearing when a cure can not be effected, hence 
 there have been placed upon the market numerous forms of worthless 
 appliances recommended as substitutes for or adjuvants to the normal 
 membrane. 
 
 It is not necessary that the natural membrane should be gone, or 
 nearly so; often an artificial membrane, well placed, will restore hear- 
 ing when the natural membrane is almost or quite intact. But little 
 can be written on the application of these aids to hearing, their bene- 
 ficial use almost entirely depending upon the kind selected, its prac- 
 tical application, etc. Simple as it would appear, it is a matter of 
 tact. It may be said in general, however, that it should be applied 
 only to the end and one side of the passage, well down to the opening, 
 if there is one, and not covering the external part of the drum, but 
 leaving a small opening. 
 
 Furuncles- within the auditory canal are usually troublesome. 
 When seated either in a hair follicle or ceruminous gland, the furuncle 
 has in its center a circumscribed core which must be discharged before 
 resolution takes place. But if seated where the swollen, inflamed 
 connective tissue can not extend itself, as upon bone, the symptoms 
 of tension will be much more severe. The pain will therefore be 
 much greater in the latter than in the former case. In mild cases 
 it is of a burning, sticking or itching character. In all cases it is 
 accompanied by more or less systemic disturbance, such as fever, 
 sleeplessness and loss of appetite. The auditory canal becomes exces- 
 sively tender, an examination becomes a great dread, a slight touching 
 with a probe causing great pain. The swelling is not always well 
 marked, and on account of the closing of the canal it is difficult to find 
 the exact seat. One may recover to be succeeded by another and an- 
 other, or so great a number of small ones as to constitute a furun- 
 cular rash. 
 
 Hepar sulphur, or silica, will often effect a cure, but if the fur- 
 uncles continue troublesome, fill the auditory canal hourly with a solu- 
 tion of one part of alumina acetate to four parts of water. If they are 
 large and well marked, incise them promptly and use hot water to 
 
Eye and Ear. . 103 
 
 promote suppuration. If not well marked, find the most tender point 
 and incise that. There is no harm from the free bleeding which 
 may result. 
 
 The acute form of eczema about the ear generally begins with 
 more or less systemic disturbance, and the formation of vesicles upon 
 the auricle and within the canal. These soon burst with a discharge 
 of thin serous fluid, which spreads over the skin and dries there, form- 
 ing crusts or scales. The bursted vesicles form scabs, which if peeled 
 off expose a red surface. The denuded skin under these vesicles ulcer- 
 ates and pus forms. If a cloth is applied to the discharge from the 
 vesicles, it soon becomes stiff, the discharge drying rapidly. The effu- 
 sion being always considerable, the auricle becomes swollen and stiff, 
 cracks, and fissures, and the swelling of the canal causes some tinni- 
 tus and deafness. The itching and burning are most annoying, but if 
 the vesicles are scratched or torn the trouble is only increased. 
 
 In the chronic form the febrile symptoms and local swelling, itch- 
 ing and burning subside, the vesicles collapse, and dry scabs or crusts 
 take their place. Underneath the scabs will be found considerable 
 pus. The skin is no longer moist, but dry and rough. It is a trouble- 
 some affection, but gets well under patient treatment, and good hy- 
 gienic conditions. When the chronic form is present, consequent on 
 the cessation of menstrual life, taking the place of the usual headaches^ 
 it is often exceedingly annoying and obstinate. 
 
 Local applications are very uncertain in their results. The dust- 
 ing on of powdered starch will often be efficacious. Glycerine relieves 
 some and aggravates other cases. When vaseline is well borne, it 
 may be medicated with the appropriate remedy. 
 
 The best internal remedies are apis, arsenicum, croton tiglium. 
 graphites, mercurius, pulsatilla, silica, sulphur and tellurium. 
 
 SECTION THREE. 
 
 A large proportion of all ear diseases which the practitioner is 
 called upon to treat, is due to some form of aural catarrh. 
 
 Two forms are well recognized, the acute and the chronic. Both 
 are characterized by a tendency of the originial tissues to harden and 
 stiffen, thus forming a marked contrast to suppuration of the middle 
 ear. 
 
104 Diseases of the 
 
 Acute catarrh is an inflammation which causes a secretion of 
 mucus but stops short of the production of pus. Absorption takes 
 place, or the secretion is expelled through the Eustachian tubes. - 
 
 The principal causes are colds in the head, the exanthematous dis- 
 eases, the continued fevers, and exposure to wet and cold in any form. 
 
 Its symptoms are marked, and are embraced under a sensation of 
 fullness in the ear; hardness of hearing; noises in the ear which are 
 often very annoying; pain, worse at night, when delirium may set in; 
 vertigo, and sometimes nausea; general fever; catarrh of the pharynx; 
 anxious expression of the countenance and great restlessness. The 
 drum-head is swollen and injected. 
 
 These symptoms are those of the heaviest form. A light form 
 also attacks, and is very insidious in its course. It generally affects 
 only one, but may affect both ears. It has no pain, causes little deaf- 
 ness, but produces an uncomfortable stuffiness of the ears, and usually 
 slight tinnitus. The drum-head shows only the slightest if any 
 change. The patient usually gives slight attention to it, and it goes 
 away in a few days, often to return again and again until it becomes 
 securely seated. 
 
 In its severer forms this disease may easily be mistaken for cere- 
 britis or meningitis. The inflammation generally starts from the 
 pharyngeal end of the tube, but this may be reversed. The pain is 
 not generally so severe as in the acute suppurative form, and being of 
 a darting nature and not especially limited to the ear, is often mis- 
 taken for neuralgia. It is increased by talking, coughing, sneezing, 
 etc. , and often forms the chief complaint. Alteration in the tone oj: 
 the voice, subjective sounds, etc., may, and usually do, accompany the 
 trouble. 
 
 Scarlet fever especially, of the exanthematous diseases, shows the 
 greatest tendency to implicate the middle ear (though the result is 
 generally of the suppurative form). To avoid mistakes, either in 
 diagnosis or treatment, the ears of all patients with this disease should 
 be examined. The "earache" of childhood is identical with the 
 milder forms of this disease. 
 
 For local treatment, in the early stages, the best is a prompt appli- 
 cation of the hottest water that can be borne, constantly increasing its 
 heat as it can be tolerated. The aural douche is useful for this, or a 
 bag -syringe, the bag being hung up at a sufficient height to give the 
 requisite gentle force. A few drops of a two- to five-grain solution of 
 atropia sulphate, or of cocaine, may be dropped into the ear provided 
 the dram-head is imperforate, and will quickly in combination with 
 
Eye and Ear. 105 
 
 liot water relieve the worst pain. Children only require a solution of 
 one half the strength. Inflation of the tympanic cavity with Politzer's 
 apparatus, or otherwise, is necessary to let out the secretions; or if 
 much is secreted, or inflation impracticable, a paracentesis of the 
 drum-head should be at once performed and repeated as often as 
 essential. If the attack is mild, inflation and remedies will control it. 
 
 Particular injuctions should be laid to keep the patient from stuff- 
 ing the ear with oils, molasses, or other troublesome foreign bodies. 
 If the mastoid region becomes involved, a free incision should be 
 made as is explained under mastoid symptoms. Poultices to the inter- 
 nal parts are dangerous, and should not be used, it being almost im- 
 possible to limit their effect. 
 
 The great object of the treatment is to prevent suppuration, but 
 when once suppuration has set in, the case has become one of the sup- 
 purative form, and must be treated accordingly. 
 
 Those cases which have passed the acute stage are known under 
 the various names of sclerosis of the tympanum, prolif- 
 erous inflammation, progressive hardness of hearing, etc. 
 
 The exciting cause may often be found in the acute form. But 
 the underlying cause is found in a feeble state of the system, hered- 
 ity, acquired or inherited syphilis, phthisis, defective hygienic care, 
 as want of proper exercise, food, etc. Chronic catarrh of the throat, 
 repeated attacks of acute catarrh of the middle part of the ear, diph- 
 theria and scarlet fever, are common causes, and it is inseparable from 
 certain climates, especially after an exhausting illness. 
 
 The symptoms, more or less of which are present, are a sense of 
 fulness in the ear; deafness; vertigo often; a sensation of air-bubbles 
 breaking and cracking in the ear; noises of varying sounds, of which 
 great complaint is usually made; imperfect action and changes in the 
 Eustachian tubes; chronic naso-pharyngeal catarrh; changes in the 
 drum-head, such as alteration in position and shape of the cone of light, 
 deposits, sinking and atrophy. The ear-wax diminishes in secreting; 
 it then becomes brittle, and later on fails altogether. 
 
 The earliest subjective symptoms are generally noises and growing 
 hardness of hearing, which usually come on suddenly, and oftenest 
 affect the left ear first, and then may pass to the companion ear. 
 Sharp twinges of pain are felt every day or two. All the subjective 
 symptoms are intensified by fatigue, prolonged conversation or nervous 
 exhaustion of any kind. But nearly all, except the growing hardness 
 of hearing may be wanting in the severest cases of the proliferating 
 iorm. 
 
106 Diseases of the 
 
 The disease is very tedious in its course; often quite as much so in 
 its cure. The many names given it more or less note some of the 
 changes, and indicate a wide variance and incomplete knowledge of 
 its pathology. The noises in the ear are frequently most distressing. 
 There is no special sound indicative of special lesions, and each patient 
 is most likely to associate some familiar sounds with them. In com- 
 mon with the appearances of the drum- head, they have been made the 
 subjects of exhaustive study. 
 
 Two classes seem however to be well marked, the moist and the 
 dry, and materially affect the prognosis, the former being far more 
 amenable to treatment than the latter. In the former, under suitable 
 medication and local treatment, a more or less satisfactory restoration 
 of hearing and cure may be foretold; in the latter, in the hypertrophied 
 stage the prognosis is unfavorable; in the atrophied stage hopeless. 
 Proliferating bands are often thrown out, quite like spider-webs, and 
 tie down with firm grasp the delicate structures. A peculiar odor, 
 doubtless due to the altered secretion of the buccal glands, well sim- 
 ulated by moistening the linger with saliva and allowing it to slowly 
 evaporate, may be noticed about the breath of the majority, and is 
 most marked in the female. Relapses are very common and should not 
 discourage. 
 
 For convenience in treating of the subject, and the more properly 
 to describe a large number of cases, a class lying in the tract between 
 the acute and chronic forms, are called subacute. They are such 
 cases as have passed through the acute and linger on the border of 
 the chronic form. There is no special line of demarcation, but such 
 cases yield under less treatment, though were time of existence the 
 only element, they would justly be classed as chronic. 
 
 The incomplete knowledge of the pathology, the inaccessible posi- 
 tion of the parts to be treated, and the often vacillating mind of the 
 patient, alike combine to render the treatment the most unsatisfactory 
 of aural practice. A haphazard, empirical plan of trying this and 
 that in the expectant hope of relief, has nearly always been pursued 
 ere the patient comes under scientific treatment; and even then float- 
 ing memories of old-time necromantical cures are liable to tempt the 
 patient away. The injudicious determination of those who suffer with 
 acute affections ' ' not to tamper with the matter, but let it wear off ' ' 
 places hundreds on the list of incurable. 
 
 Tinnitus aurium, or ringing in the ear, is a more or less con- 
 stant symptom of most forms of ear disease, and oftentimes lingers to 
 the torment of the patient after all apparent disease has passed away. 
 
Eye and Ear. 107 
 
 These noises are the result of nearly every kind of irritation of the 
 auditory nerve, either in its course from the brain, or its final distri- 
 bution in the labyrinth. Any change of the normal pressure of the 
 labyrinthine fluid, as when the stapes is pressed in or drawn outward, 
 produces noises in the ear varying in direct proportion to the force 
 exerted. It is impossible, with some general exceptions, to tell from 
 the nature of the noises where the cause is, for the pressure sufficient 
 to produce these noises may be occasioned by a collection of fluid, or a 
 swelling of the lining of the tympanic cavity; by all obstructions of the 
 Eustachian tubes sufficient to interfere with the ventilation of the 
 tympanic cavity; by the exclusion, by obstruction from any cause, of 
 the air from the external meatus, etc. These noises, too, are gener- 
 ally likened to some sounds with which the patient is associated or 
 familiar, thus not infrequently removing the only guides there might be. 
 
 Crackling noises are caused by air passing through the mucus in 
 the tympanum in the moist stages of chronic catarrh, suppuration, 
 etc. Now and again a patient will be found who can voluntarily pro- 
 duce such noises in the ear. Pulsating noises are heard when from 
 any cause there is an interference with the arterial circulation. In 
 cases of aneurism these sometimes become so loud as to cause deafness. 
 
 A changed condition of the blood, as in anaemia and chlorosis, pro- 
 duces tinnitus similar to the venous blowing heard inchlorotic females. 
 All labyrinthine diseases, and often blows on the head and violent con- 
 cussions from any cause, are productive of noises in the ear. 
 
 The treatment is a matter for careful consideration in individual 
 cases. No class of ear troubles has so long resisted the remedies pro- 
 posed for its relief. The pharynx and nose should engage attention 
 at the outset, and all complications there removed and kept down. A 
 persistent endeavor to soften the dry or parchment-like membrane of the 
 Eustachian tubes and tympanic cavities by internal remedies, accom- 
 plishes as much as the usually applied local treatment, and does less 
 harm. The effects of the constant current of electricity are some- 
 times surprising if persisted in, but usually disappointing. Inhala- 
 tions, inflations and injections usually accomplish no permanent ben- 
 efit, but are useful if at all, in the order named. Perforation (para- 
 centesis) of the drum-head, or division of the muscle con- 
 trolling the tension of this membrane, are tried in the worst cases, and 
 sometimes prove beneficial. 
 
 In the early stages there is no better remedy than aconite. When 
 there is a high febrile excitement, with acute pains running along the 
 Eustachian tubes to the ear; sharp pains suddenly in the ear; dryness 
 
108 Diseases of the 
 
 and burning in the throat; it is fully indicated. Severer symptoms, 
 such as fullness in the ear; deafness and vertigo, with violent pain in 
 the ear and over the whole side of the head, also call for this remedy. 
 
 Apis mellifica is most useful when there are stinging, burning 
 pains, with intense itching. Inflammations following eruptive diseases 
 are also well met. 
 
 Arsenicum album is indicated when there is great prostration 
 and irritability following or accompanying these troubles. The pains 
 are periodical, and there is chilliness and shuddering, attended by 
 humming in the ears and loss of hearing. 
 
 Baryta iodata is highly useful in chronic thickening of the mucous 
 membrane, and to reduce enlarged tonsils. 
 
 Belladonna is called for when there is local congestion, man- 
 ifested by throbbing pains, cerebral excitement, or delirium, wild ex- 
 pression of the eyes, with intense pain. 
 
 Cantharis is valuable in the dull, heavy, and extremely sore throat 
 often accompanying these troubles. 
 
 Causticum is valuable in the proliferating form. Paralysis is re- 
 lieved by it. 
 
 Hepar sulphuris is very useful in promoting resolution when 
 suppuration is immediately threatening. It arrests and cures ulcer- 
 ation of the tympanic membrane. Abscesses are speedily cured by its 
 administration. 
 
 Kali iodatum has a beneficial action on thickened mucous mem- 
 branes. 
 
 Mercurius is one of the best of internal remedies, having a pro- 
 nounced action on the thickened mucous membrane. Sharp, stinging 
 pains extend into the ears. Pain abates toward morning. Perspir- 
 ation profuse, but not relieving. It is especially valuable in the pro- 
 liferous form of middle ear disease. Hardness of hearing due to 
 swollen tonsils, and when due to obscure troubles, or syphilitic origin 
 is well met by this remedy. 
 
 Pulsatilla is a valuable remedy in catarrhal affections of the 
 Eustachian tubes. 
 
 Acute suppuration is an inflammation which quickly passes 
 over the mucus stage and hurries on to purulent inflammation. It is 
 characterized by a tendency to break down and destroy the original 
 tissues. It has two forms, acute and chronic. Unlike acute catarrh, 
 it is almost never insidious in its attacks, but bold and pronounced. 
 
 The main causes are often a direct result of a somewhat prolonged 
 acute catarrh; the suppurative form is always preceded by the ca- 
 
Eye and Ear. 109 
 
 tarrhal, though in many cases the latter is overlooked and the dis- 
 charge of pus is the first thing noticed. 
 
 In severe cases the symptoms are rapid and violent. All the symp- 
 toms of acute catarrh are present, but greatly intensified as a rule. 
 The pain is intense, causing great suffering, and is generally referred 
 directly to the ear, though extending to the eye and temple, and back- 
 ward to the occiput. General fever and tendency to delirium are usu- 
 ally marked. There is great liability to confounding the disease with 
 brain trouble. The drum-head bulges out, is swollen and injected, 
 and not infrequently colored yellow from the pus behind. 
 
 Diagnostic points will be found in the fact that any given quantity 
 of mucus in the tympanic cavity will not cause the amount of bulging 
 out of the drum-head that a like quantity of pus will. This bulging 
 is usually confined to the posterior half of this membrane. The pain 
 is usually much more intense than under the catarrhal form, and is 
 accompanied by a general systemic disturbance. With all this, how- 
 ever, the auricle and meatus may be quite insensible to gentle trac- 
 tion, freeing all suspicions of external otitis as the cause of the pain. 
 
 The tympanum in such attacks is practically a shut cavity, by 
 reason of the closure of the Eustachian tube, and confines a raging 
 abscess. On account of the close proximity of the cranial cavity and 
 its contents, and its intimate connection with the tympanic cavity, the 
 life of the patient is often greatly endangered. Prompt treatment is 
 sometimes necessary to save life, and saves months of after-treatment 
 in the event of recovery. 
 
 In general, swelling in front of the auricle is usually of little 
 moment; behind the auricle it commands attention. In case the mas- 
 toid region becomes involved it should be treated on the principles 
 laid down hereafter. 
 
 The tendency of this disease is to destroy the drum-head and sweep 
 away the contents of the tympanic cavity. Such results are to be 
 carefully guarded against, as destructive of hearing. If it passes into 
 a chronic form, the treatment is tedious and more or less unsatisfac- 
 tory. 
 
 For local treatment, the congestion and pain are to be reduced as 
 quickly as possible. Hot water used as indicated under acute catarrh, 
 will do this, though great relief to the pain will be derived from put- 
 ting a few drops of a two- to five-grain solution of atropia sulphate, or 
 of cocaine, in the ear, which may be safely done provided perforation 
 of the membrane has not taken place. The tendency to poisoning by 
 the solution running directly into the pharynx must not be forgotten. 
 
110 Diseases of the 
 
 Children only require a solution of one-half the strength. A para- 
 centesis should be done early; if any pus has formed, it lets it out; if 
 none has formed, the relief to the pain is very grateful, and renders a 
 knowledge of the condition of the tympanic cavity certain. All forms 
 of continued poulticing are to be avoided. General treatment must 
 be directed to relieving the pain and producing sleep. Special atten- 
 tion should be given to the free action of the skin. 
 
 Otorrhoea, or chronic suppuration, is the baDe of the 
 laity, and sufferers are warned to do nothing, being told the discharge 
 is innocuous or beneficial, and that a stoppage would be injurious. 
 On the contrary, though death is not an infrequent result of neglected 
 otorrhcea, no harm ever comes from properly stopping a foul discharge; 
 improperly stopped or corked up, under the impression that when not 
 seen the suppuration no longer exists, great harm might be done. 
 
 The chief causes of chronic suppuration are an acute inflamma- 
 tion of the tympanic cavity and surrounding parts, and disease of the 
 bones. Diphtheria, and scarlet fever especially, add largely to the 
 most severe cases. 
 
 The symptoms are deafness, with a purulent discharge of an offen- 
 sive odor from the tympanic cavity into, and often out of, the external 
 auditory canal. The pus being cleansed away, there may be seen a 
 perforation of the drum-head, most frequently in the posterior inferior 
 portion, though it may be anywhere, and varying in size from a pin- 
 hole to two-thirds of the membrane. A drop of pus is often adher- 
 ing in the perforation, and pulsates synchronously with the heart's 
 action. The external meatus and the outer surface of the drum-head 
 have a bright-red appearance due to the constant bath of pus. More 
 or less pus secreted from the walls of the external meatus is also pres- 
 ent. The general health is frequently below the normal standard, 
 and the pharynx will be found in a catarrhal state. 
 
 In any form of treatment, there can be no success without abso- 
 lute cleanliness of the tympanic cavity and the external meatus. The 
 anatomical relations are such that the foul discharge remains a source 
 of constant irritation and self-perpetuation, instead of flowing away. 
 The ear should be appropriately syringed out as often as is necessary 
 to keep it clean, and from five to twenty drops of a ten per cent, solu- 
 tion of carbolic acid to a pint of hot water, will be found an excellent 
 solution for this purpose. A two to four-ounce hard-rubber aural 
 syringe should be obtained, the hot solution prepared, and the cavities 
 thoroughly cleansed. Care is requisite that the patient does not take 
 cold after such treatment. Some cases do better when the canal is 
 
Eye and Ear. Ill 
 
 cleansed with absorbent cotton. This may be used on a cotton-holder 
 and the canal carefully mopped out under a full light from the otos- 
 cope. Politzer's bag, or other means of inflation should be practiced. 
 Local treatment of tener fails to do good from carelessness and inatten- 
 tion of the attendant or patient, than from any other cause. Patience 
 and perseverance are rewarded by success. 
 
 Caustics, astringents, etc., may be employed, but are liable to do 
 damage. They are useless unless strong, and in the same ratio the 
 more dangerous. In a certain number of old, neglected chronic cases 
 their proper use will greatly accelerate the cure. Nitrate of silver, 
 compound nitrate of silver, and sulphate of copper are the most reli- 
 able, and may be used in varying strengths. Boracic acid on cotton 
 moistened with cosmoline, or applied with a blower, is useful. All 
 preparations should be applied on a thoroughly cleansed surface. 
 
 Much discussion has taken place on the best form of treatment, 
 wet or dry, but individual cases demand each, and neither is always 
 alone successful. 
 
 Polypi are a very frequent result of neglected suppuration. 
 Though sometimes liable to be confounded with malignant growths 
 their diagnosis is generally easy. 
 
 They usually consist of loose connective tissue, cells and blood- 
 vessels, partaking of the nature of fungous granulations, and grow 
 most commonly from the tympanic mucous membrane, more rarely 
 from the surface of the inner half of the external canal. Of a bright 
 red color, usually granulated like a strawberry, though sometimes 
 smooth, they vary in size from a pin-head to a long tortuous body, 
 closing entirely the external canal or appearing beyond the external 
 orifice. They may be attached by a more or less narrow peduncle 
 (pedunculated) or sit upon a foundation approximative to their 
 size (sessile). Soft and excessively tender, they bleed on slight 
 contact, and constantly bathed in pus, are offensive in odor. Their 
 spongy nature, soft and pliable, often makes the mechanical obstruc- 
 tion of the canal and consequent retention of the pus a source of 
 great danger. 
 
 Local treatment consists in removal by any instrument best suited 
 to the position in which they are found. This results in a permanent 
 cure, slight after-treatment being only necessary. A wire ensnaring 
 the growth and heated by electricity quickly removes, and by the 
 application of the resultant actual cautery restrains the profuse hem- 
 orrhage. A minute drop of acid (chromic, nitric, mono-chloro-acetic, 
 or carbolic), will often be sufficient for those of small size. A satu- 
 
112 Diseases of the 
 
 rated solution of bichromate of potash directly applied will sometimes 
 be effectual, and is painless. 
 
 When from any cause the suppuration is suppressed, what are 
 known as mastoid- symptoms may supervene. Periostitis 
 
 is the most common mastoid complication, and is apparent by tender- 
 ness on pressure over the mastoid region of the temporal bone. In 
 case of involvment there will be in addition to the tenderness (which 
 is often extreme) swelling, redness, and pain, the latter frequently 
 violent. But redness and swelling are not infrequently present in the 
 mastoid region in connection with aural disease, and require no local 
 treatment. 
 
 In this periostitis local treatment is absolutely necessnry and should 
 be prompt. A free incision over the mastoid process down to the bone 
 should be made, and poultices applied. If the incision be made par- 
 allel to and about one-quarter of an inch behind the auricle, about 
 one-half of an inch to an inch in length, and care be taken to cut 
 upward, the operation is a simple affair. In the early stages no pus 
 will be found, but the relief to the tension, so important in periostitis, 
 will be most grateful. In latter stages, suppuration may be profuse 
 and of a foul odor. 
 
 Caries and Xecrosis are consequences of extension of the in- 
 flammation just described, and require the surgical treatment usually 
 given these troubles when occurring elsewhere. In the severest cases 
 cerebral abscess is not an uncommon result, but often masked 
 in its symptoms. Nausea and vomiting, or a chill usually precede 
 fatal symptoms. But in exceptional cases long, tedious brain trou- 
 bles result, though paralysis, coma and death more frequently. 
 
 Arsenicum iodatum is useful in profuse, ichorous discharges ac- 
 companied by great prostration. 
 
 Asafcetida meets purulent discharges, with diminished hearing, 
 after the abuse of mercury. 
 
 Auruni metallicum is particularly valuable in troubles of syphilitic 
 origin, when there are thickening of the membranes and swollen cer- 
 vical glands, worse on touch. The tissues of the external meatus are 
 bathed in a fetid pus, the odor being characteristic of necrosed bone. 
 It is also valuable in fistulous openings and sinuses in the mastoid pro- 
 cess, and in caries of the mastoid process and ossicles. 
 
 Calcarea carbonica is one of the most useful remedies in these dis- 
 eases. It meets polypi associated with purulent discharge; scrofulous 
 affections of the bones; thickening of the drum-head, and inflamma- 
 tory swelling of the parotid glands. Patients with large abdomen 
 
Eye and Ear. 113 
 
 and warts on the hands, scrofulous subjects, fat, rapidly -growing, 
 large-headed, soft-boned children, especially demand this remedy. 
 
 Cantharis is particularly suited to chronic inflammation of the 
 Eustachian tube and tympanic cavity, and accompanying low grades 
 of inflammation in the external auditory canal. 
 
 Capsicum is indicated in redness and swelling over the mastoid 
 region. There are itching and pressure deep in the ear. It is also 
 valuable for acute symptoms in chronic cases, the mastoid cells be- 
 coming involved. 
 
 Carbo vegetabilis is useful in mechanical obstruction to the Eusta- 
 chian tubes from swelling of the tonsils. 
 
 In mercurius the discharges are thin and acrid, the ears, teeth and 
 face ache, and all symptoms are worse at night. The ear troubles are 
 accompanied by a vesicular eruption on the face and lower limbs. 
 
 Mezereum finds a sphere of action in chronic ear complaints associ- 
 ated with syphilis. 
 
 The pains in the bones of the skull are increased by touch, and 
 worse at night. 
 
 Nitric acid is useful in caries of the mastoid process. It is also 
 especially useful after the abuse of mercury, and in diseases of the ear 
 following syphilis. 
 
 Pulsatilla nigricans has a good action on mild, bland discharges in 
 the characteristic subject. 
 
 Silica has a direct action on the middle layer of the membrana 
 tympani. It promotes suppuration, and is invaluable in obscure ear 
 troubles. Collections in the Eustachian tubes are relieved by it. 
 
 Sulphur meets purulent, offensive discharge, with eruptions on the 
 face and body. Ear complaints from suppressed discharges and 
 eruptions are relieved. 
 
 Tellurium is indicated by an offensive otorrhcea, smelling like fish- 
 brine. The characteristic patient is almost the exact opposite of the 
 Pulsatilla subject, being angular and sharp. 
 
 SECTION FOUR. 
 
 Xervous deafness primarily is an exceedingly rare disease. 
 Secondarily it is commoner, though it may be associated with some 
 form of middle ear disease. Many cases of deafness are erroneously 
 
114 Diseases of the 
 
 attributed to this trouble when the real cause is hidden. There are 
 no external signs or appearances of the tympanic membrane from 
 which this trouble can be diagnosticated, but its presence is assured 
 in the main by exclusion of all diseases of the external and middle parts 
 of the ear from a careful examination, and an accurate knowledge of 
 the values and peculiarities of the tuning fork. No theoretical 
 course can be laid down, so that unless a practical familiarity with the 
 fork is had, errors in diagnosis may be made. 
 
 The diagnosis of this class of diseases may be also confirmed by a 
 consideration of the following items: 
 
 The history. — This may directly connect the defects of hearing 
 with other nervous troubles. Care should be exercised, however, that 
 the diagnosis is not misled by circumstances directly attributable to 
 mechanical causes. The degree of deafness. — In this it is difficult to 
 say at just what point, but a very excessive degree cannot depend on 
 absence of conduction; in other words, the congenital absence of the 
 conducting apparatus does not necessarily involve as low hearing 
 power as the disease may produce. Certain peculiarities of hearing. — 
 Hearing worse on attempting to listen, after excitement, fatigue or 
 mental depression. A better hearing from some sounds than for others. 
 
 Cases of ear disease attended with loss of equilibrium accompanied 
 by sudden deafness, should be known as labyrinthine disease; 
 other symptoms such as nausea, vomiting, vertigo, and tinnitus aurium 
 are also present. A number of these will be recognized as accompany- 
 ing affections of the middle ear and cerebro-spinal meningitis. 
 
 There is another class of patients, however, which is often classed 
 under this head of nervous deafness, but ought to be excluded and 
 the term dropped as erroneous. This is, those patients who are weak, 
 unsteady in muscular movement, debilitated in nervous tone, despond- 
 ent, anxious and affected with a chronic disease of the ear. Nearly 
 all such cases belong to those of the middle ear, and if impinging on 
 the internal ear class, it is by extension to that portion of the ear, and 
 not as the primary seat of disease. Persons who are debilitated, 
 anxious and unsteady have not necessarily impairment of hearing, or 
 any symptoms of derangement of the auditory nerve; and affections of 
 the auditory nerve do not necessarily weaken, though they may cause 
 unsteadiness of gait. 
 
Eye and Ear. 115 
 
 SECTION FIVE. 
 
 With rare exceptions, all deaf mutes are dumb because they cannot 
 hear. With extremely rare exceptions there are no changes in the 
 larnyx, except such as may come from disuse of that organ, and could 
 mutes hear they would soon learn to speak. From this primary fact, 
 then, it may be seen how important it is that the ear should be cor- 
 rectly understood. 
 
 There are two classes of deaf- mutism, congenital and acquired. 
 
 Infants are conscious of sounds at about the third month, of 
 particular sounds, such as whistling, chirping, etc., at about the fourth 
 month, but from the fourth to the sixth month is the earliest at which 
 an opinion can be formed as to whether an infant is deaf or not. But 
 inasmuch as most deaf mutes have a certain amount of h earing, they 
 may be classed as those who can hear the human voice as sounds, but 
 are unable to distinguish words, amounting to about one-tenth of the 
 whole; those who can distinguish loud noises, such as clapping the 
 hands, ringing of bells, thunder, cannon firing, etc., amounting to 
 about five-tenths of the whole, and those who are completely deaf, 
 numbering about four-tenths of the whole. 
 
 From many thousand cases examined, it has been deduced that the 
 muscles are mobile which open and close the larnyx, and the vocal 
 cords vibrate perfectly. The cords do not, however, correctly adapt, 
 especially in the formation of vowels. Not infrequently a slight 
 catarrh of the cords is also present, but all these are doubtless conse- 
 quent on non-use, and would disappear on exercise of the proper 
 functions. 
 
 Climate exercises a great effect in the production of mutism. Swit- 
 zerland furnishes the greatest number; Belgium, the least. The vari- 
 ous sections of England, even, vary greatly in the number of mutes 
 found within their borders. As might be expected, a like dissimilarity 
 is found in the various States of our Union. 
 
 Did mutes hear, they would learn to speak. It does not follow, how- 
 ever, that all who are deaf become mutes. If a patient becomes deaf 
 during childhood, he will certainly become dumb ; if during youth, he is 
 apt to ; but after he attains to years of discretion, it is exceedingly rare 
 that the effects are so dire. Changes, however, gradually take place, 
 and of a serious nature. The mental powers are apt to become 
 
116 Diseases of the 
 
 blunted, the mind works sluggishly. Of less moment, but still 
 serious, are the changes of voice. Unable to hear themselves speak, 
 they can not modulate their tones; hence it is common to hear a 
 deaf person raise his voice almost to a shout in some confidential 
 communication or sink to a whisper in a public address. For this 
 reason, also, clergymen and public speakers are obliged to give up 
 their occupation when serious impairment of hearing takes place. 
 
 The causes of deaf-mutism are to be found in the middle and in- 
 ternal parts of the ear, such as the results of the exanthematous dis- 
 eases (prominent among which are scarlet fever and measles), brain 
 diseases, falls, frights, etc. 
 
 The prognosis and treatment of these diseases, combined with the 
 age of the patient, will be the foundation on which to base the prog- 
 nosis and treatment of deaf-mutism. Only by a well-grounded and 
 comprehensive knowledge of aural disease, combined with experience, 
 can a proper opinion be founded. The principles of aural surgery, 
 combined with the principles of general medicine, must be well con- 
 sidered. Here, as well as elsewhere, a too exclusive attempt at special 
 and local treatment will bring failure instead of success. 
 
 Congenital deaf-mutism is incurable in the present state of our 
 knowledge. The aid of surgery has been well tried by skillful sur- 
 geons, and some beneficial results obtained; but the standard of in- 
 firmity has only been raised ; the patient has not been removed from 
 the class. 
 
 The treatment of the deaf-mute may be divided into prophylactic, 
 medical and instructive. 
 
 The prophylactic treatment should consist of the proper hygienic 
 treatment, enforced sanitary regulations, such as isolation from all 
 malarious influences, mental rest and cheerful company, warm and 
 abundant clothing. There could be nothing better in this direction 
 than agreeable and remunerative employment. 
 
 The medical treatment should consist of carefully meeting and 
 warding off all unfavorable symptoms as they arise; and in every way 
 encouraging and sustaining such hearing as is apparent or may become 
 developed. 
 
 In each case all should be done which will tend to conserve the 
 hearing power. When a discharge is present, the auditory canals 
 should be kept clean, the bones protected from caries, and at least 
 extended ulceration of the membrane prevented. The cause of any 
 existing otorrhcea should be carefully sought out, removed and the 
 chronic suppuration cured. 
 
Eye and Ear. 117 
 
 ;, The deaf nmte who presents the most favorable conditions for 
 treatment is he whose accidental deafness has supervened at the age 
 at which he begins to hear and speak, and who still retains some faint 
 evidence of hearing and speech. If the organic lesion, the first canse 
 of the infirmity, be seated beyond the nerve centers; if the child be 
 intelligent, and have no brother or sister in the same state as himself; 
 if he be the child of healthy parents, who have no connection by con- 
 sanguinity, and if he have never previously been under treatment, 
 the chances of cure are numerous; but if all these conditions are met 
 with in the same subject the chances almost reach to a certainty. On 
 the contrary, they decrease in value in proportion as one or more of 
 these conditions are wanting, and when all are wanting we should 
 entertain scarcely any hope." 
 
 Among the means of keeping up such hearing as may be present, 
 the ear-trumpet should be mentioned. Constant use often enables a 
 •little patient to become familiar with sounds, and render his wishes 
 intelligible. To the older one it is often the only means left by which 
 he can retain perception of tones. It is greatly to be regretted that 
 a more convenient appliance of such general application as the trum- 
 pet has not been invented. Similar devices have but a limited useful- 
 ness, though in exceptional cases they act in a favorable manner. 
 
moex 
 
 PAGE 
 
 Abscess, cerebral 112 
 
 Ametropia 75 
 
 Antisepsis 10 
 
 Apboria 78 
 
 Asthenopia 78 
 
 Astigmatism 75 
 
 Aural catarrh 103 
 
 Aural suppuration 108 
 
 Bandages 11 
 
 Cataract 61 
 
 Cerates 11 
 
 Choroid, diseases of 48 
 
 Ciliary body, the 51 
 
 Ciliary muscle, spasm of 91 
 
 Conjunctiva, diseases of 26 
 
 Cornea, diseases of 33 
 
 Deaf -mutism 115 
 
 Disinfectants 10 
 
 Eczema of the ear 103 
 
 External auditory canal 101 
 
 Eye, injuries of 72 
 
 Foreign bodies, extracting-, ear 101 
 
 Foreign bodies, extractini>\ eye 10 
 
 Furuncles 102 
 
 Glaucoma 58 
 
 Hypermetropia 77 
 
 Inflating, methods of 97 
 
 Irido-choroiditis 54 
 
 Irido-cyclitis 51 
 
 Iris, diseases of 43 
 
 Labyrinthine disease 114 
 
 Lachrymal apparatus, diseases of ■ 25 
 
 Lens, diseases of 61 
 
 PAGE 
 
 Lenses 79 
 
 Lids, diseases of '. 24 
 
 Mastoid disease 112 
 
 Mydriasis 54 
 
 Mydriatics 8 
 
 Myopia 76 
 
 Myosis 54 
 
 Myositics , 9 
 
 Nasal disease 8 
 
 Nervous deafness 113 
 
 Noises in the ear- 107 
 
 Oblkpie illumination 16 
 
 Ophthalmic diagnosis 5 
 
 Ophthalmoscope, the 12 
 
 Optic disc, cupping of 65 
 
 Optic disc, diseases of 63 
 
 Optic nerve, diseases of 63 
 
 Otorrhea 110 
 
 Otoscope, the 96 
 
 Paracentesis of the ear 107 
 
 Paracentesis of the eye 46 
 
 Pharyngeal disease 100 
 
 Pinguecula 31 
 
 Polypi Ill 
 
 Presbyopia 91 
 
 Prisms 92 
 
 Pterygium 31 
 
 Retina, diseases of 66 
 
 Retinoscopy 32 
 
 Shades 11 
 
 Skiascopy 22 
 
 Sympathetic ophthalmia 52 
 
 Test-types 85 
 
 Tinnitus aurium 106 
 
 Vitreous bodv, diseases of 71 
 
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