s 
 
HOMEOPATHIC MEDICAL PRACTICE: 
 
 SYSTEMATIC TREATISE 
 
 DISEASES OF THE BRAIN AND EYE; 
 
 FOR THE USE OF 
 
 GENERAL PRACTITIONERS AND STUDENTS. 
 
 
 
 By C. P. HART, M.D. 
 
 FORMERLY SURGEON-IN-CHARGE OF THE SURGICAL WARDS, CHIEF SURGEON TO THE EYE 
 
 DEPARTMENT, AND PRESIDENT OF THE BOARD OF MEDICAL EXAMINERS OF BROWN 
 
 GENERAL HOSPITAL, LOUISVILLE, KY.J ASSISTANT EDITOR OF THE 
 
 AMERICAN HOMOEOPATHIC OBSERVER J AUTHOR OF 
 
 REPERTORY TO NEW REMEDIES, 
 
 ETC., ETC. 
 
 0, 
 
 WITH NUMEROUS TABLES AND ILLUSTRATIONS. 
 
 
 DETROIT: 
 
 PUBLISHED BY EDWTN ALBERT LODGE, 
 
 AMERICAN OBSERVER OFFICE. 
 
 1878. 
 
 ft 
 
Itftf 
 
 ut* 
 
 Entered according to Act of Congress, in the year 1877, 
 
 By EDWIN ALBERT LODGE, 
 
 In the Office of the Librarian of Congress, at Washington, D. C. 
 
 ALL RIGHT RESERVED. 
 
 Wm. A. Scripps, Printer, 
 
 Arcade Building, 46 Larned St. West, 
 
 Detroit, Mich. 
 
PREFACE. 
 
 The present work, consisting of brief treatises on Diseases 
 of the Brain and Eye, was originally designed to form the 
 initial portion of a more general work on the Homoeopathic 
 Practice of Medicine. But as the Author's time is now so fully 
 occupied by professional duties as to prevent its speedy com- 
 pletion, and as the parts are complete in themselves, and will 
 make a convenient Manual on Diseases of the Brain and Eye, 
 the publisher has decided to issue them as a distinct work. 
 The portion relating to Ophthalmology having been published 
 separately, the following remarks, taken from the Preface to 
 that volume, will be equally applicable to this : 
 
 Unfortunately, the science of which we treat is still regarded 
 by many as too abstruse, and the practice of it too difficult, 
 for the general profession, and hence it has been relegated, 
 for the most part, to a comparatively small number of prac- 
 titioners. We say unfortunately, because the vast majority of 
 ophthalmic diseases are still treated, and of necessity always 
 will be treated, by the ordinary medical attendant. The 
 important question, then, is, not whether diseases of the eye 
 
4 PREFACE. 
 
 should be turned over to the specialist for more scientific 
 investigation and treatment — the propriety of which, in many- 
 cases, no one who has any regard for the welfare of the patient 
 will deny — but whether the general practitioner, who, nine 
 times out of ten, is expected to treat these cases, shall be 
 properly qualified to discharge a duty which, whether qualified 
 or not, he is required to perform. Besides, even if it were 
 possible for the majority of such cases to be referred to experts, 
 the general practitioner would still need to be as fully informed 
 on this as on other branches of medical learning, in order to 
 enable him to give proper and timely advice to his patients, 
 and to secure to himself the advantages, too numerous to 
 mention, resulting only from a well-rounded medical education. 
 Let us not be misunderstood. We are not calling in 
 question the propriety of referring all complicated and difficult 
 cases to specialists, but, as nine-tenths of all diseases of the 
 eye are either inflammatory or functional, and as only a small 
 proportion of eye difficulties, except such as require manual 
 dexterity in operating, will be sent to ripe specialists — of which 
 there indeed but very few— we are simply emphasizing the 
 need of greater competency on the part of those who are daily 
 called upon to diagnose and treat this important class of cases. 
 And we opine that the chief reason the general profession is, 
 as a body, so lamentably ignorant of Ophthalmology, is not in 
 consequence of the abstruseness of the science, for this is no 
 greater than that of any other department of medicine and 
 surgery ; more especially since the discovery of the ophthal- 
 moscope — the use of which has greatly simplified the subject, 
 
PREFACE. 5 
 
 and rendered many parts of it much more definite and easy of 
 comprehension. But we are of the opinion that the reason of 
 this acknowledged incompetency lies chiefly in the paucity of 
 suitable Manuals. Not that the profession is wholly without 
 valuable aids of this character, but that those already published 
 are, for the most part, too concise to serve as guide-books to 
 the student and general practitioner, or else savor too much of 
 prolixity, in consequence of the introduction of unnecessary 
 details, or of matter which belongs rather to the province of 
 strictly theoretical treatises. 
 
 Whether this volume will meet the requirements above 
 suggested, is not for the author to affirm. He can, however, 
 truly say, that he has labored conscientiously and assiduously 
 to bring it up to the standard of what he conceives to be 
 requisite in a text-book of this character ; and he will feel 
 amply compensated for his labors if the work shall be found 
 free from any serious defects, and, at the same time, not 
 wanting a reasonable degree of the only merit within the scope 
 of his design, namely, that of furnishing a clear and concise 
 description of ophthalmic diseases and their appropriate treat- 
 ment, together with a correct and intelligible account of the 
 facts, principles and discoveries furnished by the ablest of the 
 American, English and German authorities. 
 
 We have not deemed it necessary, nor even desirable, to 
 cite the authority for every important statement made in the 
 text. To have done so would have greatly encumbered our 
 pages, and increased the size and expense of the work. We 
 have, however, in most cases, given due credit for any fact or 
 
6 PREFACE. 
 
 discovery the authorship of which it is important the reader 
 should know ; and would refer those who desire to con- 
 sult any of the original sources of information to the admirable 
 treatise of Stellwag, whose bibliography of every department 
 of the literature of Ophthalmology, is sufficiently ample to 
 satisfy the most exacting. 
 
 C. P. HART. 
 Wyoming, Ohio, October, 1877. 
 
ERRATA. 
 
 Owing chiefly to the fact that some of the proof-sheets failed to 
 reach the Author in time for revision, a number or typographical 
 errors remain uncorrected. Fortunately, most of them are of such a 
 character as to be readily understood by the reader, and will not, 
 therefore, need to be pointed out. In order, however, to avoid any 
 ambiguity, the reader will please insert, the pronoun their between 
 "require" and "separate," on page 102, fifth line ; omit the period 
 after the word characteristic, on page 254, second paragraph; and 
 substitute edgeiox "eye" in note on page 122 ; epichondral for " epis- 
 cleral" on page 136, twenty-first line; it for them in the tenth and 
 twelfth lines on page 188; T for " Tn" in parenthesis on page 213 ; 
 and Aurum for " Arum " on page 254. 
 
PRACTICE OF MEDICINE. 9 
 
 GENERAL OBSERVATIONS. 
 
 Although this department, as its title indicates, is intended to be 
 devoted strictly to the practice of medicine, yet, owing to the erro- 
 neous notions still prevalent concerning the system of practice 
 herein inculcated, its principles are often misunderstood, perverted 
 and misapplied. It will, therefore, not only not be out of place, so 
 far as may be consistent with our general plan, to endeavor at the 
 outset to correct such erroneous views, by a few preliminary obser- 
 vations on the true principles of our system ; but we may reasonably 
 hope, by so doing, to make their practical application by the inex- 
 perienced more intelligible and easy, as well as to prevent, to some 
 degree, those perversions of them which arise altogether from igno- 
 rance. Still, as Hahnemann himself observes, (Organon, §i,) "the 
 first and sole&vXy of the physician is, to restore health to the sick," and 
 not to spend his time in constructing and explaining, much less in 
 contending about mere theories, whether true or false. 
 
 In pursuance of this plan, we shall first lay down a few of the 
 more important definitions and homoeopathic aphorisms, after 
 which we shall treat briefly of symptoms, both pathogenetic and 
 morbid,* and then of the homoeopathic medicines, their doses, du- 
 ration of action, and repetition. 
 
 DEFINITIONS AND APHORISMS. 
 
 Disease is a departure from health \ and is either local, as affecting 
 only a part of the animal sytem or functions, or constitutional^ as 
 embracing, to a greater or less extent, the whole system. 
 
 Diseases are either acute or chronic, the former term being applied 
 to such derangements of the health as are speedily overcome, and 
 produce no permanent organic changes ; and the latter to those 
 diseases which are either slow in their development and progress, or 
 which, from wrong treatment or otherwise, are extended far beyond 
 the natural term of their duration. 
 
 They are also divided into primary, and secondary or consecutive, 
 the former term being applied to the original disease, or first series 
 
 * Strictly speaking, all symptoms are morbid, since they are the result of 
 diseased action ; but we shall use the term in its ordinary sense, to denote 
 only those symptoms which belong to natural diseases, in contradistinction to 
 those which are artificially excited, namely, the pathogenetic, or medicinal. 
 2 
 
10 HOMOEOPATHIC 
 
 of derangements ; and the latter to the subsequent morbid phenom- 
 ena, particularly when they grow out of, or are in any way dependent 
 upon, or referable to, the primary disease. 
 
 The causes of disease may be either external or internal, mechan- 
 ical, chemical, pathogenetic, or toxical. 
 
 Among the most prolific internal causes of disease, is a depraved 
 state of the blood, or taint of the system, affecting to a greater or less 
 extent nearly the whole human family — the resultant of former dis- 
 eases on the human system, which, variously modified, have come 
 down to us from our ancestors — and called by Hahnemann, psora. 
 Whatever opinion we may entertain concerning Hahnemann's theory 
 on this subject, or however unfortunate he may have been — if, in- 
 deed, he was unfortunate — in the selection of a term by which to 
 designate this peculiar condition, the fact itself cannot be ignored, 
 even by those who attempt to throw ridicule upon it. The condition 
 does exist, and not only acts as a prolific cause of disease, but greatly 
 modifies diseases originating from other causes. Ordinarily it exists 
 in a dormant or latent state, producing a chronically depraved state of 
 health, usually termed dyscrasia; but when it becomes active, as it 
 does when other causes have disturbed the comparatively healthy 
 balance which the vital force, aided by time, has served to produce, 
 or when thrown into activity by the effects of remedial agents, then 
 its presence becomes so pronounced that the most prejudiced can- 
 not fail to see it. What matters it, then, so we clearly recognize the 
 condition itself, whether we call it psora, dyscrasia, chronic blood 
 disease, or any thing else? As long as no better name is found 
 for it, we have no hesitation in calling it psora, and psora it shall be ! 
 " Multa non sunt sicut multis videntur /" 
 
 Diseases can properly be said to be cured, only when the affected 
 parts and functions are restored to their original state ; that is to say, 
 when the disease is thoroughly eradicated, and its effects entirely 
 removed from the system. On the other hand, when diseases, either 
 through treatment or otherwise, simply disappear, or become latent, 
 without being thoroughly eradicated, they are said to be suppressed. 
 It is this suppression of disease, the ordinary result of allopathic 
 treatment, which constitutes true psora, as above defined, and is the 
 chief cause of nearly every chronic disease. Whenever it becomes 
 active, there is generally an effort, so to speak, on the part of nature 
 
PRACTICE OF MEDICINE. II 
 
 to eliminate it from the system by throwing it to the surface, consti- 
 tuting the various forms of tetter, and other itchy eruptions, whence 
 the name by which Hahnemann designated the affection, namely, 
 psora, a term derived originally from the Greek, and signifying to rub. 
 
 From the foregoing, it is evident that the psora, properly so 
 called, is a very different affection, ordinarily, from that single vulgar 
 form of it commonly called the itch, to which allopathists would fain 
 confine it. The latter is the least significant, as it is the most super- 
 ficial, of all its multiplied forms and manifestations, and generally 
 depends upon some local cause of irritation; while the former is a 
 profound, peculiar, compound morbific element, whose impress is so 
 clearly stamped upon almost every form of disease, as greatly to modify 
 its character, duration, history and treatment. It is, in fact, as before 
 stated, the expression of the difference between the cure and the 
 suppression of disease, which has resulted from the general non- 
 observance in treatment, from time immemorial, of the true and only 
 law of cure, the homoeopathic, which we will now explain. 
 
 It was a discovery of the immortal Hahnemann, that diseases can . 
 only be cured by remedies which are capable of producing similar 
 diseases in healthy persons. This irrefutable law of nature is ex- 
 pressed by the formula, " similia similibus curantur," or like is cured 
 by like, a law as simple and beautiful in its expression, as it is 
 universal in its application ; and which is destined to revolutionize 
 the whole art and science of medical practice. 
 
 This great natural law of cure had suggested itself to several 
 early physicians, especially Stahl, whose words are as follows : " The 
 received method in medicine, of treating diseases by opposite 
 remedies — that is to say, by medicines which are opposed to the 
 effects they produce, (contraria contrariis) — is completely false and 
 absurd. I am convinced, on the contrary, that diseases are subdued 
 by agents which produce a similar affection." (Similia Similibus.) 
 — See Introduction to Hahnemann 's Organon. But it was not until 
 the brilliant genius of Hahnemann set it forth disclosed in all its 
 beauty and perfection, with irrefutable reasoning and the most ample 
 illustration, that it began to be generally recognized by the learned 
 as the true, unerring, a?id universal law of nature ; while now, it may 
 be truly said, there are but few so ignorant and undiscerning, as not 
 in some way " to do it homage." 
 
12 HOMCEOPATHIC 
 
 Experience shows that, agreeably to this law, those medicines 
 which, taken in large quantities, produce in healthy organisms symp- 
 toms similar to those of the disease, are the therapeutical agents 
 that, in small and convenient doses, cure it in the most prompt, 
 certain, and permanent manner. Hence it follows, that homoeopathic 
 remedies annihilate disease, by exciting in the system a certain 
 artificial malady, which so closely resembles the natural one, as to 
 destroy the symptoms of the disease to which such relation is 
 sustained. 
 
 In order, therefore, to effect a satisfactory cure of any particular 
 disease, we have, in the first place, to select from all others that 
 medicine whose effects, symptoms, or manner of action, upon the 
 healthy organism, most nearly resembles the symptoms of the disease 
 which we aim to cure ; and, secondly, to administer it in such form 
 and manner, and with such frequency, as experience shows to be 
 best adapted to the end in view. The first of these prerequisites we 
 shall consider under the head of 
 
 SYMPTOMATOLOGY. 
 
 Symptoms are of two kinds or classes, namely : those belonging 
 to natural diseases, called morbid, and those developed by medicinal 
 agents, acting upon healthy organisms, termed pathogenetic. Their 
 character is essentially the same, and they differ only in degree and 
 manner of production. The former are the expression, or represen- 
 tation, so to speak, of natural diseases, or maladies ; the latter of 
 analogous artificial diseases. The former are arranged in particular 
 groups, more or less variable, according to the age, sex, temperament, 
 and general constitution of the patient ; the latter in certain other 
 groups, more or less similar, according to the nature of the medicine 
 producing them, their mode of preparation and administration, and 
 the condition and susceptibility of the provers, or those upon whom 
 they are made to act. While there are no known medicines capable 
 of producing groups of symptoms precisely the same as those of 
 natural diseases, many of them furnish groups of striking similarity, 
 whereby we are enabled to select, agreeably to the law of " similia" 
 such as prove curative in natural diseases. These, when rightly 
 selected and administered, never fail of effecting perfect cures ; such 
 medicines are therefore called specifics. Hence a thorough knowl- 
 edge of the Materia Medica, and especially of the pathogenetic 
 
PRACTICE OF MEDICINE. 1 3 
 
 symptoms peculiar to the several remedies, and which are termed 
 characteristics, is essentially necessary to success in homoeopathic 
 practice. Such knowledge can only be acquired by studying and 
 carefully noting the effect of medicines on the healthy subject. 
 Happily, so far as the production of a true Materia Medica is 
 concerned, this work in the vast realm of pathogenetic investigation, 
 has already been performed by numerous observers and provers, 
 upon whose veracity and accuracy we can implicitly rely. Of these, 
 Hahnemann justly stands at the head ; while the names of Stapf, 
 Hartlaub, Hering, Franz, Nenning, and a host of others, furnish a 
 constellation whose light pales only before that of the illustrious 
 founder of the homoeopathic system. 
 
 Notwithstanding all this, it is not to be denied that our Materia 
 Medica has already become encumbered with many indefinite and 
 unreliable "symptoms " whose presence in our works renders it 
 extremely difficult, in many cases, to make a proper selection. 
 Hence it becomes necessary in searching for a specific, to carefully 
 sift, compare, and weigh the several symptoms, both of the remedy 
 and the disease, selecting that which furnishes the most striking and 
 perfect resemblance between them, at the same time having regard 
 to the following principles : 
 
 i. Symptoms have a relative value only ; that is to say, the patho- 
 genetic characteristics of a medicine are of greater or less value, 
 only as compared with those which have or have not the same char- 
 acteristics ; so that those symptoms, which at one time, or in one 
 series of comparisons, have no particular value, may at another 
 time be of the greatest importance. Hence no pathogenetic or 
 medicinal symptom should be disregarded, or lightly esteemed, be- 
 cause common to other remedies, any more than we should be 
 justified in neglecting similar symptoms in the treatment of disease. 
 
 2. The totality of the symptoms is the only true indication in the 
 selection of the remedy. For although, as before remarked, there 
 are no well-recognized pathogenetic groups of symptoms precisely 
 the same as those of natural diseases, there are those which bear 
 such a striking resemblance to them, as plainly to indicate their reme- 
 dial virtues under the law of " sitnilia." But since they are often 
 associated with others of a diverse character, it is necessary always 
 to have regard to the totality of the symptoms, otherwise the law 
 could not justly be said to apply. 
 
14 HOMCEOPATHIC 
 
 3. A remedy to be perfectly homoeopathic, must be capable of 
 producing all those symptoms which are peculiar ', extraordinary and 
 characteristic in the natural disease. When this resemblance exists, 
 the disease will generally yield to a single dose of the medicine, 
 provided the remedy be properly administered, and due attention 
 given to hygienic influences. 
 
 4. If a remedy is chosen which is not strictly homoeopathic to 
 the disease, that is, to the totality of the symptoms, it will, especially 
 in appreciable doses, give rise to symptoms not properly belonging 
 to the disease, and therefore referable only to the remedy ; or it will 
 have the effect of increasing the morbid symptoms, producing what 
 is called homoeopathic aggravation. If, in these cases, the pathogenetic 
 symptoms are sufficiently similar to those of the disease, to give the 
 remedy a decidedly homoeopathic effect, the disease will, as in the 
 former case, generally yield to a single dose of the medicine, pro- 
 vided sufficient time be allowed for the homoeopathic aggravation to 
 subside. 
 
 THE HOMOEOPATHIC MATERIA MEDICA. 
 
 The homoeopathic materia medica, in its complete form, contains 
 such a vast number of symptoms, natural, morbid and pathogenetic, 
 that the student is apt to be overwhelmed by their multiplicity and 
 unscientific arrangement. I have therefore made a selection, under 
 the head of " Characteristic Materia Medica" embracing only such 
 pathogenetic symptoms as are peculiar to the several remedies, or 
 have been confirmed by clinical experience. Of course, this is not 
 intended in any sense as a substitute for our more elaborate works on 
 the subject, but simply as an aid to the student in acquiring an easy 
 and at the same time definite knowledge of the characteristic symp- 
 toms of our principal medicines. A thorough knowledge of these 
 symptoms, together with the analytical system of diseases and their 
 remedies, will enable any competent person to select, without diffi- 
 culty, the true specific for any group of symptoms which may present 
 themselves in the course of any disease, either acute or chronic. 
 These tables the student will do well to memorize, especially those 
 pertaining to the more common and special forms of disease, as well 
 as the characteristic indications of the remedies employed. This 
 amount of familiarity with the homoeopathic materia medica, and the 
 pathogenesis of medicines, is necessary in order to give the required 
 coup d'ozil of the symptoms, so that the relation of the remedy to 
 
Practice of medicine. 15 
 
 the disease may be readily and clearly recognized, and much time 
 and suffering, as well as unnecessary labor and research, avoided. 
 
 THE HOMOEOPATHIC DOSE. 
 
 Owing to its extreme minuteness, the efficiency of the homoeopathic 
 dose, whether the medicine be exhibited in the first or last attenua- 
 tions, has often excited the astonishment of the inexperienced. 
 Many ingenious attempts have been made to explain its efficiency ; 
 some referring it solely to a dynamic power developed in its prepa- 
 ration, and others attributing it simply to dilution. Doubtless, both 
 explanations are, to a certain extent, correct ; that is to say, that a 
 direct and absolute increase of medicinal energy is produced by 
 simple attenuation, while at the same time their peculiar virtues 
 are exalted by atomic separation. For, on the one hand, it 
 cannot be denied that within certain extreme and indefinite 
 limits, bounded only by atomic separation, medicinal substances 
 are free to act upon the living organism, only in proportion 
 as their ultimate particles, or atoms, are in a condition to be 
 brought into the most intimate connection with the living 
 tissues; while, on the other hand, it is equally certain, that true 
 atomic separation must, from the very nature of the case, set free 
 the peculiar medicinal virtue of the substance, and that in direct 
 proportion to the amount of atomic separation. So that, practically, 
 it makes but little, if any, difference which explanation is received, 
 since in both cases, the power or virtue of the medicine, whether 
 dynamic or otherwise, is proportionate to the amount of dilution, 
 attenuation, or atomization, to which the medicine is subject in its 
 preparation. 
 
 For these reasons, we would, as a general rule, recommend the 
 employment of the higher attenuations, except when used as blood 
 aliments, as antidotes to toxic symptoms, and in specific blood diseases, 
 when the size of the dose, or degree of attenuation, should be regu- 
 lated by the object in view, and by the exigencies of the case. (See 
 the remarks on doses and attenuations under the head of Diphtheria.) 
 Some, on the other hand, prefer the high attenuations only in chronic 
 diseases, and employ low ones in the acute. But, if the above rea- 
 soning be correct — and we can testify that it has been amply verified 
 in our own experience — the practitioner has only to repeat the dose 
 at sufficiently short intervals, to extinguish promptly and satisfactorily 
 
1 6 HOMOEOPATHIC 
 
 the most acute symptoms. Cases, it is true, sometimes occur, in 
 which the lower preparations seem to yield the best results ; but we 
 are satisfied, both by experience and observation, that in the vast 
 majority of cases, if sufficient care and judgment be exercised in the 
 selection and administration of the remedy, the greatest benefit will 
 be derived from the exclusive use of the higher potencies, in nearly 
 every simple or non-specific form of disease.* c. p. hart. 
 
 * The student will naturally desire some definite rule or principle by 
 which to regulate the potency, or size of dose, in particular cases. In lieu of 
 such information, which can only be acquired by long practice and observation, 
 the suggestions contained in the following extract from an article of ours, 
 entitled " Observations on the Homoeopathic Dose." published in the " Cincinnati 
 Medical Advance" for November, 1873, may be of value : 
 
 " But a still more important consideration, affecting the question of dose, 
 is the precise pathological condition of the patient. The symptoms, so far as 
 casual observation goes, may be the same, and yet different cases, or the same 
 case at different times, require either different remedies, or different attenua- 
 tions of the same remedy. This is a matter of every day observation, and yet 
 it is not sufficiently recognized in our therapeutics. To illustrate : A patient 
 is threatened with congestion of the bowels. This presupposes a congested 
 state of the portal system. The latter, more particularly, will determine the 
 remedy. The former, including, of course, all the minuter elements of 
 the case which go to make up the tout ensemble, and especially the matter of 
 susceptibility, time and degree, will cceteris paribus, determine the potency or 
 degree of attenuation. Thus, the state of greatest congestion short of actual 
 effusion, necessarily calls for the higher attenuations, since the lower ones 
 will be quite certain to precipitate the condition we wish to avoid. On the 
 other hand, slight congestions, contrary to what, at first glance, we might sup- 
 pose would be the case, generally require the lower potencies, though the higher 
 may answer the purpose ; but the latter will require, of course, to be pushed to 
 the point of successful reaction to be effective. The great difficulty in such 
 cases, is, to determine the exact pathological condition in question. If the 
 tension, so to speak, of the function, or diseased action of the part, is as great 
 as nature will bear without a decided change of condition, then the higher 
 potencies will be most effective in subduing the symptoms for which they 
 are given. On the other hand, using the same term as before, if the tension 
 is light or weak, and the diseased function or action of the part is capable of 
 a much greater strain, without any essential change in its pathological condi- 
 tion other than one of degree, or range of action, then experience shows that 
 low attenuations are equally, and in many cases, even more effective than the 
 high. In short, the whole question seems to turn upon the facility with 
 which, in any given case, reaction is capable of being excited. 
 
 Of course, there are some conditions which stand outside of this law, such 
 as chemical, chemico-vital and toxical conditions, which it would be absurd 
 in the highest degree to attempt to bring under it; such for example as 
 anozmia, in which there is a notable deficiency of haematine in the blood. 
 Here iron is required as a nutrient, and hence, cceteris 'paribus, the lower the 
 form in which we administer it, the better." 
 
PRACTICE OF MEDICINE. 1 7 
 
 REPETITION OF THE DOSE. 
 
 The repetition, no less than the volume of the dose, is a subject 
 upon which great differences of opinion still exist among 
 homceopathists. Some administer the medicine in a single dose, 
 generally of a low attenuation, and if no perceptible benefit is found 
 to result, they fly immediately to some analogous remedy, or alter- 
 nate it with others of a supplementary, or supposed corroborative 
 character, as though a curative effect were to be obtained by a direct 
 action of the medicine. But no principle of our practice is better 
 established, than that cures, properly so called, are never effected 
 by the direct action of medicines, but by the reaction of the vital force 
 excited by them. (Hahnemann, Org., §§63, 64, 68.) Hence, expe- 
 rience shows that, although a single dose of a well-selected remedy 
 is often sufficient to produce a healthy reaction, and thus start a 
 cure, which, if not interrupted by injudicious interference, mental 
 impressions, or errors of diet, will go on to completion ; yet, if the 
 disease be severe, so that reaction of the vital force is not easily 
 excited, a repetition of doses, at longer or shorter intervals, 
 according to the urgency of the case, the nature of the affection, 
 and the age, constitution and temperament of the patient, is neces- 
 sary in order to produce a salutary effect. The greatest caution, 
 however, needs to be observed in the repetition of the dose, as well 
 on the one hand to avoid aggravations resulting from excessive 
 reaction, as on the other to promote it by a steady pathogenetic 
 influence of the vital power, to the extent of a complete subdual of 
 the morbid symptoms. Nor should we fail to remember, that a too 
 sudden, or a too violent assault on the vital power, even to the point 
 of successful reaction, is often attended by unpleasant effects, espe- 
 cially if low attenuations are employed, so as in a great measure to 
 frustrate the end in view. When, therefore, the vital power rises in 
 opposition to the action of the remedy, especially when new symp- 
 toms, and not simply aggravations of the old ones, are developed, 
 we must allow sufficient time for the excitement to subside, and 
 then, if a healthy reaction has taken place, the salutary effect should 
 be allowed to continue uninterrupted to its close ; if not, it should 
 be steadily but gently stimulated by such repetition of the remedy 
 3 
 
1 8 HOMOEOPATHIC 
 
 as may be found necessary to accomplish it* Of course, the frequency 
 of such repetitions will necessarily depend, as before stated, upon the 
 nature of the disease, the urgency of the case, and the age, constitu- 
 tion, temperament and general condition of the patient. 
 
 As a general rule, we have obtained the best results by dissolv- 
 ing twenty or thirty globules of the thirtieth potency in half a tumbler 
 of water, stirring it well, and giving a teaspoonful of the solution 
 every hour, or oftener, in acute cases, and once or twice a day in 
 chronic cases. If aggravations occur, either natural or pathogenetic, 
 the medicine should be omitted until they subside, or until it is seen 
 what effect, if any, the omission has upon the symptoms, when, if a 
 curative action has been fully developed, the medicine already given 
 may be found to suffice ; if not, it should be repeated, agreeably to 
 the rules and principles already suggested. If the disease be a 
 violent one, such as croup or cholera, the medicine should be ad- 
 ministered every five, ten or fifteen minutes, according to the urgency 
 of the case. In all instances, whenever an amelioration of the 
 symptoms takes place, the administration of the medicine should be 
 suspended ; but should they recur, or convalescence cease, the 
 same medicine should be immediately resumed, or another appro- 
 priate one given. Should the salutary effects of the remedy be 
 interfered with, or suspended, in consequence of errors of diet, 
 cold, or other causes, measures should be adopted to counteract 
 the supposed cause of the interference, and as soon as the interrup- 
 tion ceases, the original medicine should be at once resumed, and 
 the disease guided to a favorable issue agreeably to the principles 
 already explained. 
 
 ALTERNATION OF MEDICINES. 
 
 Owing to the great diversity of morbid conditions, and the com- 
 paratively limited number of single remedies in every respect 
 homoeopathic to them, it often becomes advisable, especially in 
 acute cases, to give two, and sometimes three medicines, in alterna- 
 tion, whenever necessary to cover the characteristic symptoms of the 
 disease. In this way, for instance, in Croup, we sometimes find it 
 expedient to give Aconite, Hepar sulph. and Spongia in rapid succes- 
 
 * Jahr, Snelling's Hull's, to which work we are under great and frequent 
 obligation. 
 
PRACTICE OF MEDICINE. 19 
 
 sion, or alternation ; or, after Aconite, the two latter in alternation ; 
 or we may have occasion to give Phosphorus and Bromine, in the 
 same manner, according as the particular forms and stages of the 
 disease seem to require. In the same manner, also, in Erysipelas, 
 we give Aconite and Belladonna, or Belladonna and Rhus, or Rhus 
 and Phosphorus, according to the various forms and stages of the 
 disease. 
 
 Whenever in acute cases it becomes necessary or expedient to use 
 two or more medicines in alternation, great care should be taken 
 to observe the effect of each remedy upon the symptoms, and one or 
 the other of them should be withdrawn, or another more appropriate 
 one substituted, as occasion may require. At the same time, equal 
 care should be taken not to make such changes unnecessarily, or too 
 frequently, bearing in mind the fact, that the production of new 
 symptoms, when properly belonging to the disease, or the aggrava- 
 tion of old ones, are good signs, and only require that the medicine 
 should be withheld, or given less frequently, to produce the most 
 favorable results. 
 
 Some practitioners are opposed to the alternation of remedies, 
 particularly in chronic cases, but in our opinion without good reason. 
 When the medicines selected are truly homoeopathic to the symp- 
 toms — and of course no others should ever be used — we are confi- 
 dent that we have in this way often been able to abridge the treat- 
 ment several weeks, and even months. Thus, in a case of Chronic 
 Diarrhoea of over eight months standing, attended by painful 
 palpitations of the heart, and which had long resisted single remedies, 
 however judiciously administered, we prescribed Petroleum and 
 Crocus sat. alternately once a day — Petr. for the diarrhoea, and Croc. 
 for the painful palpitations — and within a week the diarrhoea and the 
 palpitations both ceased, and there was no return of either. In this 
 case China, Ferrum, Calc. c, Petr. Phos., Sulph., and a dozen other 
 remedies had been tried singly in vain. 
 
 Another patient, a merchant, had been afflicted for more than 
 three years with non-syphilitic ulcers, boils and carbuncles, associa- 
 ted with more or less muscular rheumatism, affecting sometimes one 
 part of the body, and sometimes another. For this combination of 
 symptoms we prescribed Silicea and Bryonia, in alternation, once a 
 day, for about a week, when the rheumatism being relieved, we 
 
20 HOMOEOPATHIC 
 
 withdrew Bryonia, but continued the Si/icea, until the ulcers showed 
 signs of amendment, when we withdrew the medicine altogether. In 
 the course of a few weeks the ulcerations were entirely healed ; but 
 shortly afterwards the rheumatic pains returned with greater violence 
 than at first. We then gave a single dose of Bryonia jo, and rested 
 the case. In a short time the rheumatism disappeared, and the 
 patient's health was fully restored. 
 
 We desire particularly to caution the prescriber against changing 
 the medicine in chronic cases on the first appearance of aggrava- 
 tions, even when they seem to demand it, as should always be done 
 in acute diseases, for such aggravations are much more apt to occur 
 in chronic cases, especially when medicines are alternated ; but if 
 the medicines given are homoeopathic to the principal symptoms, the 
 aggravations will shortly subside, so soon as the vital force has 
 become paramount to the disease. All that is necessary in such 
 cases is, to diminish the frequency of the doses until the curative 
 action is fully established. 
 
 DURATION OF THE ACTION OF MEDICINES. 
 
 Every medicine has a peculiar effect on the living organism, as 
 well with respect to its period of action, as to the medicinal symp- 
 toms it is capable of producing. As a general rule, the duration of 
 action of vegetable remedies is much shorter than that of mineral 
 medicines, the former generally lasting only a few hours or days, 
 whilst the latter frequently continues many months, and even years. 
 Thus, the action of Aco?iite is sometimes limited to a period not 
 exceeding half an hour, while, on the other hand, the effects of 
 Mercury on the system often extend through months and years, and 
 even through life. 
 
 Observation also establishes the fact, that the pathogenetic 
 effects of medicines are subject to precisely the same laws of period- 
 icity that control diseased action. This gives rise to what are called 
 secondary symptoms, in which the primary effect of the medicine is 
 frequently followed by one of an exactly opposite character. It also 
 produces those medicinal aggravations which are frequently mistaken 
 for the exacerbation of natural disease. These aggravations are gen- 
 erally found to recur, in most chronic affections, every seven or eight 
 days, being more marked on each alternate day or week, until, after 
 
PRACTICE OF MEDICINE. 21 
 
 the lapse of six or eight weeks, they commonly subside altogether. 
 Hence it becomes necessary in many chronic affections, especially 
 when medicinal exacerbations occur, not to repeat the remedy oftener 
 than once a week, and sometimes not oftener than once in two or 
 three, or even once in six or eight weeks, in order not to interfere 
 with the healthy reaction of the vital force. In fact the same, rule 
 applies in chronic cases of this character, as in those which are acute, 
 with this difference, that we measure the interval between the doses 
 in the former by weeks instead of hours or days, the period which is 
 found to govern the medicinal aggravations determining the repeti- 
 tion of the dose in all cases. 
 
 We have hitherto regarded the medicine employed as having been 
 rightly selected ; but if otherwise, one of two things will follow ; 
 either the medicine will have no perceptible effect whatever upon 
 the disease, or it will give rise to symptoms which, not being similar 
 to those of the disease, will only add to the discomfort of the patient, 
 and if long-continued will greatly aggravate the case. In either 
 event, the medicine should be immediately replaced by one whose 
 mode of action corresponds more accurately to the ense?nble of the 
 malady, and which will at the same time cover the principal symp- 
 toms produced by the remedy just omitted. The safest and most 
 practical rule to follow in these cases is, to watch attentively the 
 moral condition and general aspect of the patient, and if ameliora- 
 tion takes place in these particulars, to await the further action of the 
 medicine; if not, the state of the patient becoming progressively 
 worse and worse in these respects, no time should be lost in seeking 
 a more appropriate remedy.* Care should be taken, however, not 
 to reject a remedy which has been carefully chosen, whatever may 
 be the momentary or occasional character of the aggravations 
 depending upon it, until sufficient time has elapsed to observe the 
 alternations of good and bad symptoms, which, as before stated, 
 should be at least seven or eight days in chronic cases, and from five 
 to fifteen or thirty minutes in those which are acute. This rule 
 should be followed in every case in which aggravations or secondary 
 symptoms are observed ; in every other we should follow the general 
 directions already laid down under the head of "repetition of dose." 
 
 * Jahr. 
 
22 
 
 HOMCEOPATHIC 
 
 
 
 
 
 
 TABLE I. - 
 
 -ANALYSIS 
 
 
 
 
 
 r 
 
 r Weak, 
 
 China. 
 
 Ansemic, 
 
 
 
 
 
 
 
 Ferr. 
 
 
 r 
 
 
 
 r 
 
 
 
 m 
 
 o 
 
 ' Gland. Swell. 
 Iod. Sil. 
 
 
 i 
 
 1 *5 
 
 Accelerated, 
 
 J.C071. 
 
 Retarded, 
 
 
 
 Cold, 
 
 
 
 13 - 
 
 Tubercle, 
 
 
 13 
 
 Digital. 
 
 
 
 I>ulc. 
 
 
 
 
 Phos. 
 
 
 j 
 
 Irregular, 
 
 
 
 
 
 s 
 
 o 
 
 TettersUlc'rs, 
 
 
 b 
 
 ^Lrsen. 
 
 
 
 
 
 %-J 
 
 GQ 
 
 Ars. Merc. 
 
 
 
 
 
 Concussion, 
 
 
 5 . 
 
 DD 
 
 
 ' Anasarca, 
 
 
 .2 
 
 Quick, 
 
 Bryonia. 
 
 
 r 
 
 
 
 s 
 
 o 
 
 
 Arsen. 
 
 
 rt 
 
 Slow, 
 
 
 , 
 
 
 
 Q 
 
 tJ 
 
 Ascites, 
 
 
 "Bh 
 
 Castor. 
 
 
 a 
 
 Exp. to Water 
 
 
 
 <x> 
 
 Hell. Merc. 
 
 ' 
 
 OQ 
 
 Irregular, 
 
 
 8) 
 
 or Damp, 
 
 \ 
 
 
 "73 - 
 
 Adipose, 
 
 
 PS 
 
 I Opium. 
 
 
 
 
 eg 
 
 Rhus. 
 
 
 
 GQ 
 
 Cede. c. 
 
 
 
 
 
 
 
 
 Pregnancy, 
 
 
 . 
 
 Increased, 
 
 
 
 
 
 m 
 
 
 
 Sepia. 
 
 
 •*3 
 
 Cole. c. 
 
 
 J ° 7 ' „ ^ 
 
 v 
 
 
 
 OB 
 
 Deficient, 
 
 , 
 
 ii 
 
 Cb/ea. 
 
 h 
 
 
 Emaciated, 
 
 C 
 
 
 Nux V. 
 
 
 fl 
 
 
 * 
 
 
 China, Ars. 
 
 
 
 <: 
 
 Canine, 
 
 *a 
 
 Grief, 
 
 & 
 
 
 ' Infancy, 
 
 
 
 
 China. 
 
 < 
 
 V 
 
 Ignatia. 
 
 fe_ 
 
 
 Cham. 
 
 ti 
 
 -g f Excessive, 
 
 ill 
 
 M 
 
 5 
 
 K 
 
 b. 
 
 
 Adolescence, C. - 
 
 0" 
 
 .!: J JLrsew. 
 
 H. 
 
 (H 
 
 
 
 Anger, 
 
 Cham. 
 
 03 
 
 
 
 •H 
 
 IS 
 
 9? 
 
 60 - 
 < 
 
 Puis. Bell. 
 Crit, Age, 
 Lach., Sepia. 
 Old Age, 
 
 
 
 •H 
 
 p I None, 
 . r Sopor, 
 
 IB 
 
 
 fe 
 
 
 Opium. 
 
 ^ 
 
 o J Opium. 
 
 
 ft 
 
 a 
 
 Jealousy, 
 Hyoscyamus. 
 
 £ 
 
 f Male, 
 
 
 
 =2 1 Sleeplessness, 
 L G#ea. 
 
 
 
 
 oq 1 Female, 
 
 
 -• f Amenorrhea, 
 
 | 1 Pulsatil. 
 
 ^ 1 Menorrhagia, 
 
 L Ignatia. 
 
 
 
 Chagrin, 
 
 Phos. A. 
 
 
 1 
 
 Puis. 
 Gentle, 
 
 
 
 
 
 
 . 
 
 Puis. 
 
 
 
 
 
 Fright, 
 
 Opium. 
 
 
 c 
 .2 
 
 •S3 - 
 o 
 
 o* 
 
 Irascible, 
 
 Nux V. 
 Melancholy, 
 
 
 f Diarrhoea, 
 
 o J ip. Merc. 
 -2 ] Constipation, 
 00 I Op.Suiph. 
 
 
 
 
 
 00 
 
 Ignatia. 
 
 
 
 
 Nostalgia, 
 Capsicum. 
 
 
 5 
 
 Cheerful, 
 
 Coffea. 
 
 
 . ( Scanty, 
 c J Canthar. 
 
 
 
 
 
 
 Sanguine, 
 
 
 'J* 1 Copious, 
 
 
 
 
 
 <u 
 
 Hyos. 
 
 
 
 
 
 
 s 
 
 Lymphatic, 
 
 
 
 
 
 
 
 
 Lach. 
 
 
 
 
 
 
 s 
 
 0> 
 
 Choleric, 
 
 
 
 
 
 
 
 Nux V. 
 
 
 
 
OF 
 
 PRACTICE OF MEDICINE. 
 DISEASE. 
 
 23 
 
 d. <{ 
 
 f I Morning. 
 
 Time >- Evening. 
 . I J Night. 
 
 •2 
 
 "I ■¥»•*• 1 Erect. 
 
 > \ Positlon JEecumbent 
 
 - 1 
 
 bC 
 
 if ,, .. I Slow. 
 
 Motlon }Ea P id. 
 
 Kest, Diet, etc. 
 
 ' Conditions 
 
 same as above and 
 
 very numerous. 
 See 
 
 Mat. Med. 
 
 Eight Side, 
 
 Left Side, 
 
 Morning, 
 
 Evening, 
 
 Day, 
 
 Night, 
 
 Motion, 
 
 Eest, 
 
 Bell. 
 
 Aeon. 
 
 Nux. 
 
 Puh. 
 
 Calad. 
 
 Sidph. 
 
 Bryonia. 
 
 Rhus tox. 
 
 Congestion, 
 
 Bell. 
 
 Fever, 
 
 Aconite. 
 
 Pleuritic Pain, 
 
 Bryonia. 
 
 Emesis, 
 
 Ipecac. 
 
 Cephalalgia, 
 
 Glonoine. 
 
 Cardialgia, 
 
 Nux Vom. 
 
 Vesic. Ervs., 
 
 Bhus lox. 
 
 Psoric Erup., 
 
 Sulph. 
 
 Algidity, 
 
 Arsen. 
 
 Delirium, 
 
 Hyoscy. 
 
 Tremor, 
 
 Arnica. 
 
 Anaesthesia, 
 
 Carbo veg. 
 
24 HOMOEOPATHIC 
 
 SELECTION OF REMEDIES. 
 
 We have purposely delayed considering the various circumstances 
 connected with the proper selection of remedies, until we had dis- 
 cussed the different questions connected with their action, in order 
 that the relations which they severally sustain to each other might be 
 more readily traced and comprehended. For, in order to be able to 
 select the most appropriate remedy in any given case, it is not only 
 necessary to be well acquainted with the pathogenesis of the several 
 medicines, but, as already stated, to keep in view the totality of the 
 symptoms, as well as the exciting cause, and other modifying circum- 
 stances. Hence, although much, and sometimes everything, depends 
 upon the homoeopathicity of the re??iedy, that is to say, the similarity of 
 its symptoms to those of the disease, it is no less important to ascer- 
 tain the immediate exciting cause of the malady, and to keep in view 
 the constitution, age, sex, disposition and temperament of the patient ; 
 and also the state of the principal bodily functions, such as the 
 respiration and circulation, appetite and thirst, sleep, catamenia, 
 stool and urine. In order to obtain a comprehensive view of the 
 whole circle of indications referred to, we will present them in tabular 
 form, with illustrative examples under each head. It is scarcely 
 necessary to remark, by way of explanation, that in these instances 
 the examples cited in the table sustain no relation to the other con- 
 ditions with which they are associated, but simply to the particular 
 symptom or condition under which they are respectively placed; that 
 is to say, the selection in this instance not having been made with 
 any reference to the general pathogenesis of the several remedies 
 mentioned — as would need to be the case in actual disease — are 
 simply illustrative of the particular indications with which they stand 
 connected in the tables. 
 
 A careful inspection of the foregoing table, will show that some 
 of the indications embraced in it should have a much greater in- 
 fluence on the selection of the remedy than others. Thus, age, by 
 itself, is no criterion for the selection of a remedy, being subordinate 
 to every other indication, and is only to be taken into consideration 
 when the other symptoms correspond. On the other hand, the 
 constitutional condition, as a general rule, is, next to the exciting cause 
 
PRACTICE OF MEDICINE. 2$ 
 
 of the greatest importance, and often exercises a controlling influence 
 upon the selection. Of course, the practitioner is not to lose sight 
 of the fact, that the medicine must in all cases be homoeopathic to 
 the characteristic symptoms of the disease \ but when these are few 
 in number, or not well pronounced, or when the auxiliary symptoms 
 are the most prominent, then the selection is made to depend to a 
 great extent, and sometimes entirely, upon the latter. Thus, for ex- 
 ample, a patient is attacked with symptoms suggestive of incipient 
 phthisis, such as a slight hacking cough, occasional slight pains in 
 the chest, scanty expectoration of saltish mucus, and suppression of 
 the menses. Here, Pulsatilla, by restoring the catamenia, will 
 probably effect a cure ; and is preferable to Phosphorus, which, were 
 it not for the suppression of the menses, (which in this case is prob- 
 ably the exciting cause of the whole difficulty,) would be the most 
 appropriate. Indeed, it may be laid down as a general rule, that 
 the sexual sphere exerts a controlling influence in nearly all the 
 diseases of females, and should therefore never be lost sight of in 
 their treatment. In these cases, it is true, the selection is made to 
 depend upon a mere function, but it is one the derangement of which 
 frequently makes a profound impression upon the system, giving rise 
 to many secondary symptoms, and is therefore entitled to the highest 
 consideration. 
 
 SUBSTITUTION OF MEDICINES. 
 
 We have already remarked, that no two medicines produce pre- 
 cisely the same pathogenetic effects ; whence it follows, that no rem- 
 edy can be a perfect substitute for another. But it frequently hap- 
 pens in the treatment of disease, that after a medicine has spent its 
 action, the symptoms have undergone so little change, as to suggest 
 the continuance of the same remedy. In such cases, the happiest 
 effects are sometimes produced by the substitution of another, but 
 similar medicine. The change in the symptoms, though slight, may 
 be sufficient to point out an analogous remedy more pathogenetic- 
 ally appropriate ; bur even when this is not the case, the new im- 
 pression made upon the symptoms by the minor differences in the 
 action of the two remedies, will frequently be found to exert a more 
 beneficial effect upon the disease, than would result from the con- 
 tinuance or repetition of the original medicine. This is especially 
 4 
 
26 HOMOEOPATHIC 
 
 true of chronic maladies, in which, as already stated, care should 
 always be taken to allow sufficient time for the remedy to spend its 
 entire force ; after which, though there should be but a mere shade 
 of variation produced in the symptoms, there can be no good reason 
 for its continuance. Indeed, we would lay it down as an invariable 
 rule in such cases, never to repeat the same remedy. The catalogue 
 of medicines of similar pathogenetic action is now sufficiently ex- 
 tensive, to enable the practitioner to substitute an analogous remedy 
 in all cases of this character. The same care, however, is neces- 
 sary in the selection of a substitute, and the same rules apply, 
 as in the selection of the original medicine, it being a supreme law 
 in the use of all homoeopathic remedies, that they should be capable 
 of producing symptoms similar to those for which they are given ; 
 and, secondly, that they should always be allowed to complete their 
 action before being changed. No medicine, therefore, however 
 analogous it may be, is ever to be substituted for another while the 
 former is still acting, and not then until, by a comparison of all the 
 symptoms, its homoeopathicity is clearly established. 
 
 With due observance of the foregoing directions, substitution, 
 agreeably to the order of succession contained in the following table, 
 will, as a general rule, be found to be the best adapted for consecu, 
 tive treatment ; the remedies named as being suitable after others 
 being those to which a preference should be given over other medi- 
 cines having analogous properties, but which sustain no such re- 
 lation to the previous treatment. While, therefore, on the one hand, 
 remedies should always be selected with reference to the totality of 
 the symptoms existing at the time the selection is made, without re- 
 gard to any definite order of succession in their administration, the 
 subsequent treatment, on the other hand, should be so conducted 
 that their administration shall correspond, as far as possible, with the 
 order of succession here given : 
 
PRACTICE OF MEDICINE. 
 TABLE II.— SUBSTITUTION. 
 
 27 
 
 REMEDY. 
 
 SUITABLE AFTER. 
 
 SUITABLE BEFORE. 
 
 Aconite. 
 
 Am. and Sulph. 
 
 Arn., Ars., Bell., Bry., Cann., 
 Ipec, Spong., Sulph. 
 
 Alumina. 
 
 Bry., Lach., Sulph. 
 
 Bry. 
 
 Ant. cr. 
 
 
 Puis, and Mere 
 
 Ant. tart. 
 
 Bar. c. and Puis. 
 
 Bar. e, Ipec, Puis., Sep.,Sulph. 
 
 Arsenicum. 
 
 Aeon., Arn., Bell., Chin., Ipec., 
 
 Chin., Ipec, Nux vom., Sulph. 
 
 
 Lach., Verat. 
 
 Veratrum. 
 
 Asa fcet. 
 
 Puis, and Thuja. 
 
 Caust. and Puis. 
 
 AURUM. 
 
 Bell., Chin., Puis. 
 
 Puis. 
 
 Belladonn. 
 
 Hep., Lach., Merc, Phosphor., 
 
 Chin., Con., Dulc., Hep., Lach. 
 
 
 Nitric Acid. 
 
 Plat., Bhus., Stram. 
 
 Bryonia. 
 
 Aeon., Nux v., Op., Rhus. 
 
 Alum, Rhus. 
 
 Calc. carb. 
 
 Chin., Cupr., Nit. ac, Sulph. 
 
 Lye, Nit. ac, Phos., Sil. 
 
 Carbo veg. 
 
 Kali, Lach., Nux v., Sep. 
 
 Ars., Kali, Mere, Phos. ac. 
 
 Causticum. 
 
 Asa f., Cupr., Lach., Sep. 
 
 Sep., Stan. 
 
 China. 
 
 Arn., Ars., Ipec, Merc, Phos. 
 
 Ars., Bell., Carb. v., Pulsatilla, 
 
 
 ac, Veratrum. 
 
 Veratrum. 
 
 Cuprum m. 
 
 Sulph., Verat. 
 
 Calc, Verat., Sulph. 
 
 Hepar s. 
 
 Bell., Lach., Sil., Spong., Zinc. 
 
 Bell., Merc, Nit. ac, Spong., 
 
 Sil. 
 Arn., Ars., Chin., Cocc, Ign., 
 
 Ipecacuan. 
 
 Aeon., Ars., Am., Verat. 
 
 
 
 Nux vom. 
 
 Kali carb. 
 
 Lye, Nat. m., Nit. ac. 
 
 Carb.v.,Petro.,Phos.,Khus.,Sul. 
 
 Lachesis. 
 
 Ars., Con., Hep., Lye, Merc, 
 
 Alum., Ars.,Bell., Carb. v.,Caust. 
 
 
 Nit. ac, Nux v. 
 
 Con., -Dulc, Merc, Nux v., 
 Phos. ac. 
 
 Ledum. 
 
 Lycopodium. 
 
 China, Sepia. 
 
 Lycopodium 
 
 Calc, Silicea. 
 
 Graph., Led., Phos., Puis., Sil. 
 
 Mercurius. 
 
 Ant. c, Bell., Hep., Lach. 
 
 Bell., Chin., Dulc, Hep., Lach. 
 Nit. ac, Sep., Sulph. 
 
 Nitric acid. 
 
 Bell., Calc, Hep., Kali., Nat. c 
 & m., Pulsat., Sulph., Thuja. 
 
 Calc, Petrol., Puis., Sulph. 
 
 Nux VOM. 
 
 Ars., Ipec, Lach., Petrol., Phos. 
 Sulph. 
 
 Bry., Puis., Sulph. 
 
 Opium. 
 
 
 Bry., Calc, Petrol., Puis. 
 
 Petroleum. 
 
 Nit. ac, Phos. 
 
 Nux vomica. 
 
 Phosphorus 
 
 Calc c, Chin., Kali, Kreos., 
 Lye, Nux v., Rhus., Sil., 
 Sulph. 
 
 Lachesis and Rhus. 
 
 Petrol., Rhus., Sulph. 
 
 Phos. AC. 
 
 China, Fer., Rhus., Verat. 
 
 Pulsatilla. 
 
 Asa f., Ant., Aur., Chin., Lach., 
 
 Asafcet., Bry., Nit. ac, Sep., 
 
 
 Lycop., Nit. ac, Rhus., Sep., 
 
 Thuja. 
 
 
 Sulph., Tart., Thuja. 
 
 
 Rhus. tox. 
 
 Arn., Bry., Calc, Con., Phos., 
 
 Bry., Phos., Phos. ac, Pulsat., 
 
 Sepia. 
 
 Phos. ac, Puis., Sulph. 
 
 Sulph. 
 
 
 Caust., Led., Merc, Puis., Sil., 
 
 Carb. v., Caust, Puis. 
 
 
 Sulph., Sulph ac. 
 
 
 Silicea. 
 
 Calc, Hep., Lye, Sulph. 
 
 Hep., Lach., Lye, Sep. 
 
 Spongia. 
 
 Aeon., Hepar-sulph. 
 
 Hepar sulph. 
 
 Sulphur. 
 
 Aeon., Ars., Cupr., Mere, Nit. 
 
 Aeon., Bell.,Cale,Cupr., Mere, 
 
 
 ac, Nux v., Puis., Rhus. 
 
 Nit. ac, Nux v., Puis., Khus., 
 Sep., Sil. 
 
 Thuja. 
 
 Nitric acid. 
 
 Nitr. ac, Puis. 
 
 Veratrum. 
 
 Ars., Chin., Cupr., Phos. ac 
 
 Ars., Arn., Chin., Cupr., Ipec. 
 
28 HOMOEOPATHIC 
 
 EXTERNAL APPLICATIONS. 
 
 Great difference of opinion still exists among homoeopathists in 
 relation to the extent, propriety and usefulness of external applica- 
 tions in the treatment of disease. Hahnemann himself regarded 
 them as extremely prejudicial, both in acute and chronic cases, 
 even when the applications were strictly homoeopathic to the disease; 
 and for the following reasons : (See Org. §§ 185 — 206.) 
 
 1. They are unnecessary. If the remedy is truly homoeopathic 
 to the morbid symptoms, the disease will be cured by its internal use 
 alone, if rightly managed. 
 
 2. They are deceptive. " For the simultaneous application of a 
 remedy internally and externally, in a disease where the principal 
 symptom is a permanent local evil, brings this serious disadvantage 
 with it — the external affection usually disappears faster than the in- 
 ternal malady, which gives rise to an erroneous impression that the 
 cure is complete, or at least it becomes difficult, and sometimes im- 
 possible, to judge whether the entire disease has been destroyed or 
 not by the internal remedy." 
 
 3. They are injurious. For if the local symptoms are not sup- 
 pressed, as they are likely to be by local applications, " they may 
 lead to the discovery of the homoeopathic remedy suitable to the en- 
 tire malady ; this remedy once discovered, the continued existence 
 of the local affection would show the cure was not yet perfected, 
 while its disappearance would prove that the evil had been extirpa- 
 ted to its very root, and the cure absolute." 
 
 Our own opinion, fortified by experience, is this : — If the disease 
 is highly acute, and the local symptoms very distressing, local rem- 
 edies, of a truly homoeopathic character, are always safe and bene, 
 ficial ; safe, because, being homoeopathic to the symptoms, they can 
 only act in harmony with nature ; and beneficial, because the symp- 
 toms in such cases are always sufficiently well pronounced, to render 
 any mistake in the selection of the proper curative agents unneces- 
 sary, while they often contribute greatly to the relief and comfort of 
 the patient. 
 
 On the other hand, in the treatment of chronic maladies, local 
 applications, as a general rule, are less necessary for the comfort of 
 
PRACTICE OF MEDICINE. 29 
 
 the patient, less promotive of recovery, and much more apt to be 
 attended by the evil consequences apprehended by Hahnemann. 
 Hence we seldom make use of them in diseases of long standing, 
 whether general or partial, but depend entirely upon internal treat- 
 ment, which alone is capable of producing permanent and satisfac- 
 tory results. 
 
 HOMOEOPATHIC REGIMEN. 
 
 Under this head we propose to point out, in a general way, the 
 several kinds of food, drink, and external influences, which are and 
 which are not allowable under homoeopathic treatment. It is evident 
 that as the homoeopathic dose is exceedingly minute, everything 
 should be excluded from the regimen, that is capable of exercising 
 any medicinal influence upon the patient, however small. Hence, 
 coffee, green tea, spiced chocolate, beer, wine, rum, gin, punch? 
 vinegar and other acids, spices, medicinal roots and herbs, fat meat, 
 especially pork, strongly seasoned viands and sauces, ice-cream and 
 pastry flavored, old cheese, rancid butter, pickles, ducks, geese, and 
 young veal, perfumery and other odorous preparations, as they al 
 act more or less medicinally, should be entirely prohibited during 
 treatment, and for some time afterwards. On the other hand, all 
 ordinary articles of diet, both solid and liquid, not included in the 
 above list, and not too highly seasoned, may be used with moderation, 
 at proper intervals. 
 
 In addition to the observance of suitable dietetic instructions, the 
 practioner should enforce proper hygienic regulations. Among these 
 may be mentioned, the avoidance of long-continued confinement in 
 close rooms, late hours, too much or two little sleep, unchaste habits, 
 the reading of sensational or obscene literature, excessive labor, 
 either bodily or mental, insufficient ventilation, sedentary or un- 
 healthy occupations, and, in fine, everything which can act injurious- 
 ly upon the health or retard the recovery of the patient. 
 
 Tobacco, in all its forms, not only antidotes homoeopathic medi- 
 cines, but, by lowering the tone of all the vital functions, greatly un- 
 dermines the health, producing dyspepsia, hemorrhages, cardialgia, 
 gastralgia, general debility, and many forms of visceral disease ; at 
 the same time it acts powerfully upon the brain and nerves, derang- 
 ing their action, and consequently the functions depending upon 
 
30 H0MCE0PATHIC 
 
 them. Hence, persons addicted to the excessive use of tobacco, 
 are almost always subject to palpitations of the heart, vertigo, head- 
 ache, weakness of the limbs, dimness of vision, loss of appetite, dis- 
 turbed sleep, and general nervous prostration. 
 
 Coffee and green tea also act in a similar manner, and if used 
 immoderately and in great strength, sometimes give rise to conse- 
 quences scarcely less pronounced, or less serious. Both of these 
 beverages contain nitrogen in large quantity, which overstimulates the 
 brain and nerves, producing sur-excitation of the senses, and followed, 
 sooner or later, by a corresponding depression of the nervous system, 
 giving rise to a large train of functional disturbances, and greatly 
 impairing the general health. Black tea, on the contrary, if pure, 
 is not injurious to homoeopathic preparations, and being far less 
 stimulating than the green, may be used in moderation, in most 
 cases, without injury ; but even this should be denied if it excites the 
 nerves of the patient, as it does of some very sensitive organizations, 
 especially when not accustomed to its use. 
 
 Instead of coffee and tea, water and fresh milk, or cocoa and 
 milk, may be used ; and in cases demanding increased nourishment, 
 clear milk, warm from the cow, is a beverage of the most wholesome 
 character, alike suited to children and to adults. Cocoa shells, also, 
 as well as pure chocolate, furnish a pleasant and refreshing beverage. 
 
 It follows that spirituous and malt liquors, as well as the 
 so-called galenical preparations of the apothecary, are exceedingly 
 pernicious, and should never be resorted to except in extreme cases; 
 and even then, none but the purest wine or brandy should be used, 
 greatly diluted, and in quantities so small as not to be followed by 
 any marked reaction. In cases demanding it, a teaspoonful or two 
 of sherry wine, or half that quantity of pure brandy, may be given in 
 broken doses, properly diluted, but its effects upon the system will 
 need to be carefully watched, and undue stimulation avoided. 
 
 The habitual use of spirituous liquors, even in moderate quanti- 
 ties, congests and inflames the lining membrane of the stomach, 
 weakens digestion, and impairs, to a greater or less extent, the vital 
 functions. Hence it sometimes becomes necessary in such cases, to 
 raise somewhat the general tone of the system before the beneficial 
 effects of medicines can be obtained. This can generally be best 
 
PRACTICE OF MEDICINE. 31 
 
 affected, by giving wine or brandy in small quantities, largely diluted, 
 being careful to observe the precautions above-mentioned. Persons 
 enfeebled by old age, also, sometimes require similar treatment, be- 
 fore the system will respond satisfactorily to the action of medicines. 
 This careful and judicious use of pure liquors, for medicinal pur- 
 poses, is a very different thing from the indiscriminate and almost 
 unlimited use of it under allopathic treatment, and still more, the 
 fearful abuse of it as a general beverage, which such practice has 
 tended to confirm. 
 
 As to malt liquors, though of undeniable benefit at first, in some 
 cases of emaciation and debility, especially during convalescence from 
 exhausting diseases, they are apt to derange the stomach, particu- 
 larly if the digestive organs are enfeebled, and, by congesting the 
 portal system, to increase the derangements and the weakness foi 
 which they are prescribed. They should, therefore, be used with 
 the greatest caution, and always tentatively, bearing in mind their 
 stimulating qualities, and their tendency to produce hepatic en- 
 gorgement. Nevertheless, to persons accustomed to their use, es- 
 pecially industrious laborers, we should not hesitate to allow a single 
 glass of pure beer, whenever such an amount of stimulation is not 
 otherwise contra-indicated. 
 
 Soda-water, when properly made and flavored, is a pleasant and 
 cooling beverage, acceptable to the stomach, and wholesome to the 
 system. Fresh sweet cider and lemonade are also pleasant drinks, 
 and not injurious during the heat of summer, if used in moderation ; 
 but, owing to their acid qualities, they should be strictly forbidden 
 while the patient is under homoeopathic treatment. 
 
 We have already indicated, in a general way, the various kinds 
 of solid food which may properly be allowed to convalescents, and 
 to a limited extent while under treatment; but preference should 
 always be given to such as are the most nourishing and easy of 
 digestion. 
 
 Fresh oysters are very easy of digestion, and so is wild game, 
 such as squirrels, quails, rail birds, rabbits and venison. Partridges, 
 wild ducks and common fowls, if not too old and tough, or too young, 
 are of comparatively easy digestion, but do not suit all stomachs. 
 Young and tender beef is always very digestible and nourishing, and 
 
32 HOMOEOPATHIC 
 
 stands at the head of every kind of animal food. Mutton is not 
 quite so easy of digestion as beef, but is very wholesome, and es- 
 pecially useful whenever there is any tendency to dysentery or 
 chronic diarrhoea. Veal is less easy of digestion than mutton, es- 
 pecially if very young, besides having a tendency to cause diarrhoea; 
 it should therefore be used very sparingly, particularly in the 
 summer season. Pork, from the fineness and closeness of its grain 
 and the amount of fat associated with it, is the most difficult of 
 digestion of all the meats, besides being more stimulating and less 
 nutritious. Its use should be totally interdicted to all but laborers ; 
 and the health of the people would be greatly benefited if it were 
 entirely banished from civilized life. 
 
 Scale fish, such as trout, perch, haddock, shad, bass, flounders, 
 whitefish, carp, blackfish, pike and codfish, when fresh, are easy of 
 digestion, and being rich in phosphorus, are well suited to consump- 
 tives, and persons suffering from nervous weakness. Eggs, also, are 
 very nutritious, and when properly cooked, are of easy digestion. 
 They should either be soft-boiled, poached, or scrambled. 
 
 Vegetable food, from the absence of nitrogen, is less stimulating 
 than animal food, and therefore better suited to the summer season, 
 hot climates, and plethoric persons. It is also better adapted to the 
 earlier stages of acute diseases, and, indeed, is the only kind of diet 
 that is generally admissable at such times. From its favoring a 
 gentle disposition, it should always be prescribed when the temper 
 is irascible and violent. Being less subject to putridity than animal 
 food, it is better suited to a scorbutic condition of the system ; but 
 on account of its greater tendency to cause acidity, flatulency and 
 stomachic weakness, it should be sparingly used in all cases likely to 
 be injuriously affected by such qualities. Graham bread, rye mush> 
 oat meal pudding, rice pudding, boiled grits, and stewed prunes and 
 peaches, are not only nourishing and easy of digestion, but are par- 
 ticularly adapted to a dry and feverish state of the system, especially 
 when attended with constipation. Farina, tapioca and sago are ex- 
 cellent articles of diet during the earlier stages of acute diseases, being 
 less stimulating than most other kinds of food, and better tolerated 
 by the stomach. 
 
PRACTICE OF MEDICINE. 33 
 
 The following dietetic regulations should be observed at all times, 
 whether in health or sickness : 
 
 i. No food is fit to be eaten that is not sound and fresh ; that is, free 
 from disease and decay. Rotten vegetables and putrid meat are 
 prolific sources of disease, and should always be rejected. 
 
 2. Food should be properly and sitfficiently cooked; that is, not too 
 highly seasoned, nor simply parboiled or watersoaked, but so cooked 
 as to leave it tender, juicy and nutritious. 
 
 3. // should always be eaten with deliberation, and well masticated ; 
 not bolted down in large masses, which is a very common cause of 
 dyspepsia, and the numerous ills connected with it. 
 
 4. Food should be taken into the stomach only at proper intervals. 
 The habit of eating at any and all times is very injurious to health. 
 The stomach needs rest ; and to get it not more than two or three 
 meals a day should be permitted. Invalids and valetudinarians 
 sometimes require to partake of food more frequently ; but in such 
 cases the quantity should be correspondingly diminished. 
 
 5. No one should ei>er eat to the point of satiety or repletion. When 
 the stomach is too much distended, digestion is slow and difficult ; 
 and disorder of both the stomach and bowels is not an unusual con- 
 sequence of indiscretion. 
 
 6. Lastly, and as a general rule, no one should eat exceptitig when 
 he is hungry, and should stop eating as soon as the sense of hunger is 
 relieved. This is a cardinal rule of dietetics, and should be observed 
 by every one who is desirous of maintaining the integrity of his 
 digestive organs unimpaired, or who aims to recover their tone and 
 efficiency after they have lost them. 
 
 MEDICAL NOMENCLATURE. 
 
 Besides being divided into acute and chronic, diseases are dis- 
 tinguished as either general, partial or local. This classification, 
 though not founded upon any definite and well-grounded pathological 
 distinction, possesses considerable convenience for purposes of refer- 
 ence, and we shall therefore avail ourselves of it in the description of 
 diseases. 
 
 That the distinction just mentioned is not well-founded, we have 
 only to instance the subject of fever, as treated in allopathic works, 
 where it is divided into as many different forms as there are types of 
 the disease, predominance of symptoms, or supposed causes for its 
 production. Thus we have inflammatory, typhous and typhoid fever, 
 fever beginning as sthenic or inflammatory, and ending as asthenic or 
 adynamic, intermittent, remittent and continued, cerebral, hepatic, 
 gastric, or gastro-enteric, hectic, and so on, almost ad infinitum; what 
 better illustration could we have of the absurdity of the old-school 
 method of treating diseases by names, instead of recognizing them 
 by their true distinctive characters — the symptoms — which is in fact 
 
 5 
 
34 HOMOEOPATHIC. 
 
 the only practical method of distinguishing them, as allopathists 
 themselves are compelled to admit, when they come to the consider- 
 ation of the special forms of disease. And yet, when we make use 
 of the only rational method of treating disease by symptoms, instead of 
 names, they hasten to cry out, absurd. Well may we respond, "O 
 consistency, thou art a jewel/" 
 
 We thus see, in marked contrast, not only the propriety of our 
 method of practice, but the absolute necessity that exists for studying 
 well the entire group of morbid symptoms in every individual case of 
 disease, and not from a few predominant symptoms that force them- 
 selves upon the attention of the most casual observer, adopt the 
 convenient but indefinite and unsatisfactory method of classifying 
 diseases under some of their many appellations, and then treating 
 them in the usual routine manner by name. This is, indeed, a very 
 convenient method for those who are too indifferent or too lazy to 
 study, and are only anxious, by pandering to the prejudices of the 
 multitude, to cover their ignorance under the cloak of learning. But 
 this course will neither satisfy the conscientious physician, nor will it 
 yield creditable results. Nothing short of a careful study and com- 
 parison of all the symptoms, will demonstrate the infinite variety of 
 diseased action, or enable the practitioner to adapt his remedies in- 
 telligently to its many forms, in conformity to the great and unerring 
 law of cure. 
 
 If, therefore, we shall so far yield to the common notions of 
 disease, as to describe some of its principal varieties under the 
 names by which they are generally known, we wish it to be distinctly 
 remembered that we do so only for the sake of convenience, and not 
 because we subscribe to the correctness of the nomenclature. Disease 
 cannot be correctly classified by any combination of technical terms. 
 It is correctly written only on the face of nature itself, by the multi- 
 plied and ever-varying symptoms which characterize it. Presumptious, 
 indeed, must that man be, whatever may be his claims to erudition, 
 who attempts to portray in words the multiform phases of disease, 
 and present them to us under the mantle of a learned nosology, as a 
 full and correct delineation of disease. For ourselves, we shall 
 attempt nothing of the kind. A few of the more prominent and 
 common forms will be described, so far as the aid of such lights as 
 recent pathology has shed upon them will permit; but we desire 
 emphatically to admonish the student, that a knowledge of disease 
 can by no means be obtained alone from books; and that the 
 highest use to which they can be applied, is to serve as guides to its 
 successful study at the bedside of the patient. 
 
PRACTICE OF MEDICINE. 35 
 
 CHAPTER I. 
 
 DISEASES OF THE ENCEPHALON. 
 
 PRELIMINARY OBSERVATIONS. 
 
 The cerebral affections which we propose to consider in 
 this chapter are those of a vascular, nervo-vascular, and in- 
 flammatory character — those which consist chiefly in a dis- 
 turbance of the mental functions will be reserved for another 
 place. 
 
 The former include anaemia and hyperaemia of the brain 
 and its membranes ; conditions the existence of which some 
 pathologists still regard as absurd and impossible, but which 
 we shall assume have been amply verified by abundant phy- 
 siological, clinical, and necroscopical evidence. 
 
 The question which formerly excited such acrimonious dis- 
 cussion, namely, whether the amount of blood in the cranial 
 cavity is always the same, has, we think, been satisfactorily 
 determined in the negative by recent physiological experi- 
 ments ; so that the existence of both cerebral anaemia and 
 hyperaemia is no longer a matter of doubt, but must be re- 
 garded as of frequent occurrence. 
 
 Before entering more fully upon the description of these 
 conditions,we shall introduce a couple of analytical tables em- 
 bracing the principal cerebral regions and sensations, together 
 with the remedies which, irrespective of other relations, are 
 chiefly indicated. 
 
36 
 
 TABLE IIL— CEREBRAL REGIONS. 
 
 Asafoetida 
 
 Belladonna 
 
 Bryonia 
 
 Cantharis 
 
 Causticum 
 
 Cina. 
 
 Digitalis 
 
 Drosera 
 
 Ignatia 
 
 Plumbum 
 
 Sabina 
 
 Aoid. Phos. 
 
 Alumina 
 
 argentum 
 
 cocculus 
 
 colchicum 
 
 phosphorus 
 
 RH 8 TOX. 
 
 Sabadilla 
 Sanguinaria 
 Spongia 
 Sulphur 
 
 Acid. mur. 
 
 Aconitum 
 
 Agaricus 
 
 Anacardium 
 
 Ant. crudum 
 
 Arnica 
 
 Camphora 
 
 China 
 
 Crocus 
 
 Euphrasia 
 
 Graphites 
 
 Hepar sulph. 
 
 Helleborus 
 
 Hyoscyamus 
 
 Kali carb. 
 
 Lachesis 
 
 Lycopodium 
 
 Natr. carb. 
 
 Nux vomica 
 
 Pulsatilla 
 
 Silicea 
 
 Spigelia 
 
 Stannum 
 
 Staphysagria 
 
 Thuja 
 
 Acid. nit. 
 
 Ambra 
 
 Argent. 
 
 Arnica 
 
 Asarum eu. 
 
 Capsicum 
 
 China 
 
 Colocynth 
 
 Crocus 
 
 Digitalis 
 
 Euphorb. 
 
 Iodium 
 
 Platina 
 
 Rhododen. 
 
 Sambucus 
 
 Sepia 
 
 Aconite 
 Ant. or. 
 asafoetida 
 Camphora 
 
 ClCUTA 
 ClNA 
 
 Cocculus 
 Cuprum 
 Merc. sol. 
 Petroleum 
 Ehus. tox. 
 Sec cor. 
 Spigelia 
 Spongia 
 Stramonium 
 
 Aurum 
 
 Baryta 
 
 Belladonna 
 
 Bryonia 
 
 Calcarea 
 
 Cannabis 
 
 Carb. veg. 
 
 Dulcamara 
 
 Drosera 
 
 Euphrasia 
 
 Ferrum 
 
 Helleborus 
 
 Hyoscyamus 
 
 Ignatia 
 
 Lachesis 
 
 Nux vom. 
 
 Plumbum 
 
 Pulsatilla 
 
 Sabina 
 
 Staphysagria 
 
 Sulphur 
 
 Verat. alb. 
 
 Aconite 
 
 Ant. cr. 
 
 Arnica 
 
 Arsenicum 
 
 Asafoetida 
 
 Asarum eu. 
 
 Belladonna 
 
 Bryonia 
 
 Camphora 
 
 China 
 
 Cina 
 
 Cocculus 
 
 Colocynth 
 
 Crocus 
 
 Digitalis 
 
 Drosera 
 
 Dulcamara 
 
 Glonoine 
 
 Helleborus 
 
 Hyoscyamus 
 
 Ignatia 
 
 Ipecac. 
 
 Mercurius 
 
 Natr. mur. 
 
 Nux vom. 
 
 Platina 
 
 Plumbum 
 
 Pulsatilla 
 
 Rhododend. 
 
 Sabina 
 
 Sepia 
 
 Silicea 
 
 Spigelia 
 
 Spongia 
 
 Staphysagria 
 
 Atomina 
 
 argentum 
 
 AURUM 
 
 Baryta 
 
 Capsicum 
 
 Cicuta 
 
 COFFEA 
 
 Gelseminum 
 
 Rhus. tox. 
 
 Verat. alb. 
 
 Ambra 
 
 Anacardium 
 
 Calcarea 
 
 Cannabis 
 
 Cantharis 
 
 Carb. veg. 
 
 Causticum 
 
 Chamomilla 
 
 Colchicum 
 
 Conium 
 
 Cuprum 
 
 Euphrasia 
 
 Ferrum 
 
 Graphites 
 
 Iodium 
 
 Kali carb. 
 
 Lycopodium 
 
 Opium 
 
 Phosphorus 
 
 Sambucus 
 
 Stannum 
 
 Sulphur 
 
 Zincum 
 
 China 
 
 Cimicifuga 
 
 Colchicum 
 
 Glonoine 
 
 Ignatia 
 
 Moschus 
 
 Nux vom. 
 
 Pulsatilla 
 
 Rhus tox. 
 
 Spigelia 
 
 Spongia 
 
 Aconite 
 
 Argent um 
 
 Asarum eu. 
 
 Belladonna 
 
 Bryonia 
 
 Camphora 
 
 Cannabis 
 
 Cantharis 
 
 Carb. veg. 
 
 Cicuta 
 
 Digitalis 
 
 Gelseminum 
 
 Hyoscyamus 
 
 Lycopodium 
 
 Merc sol. 
 
 Opium 
 
 Petroleum 
 
 Sanguinaria 
 
 Sabina 
 
 Stannum 
 
 Acid. phos. 
 
 Anacardium 
 
 Arnica 
 
 Asafoetida 
 
 Aurum 
 
 Baryta 
 
 Calcarea 
 
 Capsicum 
 
 Coffea cr. 
 
 Crocus 
 
 Cuprum 
 
 Drosera 
 
 Euphrasia 
 
 Helleborus 
 
 Ipecacuan. 
 
 Platina 
 
 Rhododend. 
 
 Sambucus 
 
 Staphysagria 
 
 Sulphur 
 
 Thuja 
 
 Verat. vir. 
 
 temples. vertex 
 
 Acid. phos. 
 Argentum 
 China 
 Rhus tox. 
 
 Aconite 
 
 Arnica 
 
 Asafcetida 
 
 Asarum eu. 
 
 Cannabis 
 
 Cantharis 
 
 Capsicum 
 
 Chamomilla 
 
 Cina. 
 
 Cocculus 
 
 Cuprum 
 
 Digitalis 
 
 Euphrasia 
 
 Helleborus 
 
 Hepar sulph. 
 
 Tgnatia 
 
 Lachems 
 
 tfHEUM 
 
 Rhododend. 
 
 Sabina 
 Spigelia 
 Spongia 
 Staphysagria 
 
 Acid. nit. 
 
 Agaricus 
 
 Alumina 
 
 Anacardium 
 
 Ant. crud. 
 
 Belladonna 
 
 Bryonia 
 
 Calcarea 
 
 Camphora 
 
 Conium 
 
 Opium 
 
 Phosphorus 
 
 Stannum 
 
 Ambra 
 
 China 
 
 Cimicifuga 
 
 Cocculus 
 
 Cuprum 
 
 Glonoine 
 
 Helleborus 
 
 Lachesis 
 
 Stramonium 
 
 Thuja 
 
 Verat. alb. 
 
 Acid. phos. 
 
 Arnica 
 
 Cina 
 
 Gelseminum 
 
 Iodium 
 
 Nux VOM. 
 
 Phosphorus 
 
 Spigelia 
 
 Aconitum 
 
 Anacardium 
 
 Ant. crud. 
 
 Argentum 
 
 Asafoetida 
 
 Asarum eu. 
 
 Aurum 
 
 Belladonna 
 
 Bryonia 
 
 Cannabis 
 
 Cantharis 
 
 Capsicum 
 
 Causticum 
 
 Coffea cr. 
 
 Colocynthia 
 
 Conium 
 
 Crocus 
 
 Euphrasia 
 
 Ferrum 
 
 Graphites 
 
 Ignatia 
 
 Ipecacuan. 
 
 Platina 
 
 Sabina 
 
 Sambucus 
 
 Sepia 
 
 Silicea 
 
 Spongia 
 
 Stannum 
 
 Staphysagria 
 
 Sulphur 
 
TABLE IV.— CEREBRAL SENSATIONS. 
 
 37 
 
 Aconitum 
 Arnicum 
 Belladonna 
 Bryonia 
 Calcarea 
 Gelsemin- 
 'lonoine 
 Helleborus 
 Ipecacuan 
 Lycopod 
 Merc- sol- 
 Nux vom- 
 Petroleum 
 Pulsatilla 
 Rhus tox- 
 Silicea 
 Sulphur 
 
 Alumina 
 
 Cantharis 
 
 China 
 
 Euphrasia 
 
 Ignatia 
 
 Sepia 
 
 Stannum 
 
 Stramonium 
 
 Verat- vir- 
 
 Acid nit. 
 
 Camphora 
 
 Causticum 
 
 Coffea cr. 
 
 Digitalis 
 
 Drosera 
 
 Dulcamara 
 
 Hyoscyamus 
 
 Nat. mur. 
 
 Phosphorus 
 
 Plumbum 
 
 Valeriana 
 
 PAIN.* 
 
 Aconitum 
 
 Alumina 
 
 Apis 
 
 Arnica 
 
 Belladonna 
 
 Baryta 
 
 Bryonia 
 
 Calcarea 
 
 Cantharis 
 
 Chamomil- 
 
 China 
 
 Cimicifuga 
 
 Coffea cr- 
 
 Colocynth- 
 
 Conium 
 
 Glonoine 
 
 Hyoscyam 
 
 Ignatia 
 
 Mux vom- 
 
 Opium 
 
 Silicea 
 
 Spigelia 
 
 Acid mur- 
 
 Ant- cru. 
 
 Arsenicum 
 
 Cocculus 
 
 Ipecacuan. 
 
 Lycopodium 
 
 Nat- carb- 
 
 Nat- mur. 
 
 Rhus tox- 
 
 Stramonium 
 
 Sulphur 
 
 Acid phos. 
 
 Crocus 
 
 Cuprum 
 
 Helleborus 
 
 Iodium 
 
 Lachesis 
 
 Mercurius 
 
 Plumbum 
 
 Sepia 
 
 Valeriana 
 
 Aconitum 
 
 Belladonna 
 
 Bryonia 
 
 Chamomil. 
 
 Cicuta 
 
 Carb- veg- 
 
 Conium 
 
 Digitalis 
 
 Dulcamara 
 
 Ferrum 
 
 Ipecacuan- 
 
 Lycopod- 
 
 Mercurius 
 
 Nux vom, 
 
 Pulsatilla 
 
 Phosphorus 
 
 Sabina 
 
 Spongia 
 
 Staphysag- 
 
 Silicea 
 
 Verat- alb- 
 
 Acid nit- 
 Acid phos- 
 Agaricus 
 Alumina 
 Arsenicum 
 Cactus 
 Camphora 
 China 
 Cimicifuga 
 Cocculus 
 Coffea cr- 
 Cuprum 
 Drosera 
 Glonoine 
 Helleborus 
 Hyoscyamus 
 Ignatia 
 Nat mur- 
 Opium 
 Petroieum 
 Plumbum 
 Spigelia 
 Stannum 
 
 Arnica 
 
 Asai'cetida 
 
 Cannabis 
 
 Crocus 
 
 Calcarea 
 
 Causticum 
 
 Euphrasia 
 
 Kali carb. 
 
 Platina 
 
 Sec. cor. 
 
 Stramonium 
 
 Sulphur 
 
 Thuja 
 
 * Tearing or 
 
 Stinging. 
 
 PRE88UKB. 
 
 Aconitum 
 
 Arnica 
 
 Belladonna 
 
 Bryonia 
 
 Calcarea 
 
 Capsicum 
 
 China 
 
 Cimicifuga 
 
 Nat- mur- 
 
 Nux vom- 
 
 Spigelia 
 
 Acid nit. 
 
 Acid phos. 
 
 Asafcetida 
 
 Asarum eu. 
 
 Arsenicum 
 
 Chamomilla 
 
 Cocculus 
 
 Ignatia 
 
 Ipecacuan 
 
 Petroleum 
 
 Pulsatilla 
 
 Sulphur 
 
 Valeriana 
 
 Acid mur, 
 
 Ambra 
 
 Argentum 
 
 Anacardium 
 
 Aurum 
 
 Camphora 
 
 Causticum 
 
 Carb. veg. 
 
 Cannabis 
 
 Capsicum 
 
 Cicuta 
 
 Cina 
 
 Coffea cr. 
 
 Crocus 
 
 Digitalis 
 
 Helleborus 
 
 Hyoscyamus 
 
 Iodium 
 
 Lachesis 
 
 Mercurius 
 
 Natr. carb. 
 
 Phosphorus 
 
 Platina 
 
 Rhododendron 
 
 Sepia 
 
 Silicea 
 
 Stannum 
 
 Staphysagrla 
 
 Zincum 
 
 Aconitum 
 
 Arnica 
 
 Belladonna 
 
 Bryonia 
 
 Cannabis 
 
 Conium 
 
 Gelsemin- 
 
 Glonoine 
 
 Lycopod- 
 
 Natrum 
 
 Nux vom- 
 
 Petroleum 
 
 Phosphor. 
 
 Rhus- tox- 
 
 Sec cor- 
 
 Acid nit. 
 
 Apis 
 
 Cactus 
 
 Calcarea 
 
 Camphora 
 
 Carb. veg. 
 
 Cocculus 
 
 Digitalis 
 
 Graphites 
 
 Ipecacuan. 
 
 Mercurius 
 
 Moschus 
 
 Nat. mur. 
 
 Opium 
 
 Pulsatilla 
 
 Spigelia 
 
 Staphysagria 
 
 Stramonium 
 
 Sulphur 
 
 Thuja 
 
 Verat. alb. 
 
 Ambra 
 
 Arsenicum 
 
 Baryta 
 
 Cannabis 
 
 Cantharis 
 
 Causticum 
 
 Chamomilla 
 
 China 
 
 Cicuta 
 
 Coffea cr. 
 
 Crocus 
 
 Cuprum 
 
 Drosera 
 
 Euphrasia 
 
 Helleborus 
 
 Hepar. sulph. 
 
 Hyoscyamua 
 
 Nitrum 
 
 Platina 
 
 Plumbum 
 
 Stannum 
 
 Zincum 
 
 RUSH OF BLOOD. 
 
 Aconitum 
 
 Belladonna 
 
 Bryonia 
 
 Cactus 
 
 Cannabis 
 
 China 
 
 Calcarea 
 
 Carb- veg 
 
 Colocynthis 
 
 Ferrum 
 
 Gelsemin- 
 
 Glonoine 
 
 Graphites 
 
 Hyoscyam. 
 
 Lycopod- 
 
 Mercurius 
 
 Nux vom- 
 
 Opium 
 
 Plumbum 
 
 Pulsatilla 
 
 Phosphorus 
 
 Rhus tox- 
 
 Sepia 
 
 Silicea 
 
 Sulphur 
 
 Spongia 
 
 Stramon. 
 
 Verat- vir- 
 
 Acid. nit. 
 
 Agaricus 
 
 Alumina 
 
 Ambra 
 
 Apis 
 
 Arsenicum 
 
 Camphora 
 
 China 
 
 Cocculus 
 
 Coffea cr. 
 
 Cuprum 
 
 Drosera 
 
 Helleborus 
 
 Hyoscyamus 
 
 Ignatia 
 
 Lachesis 
 
 Nat. mur. 
 
 Opium 
 
 Piumbum 
 
 Ranunculus 
 
 Ratanhia 
 
 Senega 
 
 Senna 
 
 Tartarus 
 
 Valeriana 
 
 Verat. alb. 
 
 Zincum 
 
 Ant. crud. 
 
 Arnica 
 
 Baryta 
 
 Cantharis 
 
 Causticum 
 
 Digitalis 
 
 Iodium 
 
 S^phyMgrl* 
 
38 DISEASES OF THE ENCEPHALON. 
 
 ANJEMIA OF THE BRAIN * 
 
 Cerebral Anaemia is a disease of such comparatively rare 
 occurrence, that it would scarcely merit separate considera- 
 tion, were it not that the similarity of its symptoms to those 
 of cerebral hyperaemia renders it liable to be mistaken for 
 that condition — an error of very grave importance in diseases 
 of the brain, even under homoeopathic treatment. 
 
 The disease consists either in a diminished supply of blood 
 circulating in the brain, {hyposmia vel ancemla stride sic dic- 
 tus,) or in the cerebral circulation being deficient in haema- 
 tine, (kydrcemia,) or in both, {liypcemia et hydtcemia) The first 
 may be referred to whatever cause impedes the flow of blood 
 to the brain, to contraction of the cerebral vessels by spasm 
 or otherwise, or by any other condition whereby the inter-cra- 
 nial space is lessened ; the second, to the various causes which 
 produce impoverishment of the blood, and give rise to general 
 anaemia ; and the last to sanguineous losses, which when con- 
 siderable always produce both paucity and poverty of the 
 circulating fluid. 
 
 SYMPTOMS. These vary considerably according as the anae- 
 mia is gradually or suddenly produced. When it occurs grad- 
 ually, the symptoms at first are similar to those of the op- 
 posite condition of hyperaemia, namely : great excitement 
 of the cerebral functions, headache, flashes of light, confu- 
 sion of sight, humming in the ears, vertigo, loss of memory, 
 and sometimes convulsions. At a later period, if the disease 
 goes on unchecked, symptoms of paralysis may supervene. 
 
 When, on the other hand, cerebral anaemia sets in suddenly, 
 as in flooding, traumatic haemorrhages, and other rapid losses 
 of the sanguineous fluid, the symptoms presented are those of 
 syncope, namely : loss of consciousness, of the senses, and of 
 voluntary motion, accompanied with a retarded pulse and res- 
 piration, and frequently with slight convulsions. 
 
 DIAGNOSIS. The greatest care is necessary, especially with 
 children, to distinguish this state from that of cerebral con- 
 gestion. When caused by debilitating losses, and especially 
 
 * See American Horn. Observer, vol. vii., p. 55. 
 
ANEMIA OF THE BRAIN. 39 
 
 when associated with general anaemia, or with an impaired 
 state of the assimilative functions, the history of the case, 
 together with the fact that the symptoms of cerebral anaemia 
 generally diminish or disappear in the recumbent position, 
 will serve to distinguish it from hyperaemia of the brain. 
 
 However induced, cerebral anaemia is always attended with 
 great danger to life, especially with children, though when 
 early recognized, and promptly and correctly managed, the 
 disease, even in its acute form, will generally yield to the 
 following 
 
 TREATMENT. In simple syncope,all that is generally requir- 
 ed in the way of treatment is, to lay the patient in a horizontal 
 position, and thus favor a return of blood to the brain If, 
 however, the fainting is of frequent recurrence, it will com- 
 monly be found to depend upon some other affection, against 
 which the treatment will need to be specially directed. 
 
 THERAPEUTIC INDICATIONS. 
 
 Arsenicum. Violent headache, humming in the ears, ob- 
 scuration of sight, particularly on raising the head, vertigo, 
 loss of consciousness, pale, chlorotic colored face, great weak- 
 ness and prostration, impaired memory, syncope. 
 
 This remedy is eminently homoeopathic to cerebral anae- 
 mia ; and is well suited to cases which are complicated or ag- 
 gravated by the injudicious use of Ferrum. Care should be 
 taken not to use Arsenicum low in this disease. I have gen- 
 erally obtained the best results from the 30th potency. 
 
 Calcarea carb. Throbbing, hammering headache, accom- 
 panied with great physical prostration, paleness of the face, 
 cold hands and feet, and mental weakness, vertigo, loss of 
 consciousness, frequent fainting fits, suspension of the senses, 
 palpitation of the heart, shortness of breathing, 
 
 This remedy is well suited to general as well as cerebral 
 anaemia. 
 
 Camphora. Vanishing of the senses, vertigo, violent throb- 
 bing headache, embarrassment of the circulation and respir- 
 ation, pale cold skin, spasms and convulsions. 
 
40 DISEASES OF THE ENCEPHALON. 
 
 Hahnemann says of this remedy : "Vertigo, loss of con- 
 sciousness, and coldness of the body, appear to be primary 
 treatment of a dose of Camph., and point to a diminished 
 afflux of the blood to those parts which are distant from the 
 heart ; whereas, the rush of blood to the head, heat in the 
 head, &c, are symptoms denoting a reaction of the vital pow- 
 ers, just as forcibly as the former symptoms denoted their 
 diminished action." 
 
 The action of this remedy is so evanescent as to require it 
 to be given in rapidly repeated doses , it is therefore best 
 suited to those cases of cerebral anaemia which take the form 
 of syncope, especially when caused by the loss of blood. 
 
 China. Headache, especially in the morning, mental weak- 
 ness, vertigo, especially on raising the head, obscuration of 
 sight, humming in the ears, fainting fits, pale cold face, cold- 
 ness of the hands and feet, great debility, with tingling, trem- 
 bling or twitching of the muscles and limbs. 
 
 This remedy is best suited to those cases of anaemia caused 
 by the excesssive loss of animal fluids. 
 
 Cina. Violent headache,which increases by reading or men- 
 tal effort, dizziness, obscuration of sight, faintness, which is 
 relieved by lying down, paleness of the face, convulsions, par- 
 alytic lameness. This remedy is especially suited to chil- 
 dren, particularly where there is any suspicion that the symp- 
 toms are caused by verminous irritation. 
 
 Ipecacuanha. Violent headache, excited and aggravated by 
 stooping, vertigo with temporary loss of consciousness, pale 
 face, cold hands and feet, nausea, with or without vomiting, 
 sweet or bitter taste, convulsive twitchings of the limbs. 
 
 This remedy, also, is well adapted to children, and likewise 
 to cases resulting from the loss of animal fluids. 
 
 Nux Vomica. Headache, especially in the morning, men- 
 tal weakness, vertigo, with obscuration of sight and whizzing 
 in the ears, loss of consciousness, syncope, sleeplessness, fright- 
 ful dreams, constipation, coldness of the whole body, spasms 
 and convulsions. 
 
 This remedy is best suited to cases attended with constipa- 
 tion, and like Arsenicum should always be used high. 
 
CEREBRAL HYPEREMIA. 4 1 
 
 Secale Cor. Vertigo, headache, loss of consciousness, men- 
 tal weakness, hammering and buzzing in the ears, obscuration 
 of sight, paleness of the face, diarrhoea, metrorrhagia, spasms 
 and convulsions. 
 
 This remedy is particularly applicable to cases of cerebral 
 anaemia caused by colliquative alvine evacuations, or by 
 flooding. 
 
 Veratrum alb. Headache aggravated by movement, espe- 
 cially stooping, giddiness, vanishing of the senses, wakeful- 
 ness, fainting fits, general coldness, violent vomiting and purg- 
 ing, spasms and convulsions, followed or attended by paralytic 
 weakness. 
 
 This remedy is suited to similar conditions to those for 
 which Secale cor. is indicated, but with this difference, that 
 while the latter is better adapted to cases of cerebral anaemia 
 depending upon uterine haemorrhage, Veratrum alb. is better 
 suited to such cases as depend on losses occasioned by ex- 
 cessive alvine discharges. 
 
 For other remedies employed in this disease, consult Ta- 
 bles V. and XII * 
 
 Diet and Regimen. The diet, particularly in cases occa- 
 sioned by loss of animal fluids, should be light and easily di- 
 gestible, liberal in quantity, and nutritious. In most cases the 
 moderate use of malt liquors may be allowed, but strong al- 
 coholic drinks are unnecessary, and should be avoided. 
 
 CEREBRAL HYPERJEMIA-CONGESTION OF THE BRAIN.f 
 
 Hyperaemia of the the brain is either active or passive. 
 
 Passive Hyperemia is the result of mechanical or other 
 causes interfering with the return of blood from the brain, 
 producing over-distension of its vessels, and consequent de- 
 pression of its functions. 
 
 Symptoms. Its characteristic symptoms are : coldness, es- 
 pecially of the head, from enfeebled circulation, impeded res- 
 piration, a sense of weight and fullness of the head, produc- 
 ing more or less stupor or drowsiness, vertigo, impaired vision, 
 lividity, or else undue paleness of the lips and face, nausea, 
 and sometimes vomiting. 
 
 * See American Horn. Observer, vol. vi., p. 556 ; vol. vii., p. 295. 
 t See American Horn. Observer, vol. ii., p. 51. 
 6 
 
42 THERAPEUTIC INDICATIONS. 
 
 Treatment. The treatment of passive congestion consists 
 in removing, as far as possible, the causes which produce it 
 Rest, both physical and mental, and the avoidance of every- 
 thing calculated to disturb the circulation, such as excess in 
 eating and drinking, are of special importance in every case, 
 and should be carefully observed. 
 
 Active Hyperemia of the brain is more common than the 
 variety just described, and is sometimes serious and even fa- 
 tal; but it derives its chief importance from being the ordin- 
 ary precursor of meningitis, hydrocephalus, and cerebral apo- 
 plexy. It is generally characterized by one or more of the 
 following 
 
 SYMPTOMS. High excitement of the cerebral functions, 
 vertigo, headache, delirium, morbid vigilance, or its opposite, 
 stupor or drowsiness, confusion of mind, loss of memory, feel- 
 ing of weight and fullness in the head, roaring and buzzing in 
 the ears, confusion of sight, and other evidences of deranged 
 vision, nausea and vomiting, and in some cases spasms and 
 convulsions, or the opposite condition of muscular weakness 
 and paralysis. 
 
 ETIOLOGY. The chief predisposing causes of cerebral hy- 
 peremia are : overrichness of the blood, or a plethoric condi- 
 tion of the system,the sanguineous temperament, the cessation 
 of growth, and the change of life. Among the more common 
 exciting causes are : exposure to heat and cold, suppressed 
 eruptions, rheumatism and gout, excess in eating and drink- 
 ing, determination of blood to the brain, excessive mental la- 
 bor, moral emotions, excitement of the passions, and mechan- 
 ical injuries. 
 
 Treatment. As in passive congestion of the brain,the first 
 thing to be done is, as far as possible, to remove or lessen the 
 exciting cause. This of itself will frequently produce entire re- 
 lief. Hence, all excess in eating and drinking, the excitement 
 of the passions, mental and bodily labor, and everything cal- 
 culated to excite the circulation, or affect the mind, should be 
 carefully avoided. 
 
 THERAPEUTIC INDICATIONS. 
 
 Aconite. Headache, with fullness and heaviness, as from a 
 weight, throbbing and piercing pains in ^the head, forehead 
 and temples ; heat and redness of the face and eyes, excess- 
 
CEREBRAL HYPEREMIA. 43 
 
 ive photophobia, flashes of light, roaring in the ears, tempo- 
 rary blindness, vertigo, aggravation of pains by movement, 
 more or less relief in the open air. 
 
 Aconite though generally inferior to Belladonna in cerebral 
 hyperaemia, is perhaps the best remedy for that condition when 
 caused by violent emotions, such as anger or fright. 
 
 Arnica. Heat and burning in the head, with coldness of 
 the body, throbbing headache in the forehead and temples, 
 increased by warmth or exercise, nausea and vomiting, verti- 
 go, delirium, loss of consciousness, tendency to apoplexy. 
 
 Arnica is always the best remedy for congestion of the 
 brain of a traumatic origin, or when produced by mechanical 
 violence, such as falls, blows, etc. 
 
 Belladonna* Sense of weight and heaviness in the head, 
 with painful stitches, vertigo, delirium, loss of consciousness, 
 redness of the face and eyes, roaring and humming in the 
 ears, dilation or contraction of the pupils, morbid vigilance,or 
 its opposite, stupor, great sensitiveness to light and noise, 
 spasms and convulsions. 
 
 This is by far the best general remedy for cerebral hyperae- 
 mia, especially for children. 
 
 Bryonia. Compressive pain in the head, especially in the 
 morning, pain in both temples, pressing outwards, photopho- 
 bia, buzzing in the ears, intolerance of light and noise, pain in 
 the head increased or caused by stooping, bleeding of the 
 nose, drowsiness during the day and disturbed and unrefresh- 
 ing sleep at night, startings in sleep, with twitchings in the 
 facial muscles, skin alternately hot and moist, nausea or vom- 
 iting, constipation. 
 
 This remedy is especially indicated when the above symp- 
 toms are unrelieved by Aconite or Belladonna. 
 
 Coffea cruda. Wakefulness at night; great nervousness and 
 exaltation of the senses ; heat in the head and face, flushed 
 face and cold feet; bleeding from the nose; buzzing in the ears; 
 diarrhcea. 
 
 Coffea is well suited to infantile cases of cerebral conges- 
 tion, especially when caused by teething or diarrhcea. 
 
 Gelseminum sempervirens. \ Headache,extending from occi- 
 put to root of nose,dull,pressive and stupefying; vertigo; dim- 
 
 * See Amer^Hom. Observer, vol. ii.Zp.143; also new series ,vol. i., p. 384. 
 t See American Horn, Observer, vol. ii., p. 164.J 
 
44 THERAPEUTIC INDICATIONS. 
 
 ness of vision; roaring in the ears; diplopia; amaurosis; sensi- 
 tiveness to light; depression of spirits alternating with mirth- 
 fulness; incoherency of thought, drowsiness, or its opposite, 
 morbid vigilance. 
 
 Gelseminum is an efficient remedy in cerebral congestion 
 caused by teething, mental excitement, sunstroke and cata- 
 menial suppression. 
 
 Mercurius. Sensation of great pressure and fullness in the 
 head, as though it would burst ; feeling as though the brain 
 was compressed by an iron band ; great anguish and restless- 
 ness, especially at night; pains in the head of a boring, tear- 
 ing, shooting character ; lachrymation and burning of the 
 eyes ; buzzing in the ears, with hardness of hearing ; vertigo. 
 
 Mercurius is particularly applicable to rheumatic, arthritic 
 and syphilitic cases. 
 
 Nux Vomica. Cephalalgia, with nausea and vomiting; 
 heaviness and confusion of the head ; soporose condition, with 
 a tendency to apoplexy, or the opposite condition of wake- 
 fulness ; burning of the eyes; intolerance of light, especially 
 in the morning; altered vision; ringing and roaring in the ears; 
 vertiginous intoxication and cloudiness. Symptoms aggra- 
 vated by eating, exercising in the open air, and by coffee. 
 
 Nux vomica is particularly suitable in such cerebral con- 
 gestions as are caused by excessive mental labor, by the hab- 
 itual use of intoxicating liquors, and by sedentary modes of 
 life. 
 
 Opium. Coma, with apoplectic symptoms ; stertorous 
 breathing, confusion of the intellect, and sense of heaviness 
 and pressure within the head, or the opposite condition of 
 sleeplessness, with delirium, throbbing of the cerebral arte- 
 ries, redness of the face, scintillations before the eyes, hum- 
 ming in the ears, spasms, convulsions and paralysis. 
 
 Opium is particularly indicated in those cases of cerebral 
 hyperemia characterized by symptoms of depression, such as 
 stupor, stertorous breathing, slow pulse, slow respiratory 
 movement, and dark, livid redness of the face, with coldness 
 and paleness of the rest of the body. It is also particularly 
 useful in congestions caused by fright or debauchery. 
 
 Pulsatilla. Drowsiness in the daytime, and sleeplessness 
 and great restlessness at night; vertigo; confusion of the head; 
 
CEREBRAL HYPEREMIA. 45 
 
 oppressive, beating headache; red, bloated face; fiery circles 
 before the eyes; diplopia; buzzing in the ears; bitter, bilious 
 taste in the mouth; nausea and vomiting. 
 
 Pulsatilla is most suitable to cases of cerebral congestion 
 occurring in young females, especially when caused by de- 
 rangement of the catamenia, It is also well adapted to cases 
 occasioned or aggravated by a disordered stomach, or by a bil- 
 ious condition of the system. 
 
 Rhus tox. Heavy, reeling headache; shaking or wavering 
 sensation in the brain, especially when walking, vertigo when 
 lying down; red and burning, or pale and puffy face; drowsi- 
 ness in the daytime and restlessness at night. 
 
 This remedy is applicable to such cases as arise from, or 
 are associated with acute articular rheumatism, and also to 
 cases caused by exposure to cold, or to getting wet and 
 chilled. 
 
 Veratrum viride. * Violent throbbing headache, heat and 
 fullness in the head, with throbbing of the cerebral vessels, 
 throbbing of the carotids, vertigo, flushed face, ringing in the 
 ears, double vision, sensitiveness to light and sound, derange- 
 ment of the stomach, palpitation of the heart, oppression of 
 breathing, weakness and diminished sensation in the limbs, 
 with spasms and tendency to paralysis. 
 
 Veratrum vir. is one of the most powerful and efficient rem- 
 edies for cerebral congestion, but nevertheless it requires to be 
 used low to be effective. Its sphere of usefulness is similar to 
 that of Belladonna. 
 
 Diet and Regimen. The diet should be plain and unstim- 
 ulating ; hence, every form of animal food, rich, or high-sea- 
 soned dishes, coffee, and other stimulating drinks, should be 
 carefully avoided. Moderation in eating and drinking, with 
 regular habits, out-door exercise, bathing, early rising and 
 cheerfulness, will facilitate recovery, and, so far as practica- 
 ble, should be observed in all cases. 
 
 For other remedies which may sometimes be found suita- 
 ble, see the following table ; also consult the therapeutic indi- 
 cations and tables under the head of Cephalalgia. 
 
 * See American Horn. Observer, vol. vii., p. 55. 
 
46 
 
 TABLE V. 
 
 d s 
 
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 X 
 
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 3 
 
 ti 
 
 S 
 
 
 
 
 
 
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 -d 
 
 0) 
 
 a 
 
 3 
 
 S <2 
 
 « S5 
 
 S ? £ £ 
 
 - _, _ _ 
 
 bo rt bo 
 
 •S § .2 
 
 H W H 
 
 a a> 
 
 d H » 
 
 MS 
 
 s s 
 
 a a 
 
 M Ph W « 
 
 « « Pw Pm 
 
 ► 
 
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 fs 
 
 o 
 
 
 
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 ^3 
 O 
 
 3 
 
 32 
 
 H 
 
 CO 
 
 P-l PL, 
 
 2 2 2 S 
 
 to to o 
 
 a -2 s 
 
 s I a 
 
 S * 0) 
 
 d m n 
 
 PQ Pi P-. 
 
 * g? 
 
 Ph <J 
 
 g? I 
 
 to to 3 c° 
 
 d S3 ^ 
 
 to to £ 
 
 G fl d 
 
 >^ 3 2 to 
 
 fl <l <) Pk « 
 
 2 -& ft 2 *C 2 
 
 □ T: -r-< r« t? "-• 
 
 O fi 
 
 o -g 
 
 6 3 
 
 P-. p-i 
 
 2 © 
 
 <J PQ 
 
 PQ O 
 
 
 3 
 
 I 
 
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 3 
 
 52 
 
 a 
 id 
 
 
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 X 
 
 d 
 
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 d 
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 g3 
 
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 02 
 
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 ■3 
 
 cc 
 
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 a 
 
 ft 
 
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 B 
 
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PRACTICE OF MEDICINE. 47 
 
 VERTIGO-STUPOR-INSOMNIA. 
 
 These morbid phenomena of the brain are frequently mere- 
 ly isolated symptoms, depending upon cerebral conditions the 
 pathology of which it is not always easy to settle, yet it is 
 often of the greatest importance to do so. We shall endeavor 
 in this article to point out the chief diagnostic signs by which 
 the several conditions in question may generally be satisfac- 
 torily determined. 
 
 i. Vertigo, or giddiness, like cephalalgia, is generally 
 symptomatic of some affection of the brain or its membranes, 
 of which it is sometimes the chief indication ; at other times 
 it is associated with disorder of the stomach, or with other 
 
 Symptoms, of which the following are the most promi- 
 nent : headache, more or less violent, in the temples and fore- 
 head, aggravated by stooping, coughing, and mental exercise; 
 buzzing or roaring in the ears, vanishing of the senses, op- 
 pression of breathing, nausea, indigestion, constipation, pulsa- 
 tion of the vessels of the head and neck, anxious expression 
 of the countenance, which is pale and bloated or red and 
 turgid, drowsiness during the day, and interrupted and unre- 
 freshing sleep at night. 
 
 DIAGNOSIS. Atlantic vertigo generally attacks the patient 
 in the morning, is aggravated by exercise, especially in the 
 open air, and is benefited by rest, particularly in the recum- 
 bent position, and by food and stimulants. Hypercemic ver- 
 tigo, on the other hand, seldom occurs in the morning, is of- 
 ten ameliorated by persevering exercise and is increased by 
 mental labor, stimulating food and drinks, and the recumbent 
 position. 
 
 Etiology. * The predisposing causes of anaemic vertigo 
 are : mechanical obstructions, contraction or spasm of the 
 cerebral vessels and organs, loss of animal fluids, etc. The 
 chief predisposing cause of hyperaemic vertigo, on the con- 
 trary, is a plethoric condition of the system, with a redun- 
 dancy of blood in the cerebral vessels. The exciting causes 
 
 * See American Horn. Observer, vol. viii., p. 284 et seq. 
 
48 STUPOR — INSOMNIA. 
 
 are : over-indulgence in eating and drinking, the free use of 
 spirituous and malt liquors, coffee, and other stimulating bev- 
 erages, excessive mental exercise, grief, indulgence of the pas- 
 sions, sedentary occupations, etc. 
 
 Treatment. This, of course, should correspond with the 
 pathological condition of the cerebral vessels, and is there- 
 fore identical with that for Ancemia and Hypercemia of the 
 Brain (which see); consult also Table XII., and the several 
 diseases of which this is a characteristic symptom. 
 
 DIET AND Regimen. In anaemic vertigo we should pre- 
 scribe a nourishing diet, moderately stimulating drinks, and 
 mental and bodily repose ; while in hyperaemic vertigo, the 
 patient should rise early, take daily exercise in the open air, 
 make free use of the flesh brush, observe regular habits, live 
 sparingly, and carefully abstain from the use of every kind of 
 stimulant. 
 
 2. Stupor, or morbid drowsiness, is a condition of the 
 brain which closely resembles natural sleep, but differs from 
 it in being far less under the control of the patient's will. It 
 is of every degree of intensity, from slight drowsiness to 
 complete coma, in which consciousness is entirely lost. Press- 
 ure upon the cerebral substance always produces it, and hence 
 it is generally referred to that cause ; but careful investiga- 
 tion shows that, like vertigo, it may depend upon exactly op- 
 posite pathological conditions, being found associated with 
 both depression and exaltation of the cerebral functions— 
 that is to say, with both anaemia and hyperaemia of the brain 
 and its membranes ; hence, the diagnosis, etiology and treat- 
 ment of this condition are similar to those of the affection 
 just described. 
 
 3. Insomnia, or sleeplessness generally results from irrita- 
 tion or over-excitement of the brain, and, as we have seen, is 
 a prominent symptom of the hyperaemic condition of that 
 organ. Certain stimulants, such as coffee and tea, exciting 
 news, joy, hope, etc., are sufficient to produce it in some indi- 
 viduals ; while the sudden withdrawal of alcoholic stimulants 
 to which the patient has long been accustomed, furnishes a 
 
CEPHALALGIA— HEADACHE. 49 
 
 striking example of its occasional dependence upon the op- 
 posite condition of nervous and vascular depression. The 
 same symptom is also frequently observed in cases of great 
 general debility, where depression rather than exaltation of 
 the cerebral functions is the apparent cause; Insomnia, there- 
 fore, requires similar discrimination in treatment to that re- 
 quired for vertigo and stupor ; indeed, there is in these affec- 
 tions such a striking resemblance to each other in their path- 
 logical conditions, as well as in their causes and associated 
 symptoms, that notwithstanding the opposite character of the 
 effects, the treatment required for each is similar and often 
 identical. * See Cephalalgia, Cerebral A nccmia and Hypere- 
 mia, and the corresponding tables. 
 
 CEPHALALGIA-HEADACHE. 
 
 Headaoh.9 is seldom an independent affection, but is gen- 
 erally symptomatic of some other disease. Sometimes it de- 
 pends upon derangement of the stomach, constituting what is 
 called sick headache ; at others it is associated with hepatic 
 disorder, constituting bilious headache ; and at others, it is 
 symptomatic of some intestinal, renal, uterine, cerebral or 
 spinal affection. The most opposite conditions of the circu- 
 lation produce it, such as active and passive congestion, ana> 
 mia,or plethora. So, also, it may depend upon nervous irrita- 
 tion, or nervous depression. Sudden cold, suppressed erup- 
 tions, severe mental labor, excess in eating and drinking, 
 rheumatism and gout, determination of blood to the head, 
 and external injuries, are among the more common causes of 
 the affection, and require to be considered in the treatment. 
 Errors of diet, also, frequently produce it, as well as the vari- 
 ous mental emotions, such as anger, grief, fright, anxiety, 
 chagrin, and even joy itself. There are also nervous and hys- 
 teric headaches, which are frequently symptomatic of uterine 
 derangement'; but these are sometimes dependent only upon 
 functional disorder of the nervous system. 
 
 Treatment. Most headaches may be readily cured by 
 the removal of the cause, and by quietude. Thus, if caused 
 
 * See American Horn. Observer, vol. iii., p. 474. 
 7 
 
50 THERAPEUTIC INDICATIONS. 
 
 by watching or by mental labor, simple rest is all that is re- 
 quired. If caused by a derangement of the stomach, absti- 
 nence from food for a short period will relieve it. So, also, if 
 coffee, beer, wine, or other drink, is the exciting cause, of 
 course it should be laid aside, or medicine will do but little 
 good. 
 
 THERAPEUTIC INDICATIONS.* 
 
 Aconite. Compressive and stupefying pains, with a sensa- 
 tion of fullness and heaviness in the head ; throbbing and 
 piercing pains in the forehead and temples, congestive head- 
 ache, with heat and redness of the face, ringing in the ears, 
 and redness, smarting or burning of the eyes ; vertigo, with 
 nausea, especially when stooping, suddenly rising, or moving 
 the head; determination of blood to the head, with throbbing 
 of the vessels of the neck, rapid pulse, and burning heat of 
 the face and scalp. Aggravation of the pains from move- 
 ment ; amelioration in the open air. 
 
 Aconite is a useful remedy for catarrhal, rheumatic and 
 nervous headaches, also for those arising from determination 
 of blood to the head. {Cerebral Congestion) 
 
 Belladonna. Intense pain in the forehead ; feeling of full- 
 ness and pressure in the head, as though it would burst; vio- 
 lent throbbing and sensation of fluctuation within the head, 
 lacerating pains over the eyebrows; undulating shocks, extend- 
 ing from before backwards, and to either side; heaviness of 
 the head, producing a feeling of intoxication ; rush of blood 
 to the head, with beating of the carotids, redness of the eyes, 
 and buzzing in the ears; excessive sensibility to light and noise 
 or clouded vision, with vertigo. {Congestive Headache) Ag- 
 gravation of the symptoms by stooping ; partial relief by ly- 
 ing down. 
 
 Belladonna is particularly applicable to cases of congestive, 
 catarrhal and arthritic headaches, especially when occurring 
 in females, and persons of highly sensitive organizations. 
 
 Bryonia. Burning, beating headache, especially in the 
 morning and after meals; rush of blood to the head, with feel- 
 
 * See American Horn. Observer, vol. viii., p. 33, et seq. 
 
PRACTICE OF MEDICINE. 51 
 
 ing of compression, darting pains in the head, especially on 
 one side ; jerking, shooting and drawing pains through the 
 head, sometimes with nausea or vomiting ; pain in both tem- 
 ples, with pressure from within outwards ; heat and congestion 
 in the head; with soreness of the scalp, aggravation by move- 
 ment. 
 
 Bryonia is most useful in those cases in which constipation 
 is the principal cause of the headache. 
 
 Calcarea carb. Semi-lateral headache, with nausea and 
 eructations ; throbbing, beating, or pressing pains in one side 
 of the head, or in the forehead ; drawing, cramp-like pain in 
 the top of the head, with coldness of the forehead, headache 
 every morning ; aggravation by study, spirits, exercise, and 
 mental emotion. 
 
 Especially suited to scrofulous subjects. 
 
 Chamomilla. Oppressive, drawing headache in one side, 
 with redness of one cheek and paleness of the other ; dull, 
 heavy, throbbing headache, with hot perspiration of the scalp; 
 nervous and hysteric headaches ; also, headaches caused by 
 cold, or associated with catarrhal affections. 
 
 Especially adapted to irritable children. 
 
 China. Lacerating, darting, cutting, hammering, conges- 
 tive headaches, especially when caused by debility, or by loss 
 of fluids; hemicrania, with soreness of the scalp; aggravated 
 by drafts of air, movement, or contact. 
 
 Cimicifuga. Throbbing and pressing pains in all parts of 
 the head, especially the occiput and vertex, and generally as- 
 sociated with pain in the back and along the spine ; feeling of 
 extreme fullness within the cranium, as though the skull would 
 burst. 
 
 Adapted to weak, nervous, hysterical females, especially 
 when the catamenia are deranged ; also, to headaches caused 
 by a debauch, or by excessive study. 
 
 Glonoine. * Throbbing headache in the forehead, vertex and 
 occiput; stitching pains in the temples, headaches arising from 
 suppression of the menses, from exposure to the sun, or from 
 rush of blood to the head, especially when characterized by 
 redness of the face and eyes. 
 
 * See American Horn. Observer, vol. x. ; p. 477. 
 
$2 THERAPEUTIC INDICATIONS. 
 
 Ignatia. Paroxysmal headache of a congestive character; 
 beating, hammering, or pulsating headache, attended by nau- 
 sea, obscurity of vision, photophobia, or frequent micturition; 
 also, by soreness of the scalp and clavus. Pains are aggrava- 
 ted by coffee, wine, tobacco, noise, or mental emotion. 
 
 Ignatia is particularly suitable for pale, irritable, hysterical 
 females,especially in cases of hemicraniaor megrim; also,when 
 the pain is limited to a particular spot, with the sensation as of 
 a nail driven into the head. (Clavus) 
 
 Ipecacuanha. Headache with nausea, or sick headache; lac- 
 erating pain in the forehead, attended by nausea or vomiting; 
 tensive, aching pains extending as far as the neck and shoul- 
 ders ; sensation of soreness in the whole brain. 
 
 Suitable after or in alternation with Nux vom. y especially af- 
 ter a debauch. 
 
 Mercurius. Tearing, shooting, boring pains in the head, 
 particularly on one side; digging, aching pains in the bones of 
 the skull ; syphilitic headache; heat and burning in the head, 
 rheumatic headache ; shooting pains in the ears, neck and 
 teeth; nightly perspirations which afford no relief; aggravation 
 of the pains at night or when warm in bed. 
 
 This remedy is especially indicated in syphilitic cases, or 
 when associated with eruptions on the scalp, falling off of the 
 hair, or cranial exostosis. 
 
 Nux vom. Congestive headache, with sensation as of a 
 nail driven into the head; lacerating pain in the forehead; 
 headache with nausea and vomiting, hemicrania ; headache 
 from watching, excessive mental exertion, and the abuse of 
 coffee or spirituous li4uors ; also, catarrhal and rheumatic 
 headaches. 
 
 Especially adapted to violent, irascible dispositions, and 
 particularly after a debauch or when attended by constipa- 
 tion. 
 
 Pulsatilla. Headache from indigestion, or from eating fat 
 meat ; headache attended with nausea from the presence of 
 bile in the stomach ; beating headache, with vomiting of bile 
 and mucus ; hemicrania, with shooting pains extending into 
 the ears and teeth ; lacerating, sticking pains in one side of 
 the head. Aggravation in the evening and when at rest ; — 
 amelioration by compression, and in the open air. 
 
THERAPEUTIC INDICATIONS. 53 
 
 Suitable to females of mild disposition, especially when the 
 menses are scanty or deranged. 
 
 Sangninaria. Periodical sick headache, characterized by 
 daily, weekly, or monthly paroxysms, beginning in the morn- 
 ing, increasing during the day, and subsiding at night, and ac- 
 companied with more or less nausea and vomiting. The pains 
 are commonly sudden, sharp and severe, like electric strokes, 
 and affect every part of the head, especially the forehead and 
 occiput. Piercing, digging, lancinating pains, most severe on 
 the right side, accompanied by chilliness, nausea, bilious 
 vomiting, and great sensitiveness to noise, light, touch and 
 motion. 
 
 Sepia. Paroxysmal hemicrania, occurring in violent shocks, 
 especially when connected with affections of the reproductive 
 system ; throbbing, beating, tearing headache, frequently ac- 
 companied by more or less heat, photophopia, nausea and 
 vomiting ; headache caused by indigestion, especially in deli- 
 cate females, or when associated with amenorrhcea, chlorosis, 
 leucorrhcea, and other uterine derangements. 
 
 Stramonium. Spasmodic, beating headache, with obscura- 
 tion of sight and dullness of hearing ; hammering in the ver- 
 tex ; giddiness, with thirst, and disposition to faint ; conges- 
 tive headache, with swelling and redness of the face and eyes. 
 
 Sulphur. Congestive headache, with throbbing and heat ; 
 pressure from within outwards, as though the head would 
 burst, especially in the forehead ; jerking, shooting, or draw- 
 ing pains in one side of the head ; obscuration of sight ; par- 
 oxysms attended with nausea and vomiting. Aggravation by 
 thinking, the open air, and by movement. 
 
 Especially suited to cases caused by suppression of erup- 
 tions. 
 
 REMARKS. 
 
 Calcarea, China, Sepia, and Sulphur, are especially adapted 
 to chronic cases, particularly when associated with some vice 
 of constitution, or derangement of the organs of digestion 
 and assimilation. Calcarea and Sulphur, particularly, are of- 
 ten indispensably necessary to effect a permanent cure, es- 
 pecially in very old, obstinate, and intractable cases. For 
 further information consult the following tables. See also, 
 Table V. 
 
54 
 
 TABLE VI. 
 
 •Toy. Grief. ITrigh.t. Chagrin. Anger. 
 
 w 
 K 
 
 o 
 
 1 
 
 > 
 r 1 
 
 ' CHAMOMILL. 
 IGNATIA 
 Aconite 
 
 Belladonna 
 Nux vomica 
 
 ' CHAMOMILL. 
 Lycopod. 
 
 Sepia 
 
 Nux vomica 
 
 Staphysagria 
 
 ' OPIUM 
 Aconite 
 Hyoscyamus 
 Spigelia 
 
 ' IGNATIA 
 Phosphor, ac. 
 Natr. mur. 
 Staphysagria 
 
 ' COFFEA 
 Opium 
 Crocus 
 Natr. carb. 
 
 ACONITE 
 
 BELLADONN. 
 
 BRYONIA 
 
 CHINA 
 LACHESIS 
 MERCURIUS 
 NIT. AC. 
 NUX VOMICA 
 SULPHUR 
 
 Alumina 
 
 Ambra 
 
 Ant. 
 
 Arnica 
 
 Aurum 
 
 Calc. o. 
 
 Cannabis 
 
 Dulcamara 
 
 Gelseminum 
 
 Glonoine 
 
 Ignatia 
 
 Iodium 
 
 Kali 
 
 Lycopod. 
 
 Manganese 
 
 Moschus 
 
 Nux vomica 
 
 Opium 
 
 Phosphorus 
 
 Pulsatilla 
 
 Chamomilla 
 
 Coffea 
 
 Colocynth 
 
 Rhus 
 
 Silicea 
 
 Spongia 
 
 Veratrum vir. 
 
 Q 
 
 o 
 
 c 
 w 
 
 m 
 
 < 
 
 NERVOUS. 
 
 ACONITE 
 BELLADONN. 
 NUX VOMICA 
 
 Chamomilla 
 
 Gelseminum 
 
 Hepar. 
 
 Sepr. 
 
 Valeriana 
 
 Arnica 
 
 Arsenicum 
 
 Aurum 
 
 Bryonia 
 
 Calcarea 
 
 Capsicum 
 
 Cimicifuga 
 
 Colocynthis 
 
 Cicc. 
 
 Coffea 
 
 China 
 
 Cypr. 
 
 Glonoine 
 
 Ignatia 
 
 Ipecacuanha 
 
 Petroleum 
 
 Platina 
 
 Pulsatilla 
 
 Rhus 
 
 Silicea 
 
 Spigelia 
 
 HYSTERICAL. 
 
 CIMICIFUGA 
 CHAMOMILL. 
 MOSCHUS 
 VALERIANA 
 
 Arsenicum 
 
 Aurum 
 
 Caul. 
 
 Cocculus 
 
 Gelseminum 
 
 Ignatia 
 
 Lachesis 
 
 Magn. 
 
 Magn. m. 
 
 Nit. ac. 
 
 Phosphorus 
 
 Platina 
 
 Sepia 
 
 Capsicum 
 Rhus 
 Spigelia 
 Veratrum 
 
 RHEUMATIC. 
 
 ACONITE 
 
 ARSENICUM 
 
 BRYONIA 
 
 CAUSTICUM 
 
 COLCHIUM 
 
 LYCOPOD. 
 
 MERCUR. 
 
 NUX VOMICA 
 
 PULSATILLA 
 
 RHUS 
 
 Belladonna 
 
 Cimicifuga 
 
 Lachesis 
 
 Ledum 
 
 Sepia 
 
 SuLrnuR. 
 
 Arnica 
 Chamomilla 
 China 
 Ignatia 
 Magn. m. 
 Nitr. ac. 
 Phosphorus 
 Spigelia 
 
 ARSENICUM 
 
 BELLADONN. 
 
 BRYONIA 
 
 CAUSTICUM 
 
 CALC. C. 
 
 PULSATILLA 
 
 Aconite 
 
 Arnica 
 
 Colocynth. 
 
 Ignatia 
 
 Kali bic. 
 
 Sabina 
 
 Sepia 
 
 Sulphur. 
 
 Aurum 
 
 Capsicum 
 
 Cicuta 
 
 Ipecacuanha 
 
 Manganese 
 
 Nit. ac. 
 
 Petroleum 
 
 Phosphor. 
 
 Veratrum 
 
 Zincum 
 
 > 
 
 % 
 
 B 
 W 
 
 s 
 
 CATARRHAL 
 
 ACONITE 
 BRYONIA 
 NUX VOM. 
 PHOSPH. 
 
 PULSAT. 
 
 Belladon. 
 
 Chamomil. 
 
 Mercur. 
 
 Sticta 
 
 Sulphur. 
 
 Arnica 
 
 Arsenicum 
 
 Carb. v. 
 
 China 
 
 Cin. 
 
 Cimicifuga 
 
 Dulcamara 
 
 Ignatia 
 
 Lachesis 
 
 Kali 
 
 Lycopod. 
 
 !!!!!!! III? 1^ g|3g 
 
 > 
 
 2 
 p 
 
 BELLAD. 
 
 CIMICIF. 
 
 NUX VOM. 
 
 PULSAT. 
 
 Aconite 
 
 Arsenicum 
 
 Caul. 
 
 Ignatia 
 
 Lachesis 
 
 Platina 
 
 Sepia 
 
 Bryonia 
 
 Calcarea 
 
 China 
 
 Cocculus 
 
 Colocynth. 
 
 Dulcamara 
 
 Ferrum 
 
 Kali bic. 
 
 Magn. 
 
 Nat. m. 
 
 Spigelia 
 
 Veratrum 
 
 w 
 3 
 a 
 
 H 
 
 ACONITE 
 BELLAD. 
 ARNICA 
 
 Arsenicum 
 Calcarea 
 Conium 
 Mercur. 
 
 Cicuta 
 Hepar. 
 Petroleum 
 Rhus 
 Sulphur ac. 
 
 ►3 
 
 d 
 > 
 
 p 
 
 H 
 in 
 
 n 
 
 > 
 
 X 
 
 H 
 
TABLE VII. 
 
 55 
 
 bo Ph 
 E .-i 
 
 o tf 
 
 'g "s 1 1 
 
 co O co £ 
 
 5 .to 
 
 o u fc £ 
 
 bo 
 C 
 O 
 
 a 
 
 5 
 
 *3 
 
 > 
 
 '5 
 
 O 
 
 H 
 
 © 
 
 
 3 
 
 1 
 
 4-1 
 
 cS 
 CD 
 CO 
 
 ■3 
 
 
 >> 
 
 3 
 
 a 
 
 at 
 
 
 
 cS 
 
 
 
 a! 
 
 o 
 
 Z 
 
 3 
 
 w 
 
 q 
 
 Pi as 
 
 o -g 
 o -s 
 
 co co 
 
 i-3 P-. 
 
 1 I 
 
 P3 O 
 
 0) 
 
 g 
 
 
 
 3 -H 
 
 4 cq pq q o o 
 
 cs o 
 
 5 8 
 
 .5 J 
 
 ft 3 "S 
 
 0) S ft 
 
 fc K » $ x oe r 
 
56 DISEASES OF THE ENCEPHALON. 
 
 MENINGITIS. 
 
 INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 
 
 Meningitis is a term which strictly speaking, signifies in- 
 flammation of the membranes of the brain ; but as it is gen- 
 erally used to denote inflammation of both the brain and its 
 membranes, and as inflammation of the cerebral membranes 
 seldom exist without involving, to a greater or less extent, 
 the substance of the brain itself; and since there are no char- 
 acteristic symptoms that can be relied upon to distinguish 
 them from each other, we shall apply the term indiscrimin- 
 ately to both ; or rather we shall use it in its ordinary sense, 
 to denote that exceedingly dangerous disease known as in- 
 flammation of the brain. There is a form of it sometimes call- 
 ed tubercular or granular meningitis, depending on the pres- 
 ence of tuberculous deposits in the membranes of the brain, 
 which being a separate affection we shall treat of under a dif- 
 ferent head. 
 
 SYMPTOMS. Inflammation of the brain is divided into two 
 well defined periods, or stages, the disease being generally, 
 but not always, preceded by certain premonitory symptoms, 
 such as vertigo, insomnia, ringing in the cars, loss of appetite, 
 and general uneasiness. 
 
 First Stage. The first stage begins with the usual symp- 
 toms of fever — such as chilliness, succeeded by heat, acceler- 
 tion of the pulse, thirst, etc. To these are added, flushing of 
 the face, intense headache, a wild, staring expression of the 
 eyes^ vertigo, intolerance of light and sound, suffusion of the 
 eyes, ringing in the ears, restlessness, anxiety wakefulness, 
 delirium, spasmodic movements, contracted pupils, hot but 
 sometimes moist skin, nausea and vomiting. The fever that 
 characterizes it is of a high inflammatory type, attended by 
 a full, hard, and bounding pulse ; throbbing of the temporal 
 arteries, rapid and irregular breathing, throbbing, stabbing, 
 and cutting pains in the head and extremities, rolling of the 
 eyes, excessive thirst, scanty and high colored urine, and con- 
 stipation. 
 
MENINGITIS. 57 
 
 Second stage. After the lapse of twelve, twenty-four, or 
 forty-eight hours, and sometimes a week or more, according to 
 the violence of the disease, the second period ^r stage of col- 
 lapse sets in. The headache now subsides, the delirium passes 
 gradually into stupor or coma, the pupils become dilated, the 
 eyes dim and sunk in their sockets, the hearing greatly im- 
 paired, the pulse small, rapid and intermittent, and the skin 
 cold and clammy ; the convulsions subside into muscular re- 
 laxation or paralysis, and a general state of insensibility suc- 
 ceeds, which soon terminates in death. 
 
 Modifications. The symptoms are of course variously 
 modified according to the extent and violence of the dis- 
 ease, the age of tbe patient, and the nature of the exciting 
 cause. Sometimes the disease begins and ends with convul- 
 sions — at other times, pain in the head, delirium or coma, 
 may constitute the principal symptom. Indeed, no disease 
 presents itself under a greater variety of forms, or with a 
 greater diversity of symptoms ; the latter, however, are gen- 
 erally present in sufficient number, and are sufficiently char- 
 acteristic, to make any mistake in the diagnosis both un- 
 necessary and inexcusable. 
 
 Etiology. Among the exciting causes of this disease, 
 may be mentioned: external violence, teething, the suppres- 
 sion of cutaneous eruptions, the translation of rheumatism 
 or gout, venereal excesses, abuse of liquor, mental emotions, 
 and certain fevers — such as typhoid fever, scarlet fever, and 
 erysipelas. 
 
 TREATMENT. The treatment of Meningitis is similar, and 
 in most cases identical with that of Hyperaemia of the Brain. 
 In addition, therefore, to the Therapeutic Indications con- 
 tained in the following Table (VIII), the practitioner should 
 consult the Indications and Tables given under the head of 
 Cerebral Hyperaemia. 
 
 DIET AND Regimen. For the first few days the diet 
 should be restricted to such simple articles as toast water, 
 gum-water, barley or rice-water, jellies, etc.; and until the 
 stage of excitement is fully past, should be of the mildest 
 and most unstimulating character. The room should be kept 
 cool, quiet and well ventilated, and the patient as compos- 
 ed as possible. 
 
58 
 
 TABLE VIII. 
 
 OD 
 
 M 
 
 < 
 
 H 
 
 S3 
 
 Vomiting of bile; espe- 
 cially indicated at the 
 commencement. 
 
 Especially suited to the 
 last stage. 
 
 Emesis. Relaxation of 
 sphincters. 
 
 Working of the jaws. 
 Opisthotonos. 
 
 Last stage, or when 
 caused by the reper- 
 cussion of erysipelas. 
 
 Especially indicated aft- 
 er retrocession of vesi- 
 cular erysipelas. 
 
 When caused by worms, 
 or pseudo-meningitis. 
 
 '72 
 
 >— 1 
 
 Burning, throb- 
 bing or lanci- 
 nating. 
 
 Throbbing, sting- 
 ing and lacer- 
 ating. 
 
 Boring, stinging, 
 burning, lanci- 
 nating or throb- 
 bing. 
 
 Sharp and violent, 
 or pressive and 
 aching. 
 
 Lacerating and 
 cramp-like. 
 
 Pressing, gnawing, 
 throbbing, or 
 lancinating. 
 
 Cramp-like. 
 
 -A 
 H 
 
 >< 
 
 Red and inflamed 
 Pupils contract- 
 ed or dilated. 
 
 Burning, stinging 
 and staring ; 
 dimness of vis ; 
 pupils contract- 
 ed. 
 Red and sparkling, 
 with distorted 
 orbs; pupils con- 
 tr'ted or dilated. 
 
 Red and inflamed ; 
 sparkling, or dim 
 and glassy. 
 
 Staring and in- 
 flamed; pupils 
 contracted. 
 
 Fiery and spark- 
 ling, protruded 
 and distorted; 
 dimness of vis'n. 
 
 Pupils dilated or 
 contracted; dim- 
 ness of vision. 
 
 
 Full and hard. 
 
 Rapid, feeble and 
 intermittent. 
 
 Small, quick and 
 intermittent. 
 
 Quick and hard, 
 or slow and in- 
 termittent. 
 
 Full and quick, or 
 small and hard. 
 
 Full and hard. 
 
 Generally quick 
 and irritable— 
 sometimes 
 trembling. 
 
 SKIN. 
 
 Dry burning heat, 
 Erysipelas. 
 
 Burning and 
 Swollen— with 
 or without 
 Moisture. 
 
 Red and burning 
 —Erysipelas. 
 
 Hot and burning, 
 sometimes cold, 
 pale and moist. 
 
 Blue or pale, Ery- 
 sipelas. 
 
 Red and burning, 
 Vasicular Ery- 
 sipelas. 
 
 Burning Heat, 
 especially of 
 the face. 
 
 CO 
 
 •A 
 U 
 
 Spasms, or Ten- 
 dency to Para- 
 lysis. 
 
 Spasms- Paraly- 
 sis. 
 
 Spasms -Paraly- 
 sis. 
 
 Cramps, Convul- 
 sive Movem'nts. 
 
 Cramps and Con- 
 vulsions. 
 
 Tonic Spasms and 
 Convulsions. 
 
 Cramps and Con- 
 vulsions. 
 
 o 
 
 CG 
 
 Delirium, with 
 great anguish. 
 
 Delirium, Giddi- 
 ness or Insen- 
 sibility. 
 
 Violent Delirium 
 — Loss of Con- 
 sciousness. 
 
 Vertigo, Delirium 
 or Sopor. 
 
 Vertigo, Loss of 
 Consciousness. 
 
 Delirium, Vertigo, 
 or Insensibility. 
 
 Violent Headache 
 Giddiness, and 
 Delirium 
 
 REMEDY. 
 
 — 
 
 c 
 
 < 
 
 ARSENICUM 
 
 BELLADONNA.... 
 BRYONIA 
 
 C 
 
 < 
 
 m 
 H 
 Q 
 
 < 
 » 
 
 
TABLE VIII — CONTINUED. 
 
 59 
 
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60 Diseases of the encephalon. 
 
 CEREBRITIS-ENCEPHALITIS. 
 
 INFLAMMATION OF THE SUBSTANCE OF THE BRAIN. 
 
 Cerebritis and Encephalitis are terms commonly used to de- 
 note partial inflammation of the substance of the brain, in 
 contradistinction to general inflammation of that organ, which 
 seldom or never occurs without involving the cerebral mem- 
 branes, particularly the pia mater and arachnoid coats, and 
 is therefore described under the head of Meningitis. 
 
 This disease is not only confined to a limited portion of the 
 cerebral substance, but it is also generally of a more or less 
 chronic character. It is, however, sometimes acute, particu- 
 larly if the inflammation involves a considerable portion of 
 the cerebral mass, in which case the inflammation passes rap- 
 idly through its several stages, and may soon terminate in co- 
 ma, convulsions, paralysis, or death. Even when the inflam- 
 matory process is limited to a very small portion of the brain, 
 it may prove speedily fatal, in consequence of the particular 
 part affected; as, for example, the corpora pyramidalia of the 
 medulla oblongata, or the part contiguous to the pia mater 
 and arachnoid membranes. 
 
 Pathology. Inflammation of the substance of the brain 
 generally begins with exudation between the fibres situated 
 along the boundary separating the cineritious and white sub- 
 stance. Sooner or later, owing to the vascular structure and 
 highly organized nature of the organ, the exudation results in 
 disorganization of the cerebral textures, producing at first 
 what is called red softening from the presence of blood in the 
 broken down tissues, which gradually changes to yellow soften- 
 ing by reabsorbtion of the coloring matter of the exudation. 
 Sometimes, for reasons difficult to explain, the exudation 
 changes to pus, into which also, the implicated tissues are 
 converted, forming cavities or abscesses in the brain, which vary 
 greatly both in size and number. These abscesses generally 
 result from injury of the cerebral substance, but do not always 
 correspond to the seat of injury. They are subject to a variety 
 of terminations. Sometimes they become enclosed in cysts of 
 false membrane, which, by limiting the extent of the inflam- 
 matory process, prevent any further disorganization of the 
 
GEREBRITIS — ENCEPHALITIS. 6l 
 
 cerebral texture ; at other times they make their way into the 
 ventricles, or to the surface of the brain, producing inflam- 
 mation of the investing membranes, and death. 
 
 Abscesses of the brain, however, do not always terminate 
 in death, as cases sometimes occur in which there is every 
 reason to conclude that the purulent matter has been absorb- 
 ed ; cicatrices having been found in the brains of old people, 
 which could only be accounted for in this manner. 
 
 Among the various pathological states incident to this dis- 
 ease is that of ulceration, which, however, is of comparatively 
 rare occurrence. The ulcers, which vary in size from a few 
 lines to several inches, are situated, for the most part, on the 
 external surface of the brain, seldom penetrating beyond the 
 grey substance. The tissues immediately surrounding the 
 ulcers, as well as the adjacent membranes, usually exhibit 
 signs of inflammation ; and occasionally they are found to 
 communicate with deep-seated abscesses. 
 
 Encephalitis of a very chronic character, instead of produc- 
 ing softening or ulceration of the cerebral substance, sometimes 
 gives rise to a state of permanent i?idnration of the part af- 
 fected. The old writers relate many such cases of partial in- 
 duration, all of which were of a very protracted nature. In 
 some cases the affected parts were unusually red and vascular; 
 in others, they were of a pearly whiteness, and of different de- 
 grees of density, from that of semi-concrete lymph to that of 
 fibro-cartilage. 
 
 SYMPTOMS. The various pathological conditions above de- 
 scribed, prepare us to expect a great diversity of symptoms 
 in different cases; they are likewise found to be extremely 
 vague and unreliable. We have already stated that the dis- 
 ease may assume more or less of an acute character from the 
 beginning, especially when large portions of the brain are im- 
 plicated. In such cases the disease generally involves the me- 
 ninges of the brain, and runs a rapid course. In other cases, 
 comparatively large portions of the cerebral tissue may be 
 affected without its functions being proportionately, or to any 
 great degree, disturbed. Even when the initial symptoms are 
 most complete, they are not always sufficiently pronounced to 
 
62 CEREBRITIS — ENCEPHALITIS. 
 
 enable us, at the outset of the disease, to distinguish it with 
 any degree of certainty from other inflammatory affections of 
 the brain. 
 
 First stage. The patient is generally attacked with severe 
 deep-seated pain in the head, commonly of a continuous, but 
 sometimes of a paroxysmal character, which frequently pre- 
 cedes all other symptoms. Afterwards, and sometimes from 
 the very commencement, other symptoms are experienced, 
 such as vertigo, dimness of vision, buzzing in the ears, dispo- 
 sition to faint, nausea and loss of appetite, hesitancy of 
 speech, wandering pains in the limbs, sensation of numbness 
 or tingling in various parts of the body, with heaviness 
 and cramps in the extremities, and an unsteadiness of gait, 
 betokening the approach of paralysis. This constitutes the 
 first stage, beyond which there is but little, if any hope of 
 recovery. 
 
 Second stage. Although the general health is now more or 
 or less impaired, the ordinary absence of fever, and of any 
 derangement of the intellect, prevents, as a general rule, ap- 
 prehensions of impending danger, until at last the patient is 
 suddenly seized with stupor, insensibility, and paralysis. — 
 From this condition the patient may so far recover as to ex- 
 hibit some signs of intelligence, but some degree of drowsi- 
 ness, apathy and mental weakness, as well as loss or impair- 
 ment of the special senses, remains. This is called the second 
 stage ; and is characterized at its close by rigid contractions of 
 the flexor muscles of the paralyzed limbs. This condition of 
 rigidity, or tonic spasm, is supposed to indicate the process of 
 softening of the cerebral tissues. 
 
 Third stage. If the patient survive the second stage of 
 the disease, the rigidity of the paralyzed muscles gradually 
 gives way, and is succeeded by the opposite condition of re- 
 laxation and flaccidity. This marks the third stage, or that 
 of complete paralysis, in which the affected portion of the 
 brain has become wholly disorganized and broken down. The 
 patient now, either suddenly or gradually, sinks into a state of 
 profound coma, from which the system never rallies, and 
 death sooner or later closes the scene. 
 
CEREBRITIS — ENCEPHALITIS. 63 
 
 The above is a very imperfect sketch of the history and' 
 progress of this disease, which is marked at different stages 
 with more or less irregularity of function, fever, delirium, and 
 spasmodic action ; giving rise to a diversity and succes- 
 sion of symptoms in different cases, which constitute certain 
 forms and varieties of cerebritis, that our limited space forbids 
 us to describe. This, however, is quite unnecessary, since the 
 description already given is sufficiently characteristic to ena- 
 ble the practitioner always to identify the disease with the aid 
 of the following 
 
 DIAGNOSIS. Cerebritis is liable to be mistaken in the first 
 stage for meningitis, and in the succeeding stages for apo- 
 plexy. In cerebral meningitis the febrile excitement is very 
 great, and is attended with spasmodic and convulsive symp- 
 toms on both sides of the body, and without decided paraly- 
 sis, succeeded by collapse. In cerebral apoplexy, on the 
 other hand, there is generally a more sudden invasion and 
 rapid progress of the disease, together with sudden and 
 complete paralysis, unattended at first with spasmodic 
 symptoms. 
 
 With reference to convulsions, coma and paralysis, it should 
 be remembered, that partial congestion from moderate com- 
 pression will produce convulsions; while increased congestion 
 from a greater degree of compression, will produce coma and 
 partial paralysis ; hence the results of cerebral congestion 
 alone are sometimes similar to those of cerebral inflamma- 
 tion. The diagnosis, therefore, should embrace other symp- 
 toms than those of convulsions, coma, and paralysis, such as 
 delirium, altered pulse, altered pupils, etc. This hint will be 
 sufficient in most cases to prevent any serious mistake in di- 
 agnosis, even when the symptoms are more than usually di- 
 verse and obscure. 
 
 ETIOLOGY. As already stated, partial inflammation of the 
 cerebral substance is frequently the result of traumatic inju- 
 ries, such as blows, falls, etc. It is also caused by the growth 
 of foreign bodies in the brain ; such as hydatids, fibrous, fibro- 
 cartilaginous, and carcinomatous tumors, and the effusion of 
 sanguinous, tuberculous and scrofulous collections. But the 
 most common causes are doubtless the same as those of sim- 
 ple meningitis ; of these, the depressing passions, long con- 
 tinued and severe mental labor, and habitual drunkenness, are 
 perhaps the most constant and powerful. 
 
64 CEREBRITIS— EN CEPHALITIS. 
 
 TREATMENT. The treatment of cerebritis in the first stage 
 or what is sometimes called irritative cerebritis, should be 
 similar to that recommended for Cerebral Hyperaemia and 
 Meningitis. So long as no insterstitial change has taken place 
 — no metamorphosis of structure — we may reasonably hope 
 to relieve the symptoms, which are simply those of congestion 
 and inflammation. But when softening has once set in, with 
 its formidable train of effects, the reactive powers of the sys- 
 tem are either wholly lost, or too much injured and enfeebled 
 to render any hope of permanent relief. Something, howev- 
 er, is always expected to be done ; and the indications being 
 similar to those mentioned under the head of Cerebral Apo- 
 plexy, the prescriber is referred to that section. Additional 
 therapeutic indications and remedies may also be found under 
 the heads of Acute Hydrocephalus and Cerebral Concussion, 
 the symptoms of which frequently correspond to those of cer- 
 tain forms and stages of chronic encephalitis, and therefore 
 require the same remedies. 
 
 We will add, on the authority of Hempel, that Kafka has 
 for some years been in the habit of employing Glonoine ist to 
 2d, with the best success in encephalitis, " When the symp- 
 toms of cerebral hyperaemia predominate, and the disorganiz- 
 ing metamorphosis is progressing!' 
 
 We beg leave to take exception to the condition mentioned 
 in the last clause as existing in the cases, though we have no 
 doubt whatever that Glonoine will prove a valuable remedy 
 in the initial and purely hyperaemic stage of the complaint. 
 
 Kafka also relates a case in which, " Side by side with the 
 symptoms of cerebral hyperaemia, those- of cerebral softening, 
 with progressive increase of the morbid phenomejia, likewise co- 
 existed; and in which, after the hyperaemic condition had been 
 relieved by the employment of Glonoine and Belladonna. — 
 Arsenicum was used apparently with marked success. If 
 it be possible for entire recovery to take place in this disease 
 after metamorphosis of the cerebral tissue has occurred, I have 
 no doubt Arsenicum will prove an efficient remedy, not only 
 because it is capable of producing decomposition of organic 
 
ACUTE HYDROCEPHALUS. 65 
 
 tissues, but because its pathogenesis as exhibited in the cepha-. 
 lalgia, vertigo, wandering pains, impaired sensibility of the 
 limbs, delirium, coma, lassitude, debility, trembling, and 
 numbness of the extremities, and the tetanic spasms, or pa- 
 ralysis, presents a perfect picture of cerebritis, and must, 
 therefore, be truly homoeopathic to that condition. 
 
 Iodium is another medicine which seems to have yielded 
 good results in some cases, and so far as the pathogenesis of 
 the remedy is concerned, is certainly appropriate, but we are 
 obliged to confess that our experience with it in this class of 
 cases has not been satisfactory. 
 
 Plumbum, also, has been strongly recommended in cere- 
 britis, but so far, we believe, only on theoretical grounds. 
 
 ACUTE HYDROCEPHALUS. 
 
 TUBERCULOUS OR GRANULAR MENINGITIS. 
 
 If the term used to designate simple inflammation of the 
 brain is etymologically inapposite, much more so is that which 
 is generally employed to distinguish scrofulous inflammation 
 of that organ, namely, hydrocephalus, or dropsy of the brain, 
 a condition belonging only to the chronic variety, since the 
 limited effusion of serum into the ventricles, which occurs in 
 some cases of this disease, is nothing like true dropsy, in 
 the sense in which that term is usually understood ; but as 
 homceopathists both recognise and treat diseases by symptoms 
 instead of names, the inaccuracy of the allopathic nomencla- 
 ture is of but little consequence. 
 
 PATHOLOGY. Acute hydrocephalus is essentially a scrofu- 
 lous inflammation of the brain ; at least, it is generally, if not 
 universally, associated with a scrofulous or tuberculous con- 
 dition of the system; indeed, the disease is chiefly characterized 
 by deposits of scrofulous matter, in the form of millet-sized 
 tubercles, or granules, in the meninges of the brain ; hence it 
 
66 PRACTICE OF MEDICINE. 
 
 is sometimes called granular or tuberculous meningitis* The 
 granulations are of a greyish or yellowish-white color, similar 
 both in character and appearance to those which sometimes 
 occur in ordinary miliary tuberculosis in other organs. They 
 are located for the most part in the pia mater at the base of 
 the brain. It is only in a small proportion of cases that they 
 occur elsewhere. This, however, it should be stated, is con- 
 trary to the original observations of Rilliet and Barthez, who 
 found them to occur most frequently upon the convex surface 
 of the brain. The truth is, they are situated mainly along the 
 course of the great vessels, particularly in the fissure of Silvius. 
 In some instances they are so closely aggregated as to coalesce, 
 forming tuberculous masses of the size of a pea or bean. There 
 is also to be found in the sub-arachnoidal space, adjoining the 
 blood vessels, a jelly-like exudation similar to what occurs in 
 simple meningitis. There is generally much softening of the 
 cerebral tissue around the ventricles, owing probably to the 
 effusion into them of a greater or less quantity of serum. As 
 already stated, miliary granules, tubercles, and other evidences 
 of scrofulosis, are generally found in other portions of the body, 
 particularly in the lungs, bronchial glands and peritoneum, 
 proving conclusively that acute hydrocephalus is nothing more 
 nor less than a true scrofulous inflammation of the brain, — a 
 fact the knowledge of which is of the greatest consequence so 
 far as prognosis and treatment are concerned. 
 
 SYMPTOMS. Acute hydrocephalus may occur at any period 
 of life, but is almost wholly confined to infancy and childhood. 
 Its course exhibits four different stages, or periods, the charac- 
 teristic symptoms of which are so different, that, for the purpose 
 of comparison, we present them in tabular form. (See pp. 68, 
 69.) 
 
 Etiology and Prognosis. Acute hydrocephalus is so 
 exceedingly fatal, in consequence of the scrofulous diathesis of 
 
 * See Am. Horn, 05s., vol. 7, p. 58. 
 
ACUTE HYDROCEPHALUS. 6j 
 
 the patient, and the presence of tuberculous matter in the 
 cerebral meninges, that the only chance for successful treat- 
 ment lies in its early recognition.* Hence it is of the utmost 
 importance that proper treatment be instituted during the pre- 
 monitory or congestive stage, as then the symptoms will gener- 
 ally be found to yield. At the same time we would caution 
 the practitioner always to be on his guard, since, in consequence 
 of the strong predisposition existing in these cases, and the 
 irritation caused by the presence of foreign matter within the 
 cranium, there will be a constant tendency to relapse upon ex- 
 posure to any exciting cause, such as falls, blows, exposure to 
 cold or heat, the irritation produced by worms or teething, 
 rapid jolting or exercise, the repercussion of cutaneous erup- 
 tions, ordinary attacks of fever and inflammation, or indeed 
 anything calculated to quicken the circulation and cause a de- 
 termination of blood to the brain. Hence the greatest care 
 should be taken in such cases to keep the child quiet ; to guard 
 against external violence or undue excitement of any kind ; to 
 
 promote the general health by gentle passive exercise ; and to 
 regulate the motions of the bowels and the functional activity 
 of the skin by diet, bathing, friction, etc., with the greatest 
 care. 
 
 DIAGNOSIS. The disease with which acute hydrocephalus 
 is most apt to be confounded is simple meningitis, which some- 
 times bears so close a resemblance to this affection as to render 
 it extremely difficult to distinguish it from the scrofulous va- 
 riety. Doubtless the most certain diagnostic sign is the co- 
 existence of a general scrofulous condition of the system. If 
 there should be no external marks of scrofula, no hereditary 
 taint, nor any signs of disease within the chest or abdomen, 
 there is reason to hope that, however characteristic the brain 
 symptoms may appear to be, the inflammation is simple ; on 
 the other hand, when such evidences of scrofulosis exist, there 
 is great reason to fear that the disease is granular meningitis. 
 When, in addition to the scrofulous or tuberculous diathesis, 
 the disease is protracted to two or three weeks, or more, the 
 proof of its scrofulous nature may be regarded as conclusive. 
 
 See Am. Horn. Obs., vol. vii, p. 59. 
 
6S 
 
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JO PRACTICE OF MEDICINE. 
 
 Treatment. The remedies which will be found most use- 
 ful in the early stages of acute hydrocephalus are: ACONITE, 
 Belladonna, Glonoine,* and Mercurius. Bell, alone, or 
 the alternate use of Aeon, and Bell., ox Bell, and Glo., in the first 
 and second stages, and of Bell, and Merc, in the second and 
 third, with proper attention to hygienic influences, will often 
 prove successful in arresting this very formidable disease. The 
 special indications for the employment of these and other suit- 
 able remedies, have already been given under the heads of 
 Cerebral Hyperoemia and Me?tingitis, whose symptoms corres- 
 pond to the curative stages of this disease, and to which 
 reference should be made for the requisite treatment. Nor, 
 considering the scrofulous nature of the affection, should the 
 remedies suitable to that condition, mentioned under Scrofula 
 and Tuberculosis, be overlooked. 
 
 CHRONIC HYDROCEPHALUS. 
 dropsy of the brain. 
 
 Chronic Hydrocephalus, unlike most chronic affections, 
 bears no affinity whatever to the acute, the latter being 
 an inflammatory disease, modified by constitutional and local 
 causes, while the former, as its name imports, is a true 
 dropsy of the brain, consisting of an accumulation of water or 
 serum within the ventricles and membranes of the brain. It is 
 almost entirely confined to children, and is both congenital and 
 acquired. Congenital cases are comparatively rare ; and owing 
 partly to mechanical violence, and, in some case, to defective 
 development of the cerebral mass, generally prove fatal at the 
 time of birth. Extra-uterine cases generally manifest them- 
 selves during infancy, or soon after birth, before the fontanelles 
 are closed, and while the cranium is capable of expansion. 
 
 Enlargement. The chief feature in these cases, and 
 that which first attracts attention, is the enlargement of the 
 
 *A m. Horn, 05s., vol. vii, p. 60. 
 
CHRONIC HYDROCEPHALUS. 7 1 
 
 head. This takes place gradually in every direction, except at 
 the base of the cranium, but is the most prominent in the 
 frontal, temporal and occipital regions. As a general rule, the 
 face is but little, if any enlarged, so that the front and sides 
 project in such a manner as to give the head a remarkably 
 wedge-shaped appearance, resembling an inverted cone or 
 pyramid. Sometimes, however, the enlargement takes place 
 equally in every direction, giving to the head the appearance 
 of an immense animated ball, too heavy to be supported with- 
 out some external aid. 
 
 Symptoms. Aside from the enlargement, which from the 
 first is generally quite manifest to the eye, the earlier symp- 
 toms are sometimes difficult of recognition. The increased 
 weight of the head, however, no less than the functional dis- 
 turbance of the oppressed brain, give to the child a somewhat 
 uncertain and tottering gait, which is characteristic of the dis- 
 ease. After a while the symptoms become more pronounced ; 
 the child becomes dull and peevish ; tremors of the limbs set 
 in, so that he can no longer walk ; the senses gradually fail ; 
 there is more or less insensibility of the skin ; taste becomes 
 perverted and weak ; the sense of smell is diminished ; dim- 
 ness of vision follows ; and finally hearing itself fails. The 
 digestive functions generally remain longer unimpaired, but 
 they, too, at last become involved ; vomiting occurs, and ema- 
 ciation, notwithstanding an increase in the amount of food, is 
 likewise produced. Costiveness and scanty urine are also at- 
 tendant symptoms. At last, symptoms of paralysis set in ; 
 the eyes are turned to one side, the pupils are dilated, and 
 vision becomes extinct. The rectum and bladder become im- 
 plicated, so as to lose all control over their contents. Finally, 
 after successive attacks of spasms and convulsions, the paraly- 
 sis becomes complete ; suffocative fits occur, during which the 
 breathing becomes labored and stertorous ; insensibility fol- 
 lows ; the pulse becomes small, feeble and intermittent ; and 
 death closes the scene. 
 
72 PRACTICE OF MEDICINE. 
 
 PROGNOSIS. Although chronic hydrocephalus is gener- 
 ally fatal, it is not necessarily so. A large proportion of cases 
 will recover if taken in time and suitable treatment instituted. 
 Indeed, there is no good reason why, at any period previous to 
 the consolidation of the cranium, it should not be as amenable 
 to treatment as any other form of dropsy. 
 
 Treatment. This is either general or local. Local treat- 
 ment has in the great majority of instances been productive of 
 more harm than good ; and may therefore be dismissed with 
 but a passing remark. Tapping is claimed to have permanently 
 relieved a few cases, but the ordinary result of the measure, as 
 might have been anticipated, has been to hasten, and some- 
 times to cause a fatal termination, by exciting inflammation of 
 the brain and its membranes. " Methodical Compression." as 
 it is called, by means of adhesive strips so applied as to pro- 
 duce uniform compression of the cerebral mass, after the man- 
 ner of Barnard, has for the most part either proved entirely 
 nugatory, or else been attended with dangerous consequences 
 from compression of both the brain and the pericranial vessels; 
 the practice, however, still has its advocates, and is claimed by 
 its author and others to have been successful in a number of 
 instances. It is only applicable to cases in which the bones of 
 the cranium are loose, and the vital powers weak, and even 
 then should be employed with the greatest caution, being 
 abandoned whenever the symptoms of compression are aggra- 
 vated by it. 
 
 The general treatment may be gathered from the fol- 
 lowing 
 
 THERAPEUTIC INDICATIONS. 
 
 Arsenicum. — Swelling, particularly of the head and face ; 
 vomiting on being raised up in bed ; impairment of the special 
 senses ; emaciation and muscular weakness ; constipation ; re- 
 tention, or involuntary discharge of urine ; anxious and op- 
 pressed breathing at night, or in the evening, in bed. 
 
CHRONIC HYDROCEPHALUS. 73 
 
 Calcarea carb. — Scrofulous swelling ; old, pale and hag- 
 gard look ; trembling and weakness of the limbs ; tottering 
 gait ; emaciation and great physical prostration ; non-closure 
 of the fontanelles ; constipation. 
 
 Helleborus. — Dullness of the senses ; sopor; pale, yellowish 
 face, with puffiness or swelling ; great weakness of the limbs ; 
 spasms and convulsions ; small, feeble pulse ; suppression of the 
 urine ; paralysis. 
 
 Mercunus. — Great restlessness ; swelling of the head ; dil- 
 atation of the pupils ; impairment of the senses ; spasmodic 
 paroxysms; collapse of the system ; paralysis. 
 
 Plumbum acet. — Heaviness of the head, with pressure as 
 though the skull was too full ; dropsy ; emaciation, weariness, 
 and increasing debility ; nausea and vomiting ; trembling of the 
 limbs ; restlessness and sleeplessness, or somnolence and loss 
 of the senses ; retention, or involuntary emission of urine ; 
 pulse, small and frequent, or slow and feeble ; constipation ; 
 spasmodic paroxysms and paralysis. 
 
 Silicea. — Scrofulous swelling of the head ; feeling as though 
 the head was filled with living things ; dullness of the senses ; 
 pale, swollen face ; suppression of stool and urine ; great pros- 
 tration and muscular weakness ; suffocative breathing ; spasm 
 of the limbs ; numbness, swelling and paralytic weakness. 
 
 Sulphur. — Scrofulous enlargement of the head ; heaviness 
 and languor of the limbs ; trembling gait ; dullness of the 
 senses ; pale, bloated face ; emaciation ; constipation ; reten- 
 tion of urine ; paralysis. 
 
 Zincum. — Small, weak pulse ; loss of consciousness ; cold- 
 ness of the body ; great weakness and heaviness in the limbs, 
 with tremor ; oppression of breathing ; constipation ; drowsi- 
 ness; heaviness in the head ; nausea with trembling and tend- 
 ency to paralysis. 
 
 Diet and Regimen. — The diet should be light and nutri- 
 tious, consisting of such articles as milk, oatmeal porridge, 
 
74 PRACTICE OF MEDICINE. 
 
 wild game, lean, tender, broiled beef, oysters, and soft boiled 
 eggs, etc. Care should be taken to give the child the advantag- 
 es of sufficient light, air and exercise, carefully guarding it from 
 exposure to the action of all depressing agents, or to bodily or 
 mental excitement. In short, everything possible should be 
 done to invigorate the body, and to guard against any prema- 
 ture development of the mental faculties. 
 
 CEREBRAL APOPLEXY. 
 
 The term Apoplexy, from a Greek word, signifying / strike, 
 is used to denote a sudden loss, more or less entire, of sensation, 
 consciousness, and voluntary motion, depending upon cerebral 
 pressure produced by congestion or extravasation within the 
 cranium ; the circulation and respiration being continued. This 
 definition is perhaps as perfect as any that can be framed ; yet 
 the attack is not always sudden, the condition sometimes set- 
 ting in gradually, even when produced by cerebral hemorrhage. 
 
 PATHOLOGY. — All cases of true apoplexy are caused by hy- 
 peraemia of the brain, by cerebral hemorrhage, or by sudden 
 effusion of serum within the cranium ; hence some pathologists 
 have divided the disease into three varieties, the simple or con- 
 gestive, the sanguineous or hemorrhagic, and the serous. These 
 distinctions, however, are of but little practical importance, since 
 it is generally impossible to determine with certainty, previous 
 to the death of the patient, which of the three conditions exist 
 in any particular case ; and since, moreover, in consequence of 
 the pressure which they alike exert upon the brain, the symp- 
 toms in either case are similar. 
 
 Some pathologists restrict the term apoplexy to cases of 
 cerebral hemorrhage alone ; but although such cases are much 
 the most frequent, nothing is more certain than that death oc- 
 casionally occurs with all the symptoms of apoplexy, in which 
 the only observable lesions of the brain are : a greater or less 
 amount of hyperaemia of the cerebral vessels, or an abnormal 
 
CEREBRAL APOPLEXY. 75 
 
 effusion of serum into the ventricles, or into the cavity of the 
 arachnoid. As just stated, however, the most common lesion in 
 cerebral apoplexy is hemorrhage, the blood being effused either 
 upon the surface of the brain or its membranes, in the ventricles, 
 or in the cerebral tissue itself. As would naturally be inferred, 
 the principal seats of hemorrhage are those portions of the 
 brain most abundantly supplied with blood vessels, such as the 
 corpora striata, optic thalami, etc. The quantity of blood ef- 
 fused varies from a few drops to several ounces. It is some- 
 times infiltrated into the adjoining tissues, producing more or 
 less suppuration, laceration and softening of the cerebral struct- 
 ure; but generally it is collected into one or more separate 
 cavities, corresponding to the points of rupture in the cerebral 
 vessels. The extravasated blood gradually undergoes absorp- 
 tion, disappearing in some cases in the course of five or six 
 months ; in others it becomes encysted and may continue sev- 
 eral years. The number of coagula generally corresponds with 
 the number of sanguineous effusions which have at different 
 periods occurred ; no less than a dozen clots, in different stages 
 of absorption, having been found in the same brain. These 
 facts are of the greatest interest and importance, as showing 
 how nature at once sets up a process of reparation, which if 
 properly encouraged, and not interfered with by depletion, or 
 other depressing treatment, is capable of effecting a complete 
 restoration of the injured organs. 
 
 ETIOLOGY. — The chief predisposing causes of cerebral apop- 
 lexy are inheritance and old age. Statistics show that it attacks 
 the descendents of apoplectic parents much more frequently 
 than others, owing either to a similarity of physical conforma- 
 tion, or, which is more likely, to some inherited weakness of 
 the system, the existence of which in the parents constitutes the 
 original predisposition to the complaint. Old age, however, is 
 the principal predisposing cause, and is doubtless the most pow- 
 erful, as the great majority of cases occur beyond the age of 
 
76 PRACTICE OF MEDICINE. 
 
 fifty. Hence, people advanced in life, especially if they are, or 
 have been very hard thinkers, or addicted to excesses of any 
 kind, are very apt to be cut off in this manner. For these reas- 
 ons, women, whose habits of life are generally more regular 
 than those of men, are less liable to the complaint. Cardiac 
 affections are supposed to favor the disease by causing more or 
 less hyperaemia of the brain, and when other circumstances con- 
 cur to produce it, no doubt they contribute to the result. The 
 same may be said of the state of the system denominated 
 plethora, arising from free living and sedentary habits. 
 
 Although the exciting causes of cerebral apoplexy are 
 numerous, they can be reduced to a very few heads. Whatever 
 tends to produce congestion of the brain, such as exposure to 
 the sun's rays, violent mental emotion, heavy lifting or strain- 
 ing, hard coughing or vomiting, playing upon wind instruments, 
 excessive venery,the free use of alcoholic stimulants, compression 
 of the vessels of the neck, dependent position of the head, as in 
 in stooping, etc. To these may be added repelled eruptions, an 
 overloaded state of the stomach, the sudden suppression of 
 habitual discharges, and exposure to either excessive heat or 
 
 cold. 
 
 DIAGNOSIS. — Cerebral apoplexy is liable to be confounded 
 with both syncope and coma. In syncope, however, the sur- 
 face is pale and cold, the features are contracted, the pulse is 
 lost at the wrist, and the respiration is suspended ; in apo- 
 plexy, on the other hand, the very reverse occurs. Coma, from 
 the great resemblance of its symptoms to those of apoplexy, 
 can only be distinguished from it by the cause, which in cases 
 of apoplexy generally depends upon sudden pressure on the 
 brain, while in other cases it is symptomatic of narcotic poison- 
 ing, inebriation, cerebral inflammation, hysteria, etc. The diff- 
 erences between these affections and true apoplexy are so 
 great, that notwithstanding the similarity of their general ap- 
 
CEREBRAL APOPLEXY. 77 
 
 pearance, a mistake in diagnosis would be alike discreditable to 
 the practioner and injurious to the patient. No such error, how- 
 ever, can occur if sufficient attention is paid to the symptoms. 
 
 PROGNOSIS. — Cerebral apoplexy is always a serious disease, 
 and, sooner or later, generally proves fatal. This is especially 
 true of cases caused by effusions or extravasations within the 
 cranium. On the other hand, cases depending on cerebral 
 hyperemia merely, without serous effusion, vascular extravasa- 
 tion, or other lesion, may be regarded favorably. But as it is 
 usually impossible, particularly soon after the attack, to deter- 
 mine these questions with any degree of accuracy, the progno- 
 sis is always more or less doubtful. 
 
 As a general rule, it may be stated, the danger to life is 
 proportional to the extent of the paralysis ; and is greatest 
 when, in addition to the mental functions, the paralysis involves 
 the organs of circulation and respiration. Among the more im- 
 portant signs threatening a fatal issue are : protracted coma, 
 convulsions, general paralysis, dilated pupils, obstructed respir- 
 ation, foaming at the mouth, frequent vomiting, coldness and 
 clamminess of the surface, and involuntary evacuations. Still, 
 if the vital powers are husbanded, the patient may possibly sur- 
 vive even these formidable symptoms, though it must be con- 
 ceded, that if the patient escape for the time, he is very liable to 
 sink sooner or later, either from a recurrence of the attack, or 
 by a general failure of the vital powers resulting from the injury 
 done to the brain. If, however, the patient survive the first on- 
 set of the disease without any subsequent aggravation of the 
 symptoms, there will always be room for hope, even when ex- 
 travasation of blood has taken place. But it should be remem- 
 bered in this connection, that about the eighth or tenth day of 
 the seizure is a critical period, for then inflammation sets in 
 about the clot, and may destroy the patient. 
 
78 PRACTICE OF MEDICINE. 
 
 Symptoms. — In the majority of cases, the attack is preced- 
 ed by certain premonitory symptoms, such as pain in the head, 
 ringing in the ears, impaired vision, giddiness, loss of memory, 
 drowsiness, and other evidences of cerebral hyperaemia ; to 
 which are added, in many cases, more or less numbness, or 
 pricking, in the extremities. In other cases, the patient, pre- 
 viously in apparent health, falls down insensible, with a total 
 abolition of the sensorial functions, or manifests a momentary 
 apprehension of impending danger, by raising his hands to his 
 head, and making some alarming exclamation, at the very in- 
 stant of falling. The degree to which the sensorial functions 
 are affected varies. In very severe cases, sensation, conscious- 
 ness, and voluntary motion, are all lost ; in others, there is a 
 greater or less degree of senso-motory impairment, the patient 
 being in a state of semi consciousness, sensible to outward im- 
 pressions, and capable, to some extent, of voluntary move- 
 ments. The pupils are at first generally contracted, frequently 
 in an unequal degree ; but in some cases they are largely dila- 
 ted, and insensible to the stimulus of light. More or less 
 paralysis is associated with the attack, however light the stroke. 
 Generally, one side of the body is motionless, constituting 
 hemiplegia. The tongue is twisted towards the paralyzed side, 
 deglutition is lost, or greatly impaired, respiration is slow and 
 heaving, and the breathing loud and stertorous. Constipation 
 and retention, or involuntary discharge of urine, are also attend- 
 ant symptoms. Though the power of voluntary motion is gen- 
 erally entirely lost, there is sometimes more or less rigidity or 
 spasmodic contraction of the muscles, confined, of course, to the 
 unparalyzed side. The pulse is sometimes slow, full and bound- 
 ing ; at other times it is weak, small and intermittent. In the 
 former case, there is more or less heat and flushing of the face, 
 with warmth of the extremities ; in the latter, the face is pale 
 and shrunken, and the extremities cold. 
 
CEREBRAL APOPLEXY. 79 
 
 TREATMENT. — During the paroxysm the patient should be 
 kept in such a position as will favor the return of blood from 
 the head. The head and shoulders should be raised by pillows ; 
 the clothing loosened about the neck and chest, and obstructed 
 access of cool air to the patient's chamber at all times secured. 
 
 The lower extremities should be kept warm by means of 
 frictions, warm foot baths, flannel wrappings, etc. ; and the 
 bowels emptied from time to time with lavements of tepid wat- 
 er, to which may be added, if necessary, a tablespoonful or two 
 of sweet oil. Attention, also, should be paid to the bladder, 
 and the urine drawn off with the catheter whenever necessary. 
 
 Diet and Regimen.— In the early stages of the attack, 
 the diet should consist exclusively of gum water, barley or rice 
 water, toast water, and such like farinaceous drinks ; but as the 
 case advances, and improvement sets in, more nutritious sub- 
 stances may be cautiously administered, such as milk, soft 
 boiled eggs, beef tea, etc., provided no ill effects are thereby 
 produced ; but if, on strengthening the diet, the face becomes 
 flushed, and headache ensues, all stimulating articles of diet 
 should be immediately withdrawn. 
 
 THERAPEUTIC INDICATIONS. 
 
 Arnica. — Drowsiness, with moaning and insensibility ; 
 eyes staring and dim ; pupils contracted or dilated ; pulse full 
 and strong ; respiration labored and snoring ; involuntary 
 evacuations of faeces and urine ; paralysis, especially of the left 
 side. This remedy is suitable for cases depending either upon 
 extravasations or determinations of blood. 
 
 Baryta. — Drowsiness, semi-consciousness, or coma somno- 
 lentum ; obscuration of vision ; pulse small and irregular ; 
 breathing short and suffocative ; frequent discharges of urine 
 and faeces ; paralysis, especially of the right side ; mouth and 
 tongue drawn to one side ; great restlessness and moaning. 
 
 Belladonna. — Drowsiness, stupor, loss of consciousness ; 
 
80 PRACTICE OF MEDICINE. 
 
 eyes red and staring ; pupils dilated ; pulse full and slow ; 
 breathing labored, irregular and stertorous ; convulsive move- 
 ments ; paralysis of limbs, tongue, etc. ; involuntary discharges 
 of faeces and urine ; redness of the face and icy coldness of the 
 extremities. 
 
 Cocculus. — Vertigo, stupor, and loss of consciousness ; spas- 
 modic rolling of the eyes, with the lids half closed ; dimness of 
 vision ; pupils contracted or greatly dilated ; pulse small and 
 hard ; breathing tight and oppressed, with snoring; frequent 
 evacuations ; convulsions and paralysis, especially of the lower 
 limbs ; and strong determination of blood to the head. 
 
 Lacliesis. — Drowsiness, sopor and insensibility ; eyes dim 
 and distorted ; pulse small, weak and irregular, or full and hard ; 
 respiration labored, with slow, heavy, whizzing breathing ; bow- 
 els generally constipated ; trembling of the muscles ; paralysis, 
 especially of the left side ; and congestion to the head, with 
 blueness of the face. 
 
 Laiirocerasiis — Insensibility, with complete loss of con- 
 sciousness and sensation ; eyes distorted and staring ; vision 
 lost ; pupils contracted and immovable ; pulse small, slow and 
 irregular ; convulsions, with subsequent paralysis, including 
 paralysis of the sphincters ; great coldness, with deficient 
 susceptibility to the action of remedial agents. 
 
 Mercnrins. — Vertigo and loss of consciousness ; dilatation of 
 pupils, with vanishing of sight ; feeble, slow and trembling 
 pulse ; dyspnoea ; urine dark and turbid ; constipation ; spas- 
 modic movements ; paralysis ; great sinking and prostration. 
 
 Nux Vom. — Sopor, with snoring ; eyes dull and blurred ; 
 pulse full and hard, or small and collapsed ; suffocative fits, or 
 anxious dyspnoea ; retention of urine; constipation ; paralysis, 
 especially of the lower limbs ; attacks preceded by vertigo, 
 roaring in the ears, headache, etc. 
 
 Opium. — Sopor, preceded by vertigo, cephalalgia, etc. ; 
 
CEREBRAL APOPLEXY. Si 
 
 pupils dilated and insensible ; pulse, slow, weak and intermit- 
 tent ; respiration slow and snoring ; constipation ; retention of 
 urine ; convulsive movements, with trembling of the limbs ; red 
 and puffed face ; attacks preceded by cerebral congestion 
 disposition to sleep, and vacant look. 
 
 Pulsatilla. — Drowsiness and loss of consciousness ; eyes 
 dull and bleared ; pulse very weak ; respiration impeded and 
 rattling ; retention or incontinence of urine ; constipaticn ; ex- 
 cessive debility and trembling ; crimson hue of the face, with 
 swelling ; and, if occurring at or before the climacteric period, an 
 arrest or disturbance of the menstrual functions. 
 
 Stramonium. — Vertigo, stupor and insensibility ; pupils 
 dilated and insensible ; pulse small, irregular and almost ex- 
 tinct ; deep stertorous breathing ; frequent blackish stools ; 
 involuntary emissions of urine ; spasmodic rigidity and trem- 
 bling ; loss of sense and of voluntary motion, with suppression 
 of all the secretions. 
 
 Zinc. met. — Great drowsiness, with frightful dreams, or 
 stupor ; weariness, with vanishing of sight ; quick and irregular 
 pulse ; spasmodic dyspnoea ; retention of urine ; constipation ; 
 paralytic weakness, heaviness and trembling ; cold hands and 
 feet, stupefying headache, and livid face. 
 
 COUP de SOLEIL ; SOLIS ICTUS-SUNSTROKE. 
 
 Sunstroke may be defined to be a paralysis of the cere- 
 bral functions caused by heat, the result, generally, of long con- 
 tinued exposure to the direct rays of the sun. It is a disorder, 
 which, so far as the general symptoms are concerned, bears a 
 close resemblance to apoplexy ; indeed, until within a recent 
 period, it has commonly been regarded as a species of that dis- 
 ease. Since, however, the term is used to denote two different 
 conditions, namely, true sun stroke and ther7nic exhaustion, it is 
 
%2 PRACTICE OF MEDICINE. 
 
 well to remember, that while the former is distinguished by in- 
 tense fever, the temperature ranging from 108 to 112 , togeth- 
 er with symptoms denoting a profound depression of the ner- 
 vous system, such as insensibility or loss of consciousness, dys- 
 pnoea, lividity of the face, stertorous breathing, coma, convul- 
 sions, paralysis, etc. ; the latter, on the contrary, is character- 
 ized by faintness, or a tendency to syncope, a pallid countenance, 
 a pale, cool and moist skin, and a rapid but feeble circulation. 
 SYMPTOMS. — The attack is generally preceeded by certain 
 premonitory symptoms, such as excessive thirst, more or less 
 giddiness or vertigo, a sense of faintness, frequent disposition 
 to urinate, stupidity, and sometimes drowsiness. The bowels 
 are generally constipated, but sometimes diarrhoea occurs, es- 
 pecially in the case of children. Unless relieved, the patient 
 either gradually or suddenly, falls into a state of insensibility, 
 attended with coma, stertorous breathing, convulsions, etc. ; 
 or he is attacked with syncope, which not unfrequently proves 
 immediately fatal. 
 
 ETIOLOGY. — A hot, moist* and close atmosphere, over 
 exercise, tight and unreasonable clothing, the breathing of 
 vitiated air, and whatever tends to produce suffocation, all con- 
 spire to produce an attack ; especially if there be superadded, 
 great bodily fatigue, a heated atmosphere, or prolonged expos- 
 ure to the direct rays of a tropical sun. Hence, soldiers serving 
 in hot climates often suffer from sunstroke, their warm, tight- 
 fitting uniforms, heavy accoutrements, and long, weary marches, 
 predisposing to, and frequently precipitating such attacks, es- 
 pecially when exposed to the rays of a burning sun. 
 
 Dr. R. R. Gregg, of Buffalo, the author of what is known 
 
 * " When the air is already charged with vapor, evaporation takes place slowly. Hence 
 the deadly nature of heat and moisture when combined. The evaporation from 
 the skin being checked the body has lost its power of cooling itself. In these facts is to 
 be found the explanation of the circumstance, that in the dry air of southern central Africa, 
 sunstroke is least frequent, whilst it is most fatal in the moist climate of the low plains of 
 India. Moisture in the air is therefore a favoring circumstance for the production of sun- 
 stroke."— Dr. H. C. Wood, Jr. 
 
COUP DE SOLEIL. 83 
 
 as the "vapor theory!' assumes the cause of sunstroke to be 
 " pressure upon the brain by vapor generated from the water of 
 the blood by the excessive heat of the body that exists in such 
 cases." This may possibly be true, at least in some cases, but 
 as it is a mere hypothesis, it is not entitled, in the present state 
 of our knowledge on the subject, to any great weight. One 
 thing, however, is certain, the true and only known cause of sun- 
 stroke is heat, and heat alone, but the modus operandi of its ac- 
 tion has not yet been demonstrated. 
 
 PATHOLOGY. — As already remarked, the opinion was long 
 entertained, that sunstroke is simply a form of congestive apop- 
 lexy. Hence, the old, but generally fatal treatment by bleed- 
 ing. It is now known that the chief pathological state is one of 
 extreme pulmonary congestion, the brain itself being in a nor- 
 mal or nearly normal condition. This fact is well illustrated 
 by the post-mortem appearances in the three fatal cases observ- 
 ed by surgeon Russel, of the 68th regiment of British troops 
 stationed at Madras, and described by him in a communication 
 read before the London College of Physicians, and afterwards 
 published in the Medical Gazette. " The brain," he says, " was, 
 in all, healthy ; no congestion or accumulation of blood was ob- 
 servable ; a very small quantity of serum was effused under the 
 base of one, but in all three tlie lungs were congested even to 
 blackness througJi their entire extent ; and so densely loaded 
 were they, that complete obstruction must have taken place. 
 There was also an accumulation in the right side of the heart, 
 and the great vessels approaching it."* In these, as in other 
 cases, death resulted from asphyxia. 
 
 Treatment. — The burning temperature of the surface, es- 
 pecially of the head and neck, should be reduced as quickly as 
 possible by the free application of cold water, ice, cool air, etc., 
 to the surface, at the same time that the great nervous depress- 
 
 * Graves' " Clinical Medicine," Th'd. Am. Ed. s p. 118. 
 
84 PRACTICE OF MEDICINE. 
 
 ion, and consequent embarrassment of the circulation, is over- 
 come by the cautious administration of stimulents. Whenever 
 practicable, the cold effusion to the head, neck and shoulders, 
 continued until the temperature sinks to 98 or ioo°, is the 
 most speedy and effective way of rescuing the patient from his 
 state of extreme danger. The same end, also, may be speedily 
 and safely accomplished by the judicious use of warm water, so 
 applied as to promote evaporation from the surface.* Thermic 
 exhaustion on the contrary, and the various complications and 
 sequelae, such as convulsions, nausea, vomiting, meningitis, etc., 
 will be best met by time — which is an essential element of cure 
 in most cases — aided by suitable internal medication, agreeable 
 to the following : 
 
 THERAPEUTIC INDICATIONS. 
 
 Aconite. — Burning heat, especially in the head and face, 
 with burning dryness of the skin, excessive thirst, redness of 
 the eyes and cheeks, restlessness and anxiety, nausea, vertigo, 
 and headache aggravated by warmth. 
 
 Aconite is well adapted to relieve the sufferings excited by 
 sunstroke, or by exposure to intense heat, and also to guard 
 against the dangers of excessive reaction ; but it should never 
 be employed in a low form at least, until the period of greatest 
 depression is fully passed. 
 
 Antimonium tart. — The leading indications for the use of 
 this remedy are similar to those given for Aconite, and it should 
 be used with the same precautions ; but it is more especially in- 
 dicated when, in addition to those symptoms, there is much 
 gastric disturbance, great prostration, languor and sense of ex- 
 haustion, or when attended with syncope, convulsions, or 
 paralysis. 
 
 Belladonna. — This remedy is indicated whenever brain 
 symptoms predominate, such as severe headache, vertigo, deliri- 
 
 See Am. Horn. Ois., vol. vi, p. 55. 
 
COUP DE SOLEIL. 85 
 
 um, sensitiveness to light and sound, great anguish, etc., and also 
 when the attack is sudden, the patient falling down insensible, 
 as in apoplexy, with coma, stertorous breathing, lividity of the 
 face, and other symptoms of cerebral and pulmonary congestion. 
 
 Bryonia. — is indicated when, in addition to most of the 
 symptoms already mentioned, there is heaviness and weakness 
 of the limbs ; when the slightest exertion occasions fatigue ; 
 and when there is a marked tendency to syncope, or much un- 
 easiness and apprehension ; also when there is great weakness 
 of digestion, with more or less nausea, vomiting and diarrhoea, 
 especially in children. 
 
 Camphor* — During the first stage, when great depression of 
 both the nervous and circulatory systems exist ; also, after re- 
 action sets in, provided Aconite, Belladonna and Bryonia fail 
 to relieve. 
 
 Glo?ioine. — Intense headache, with throbbing in the front, 
 top and back part of the head, especially when followed by sud- 
 den loss of consciousness. 
 
 Helleborns. — Persistent headache, attended with drowsi- 
 ness, or other evidence of serous effusion within the cranium. 
 
 Hyoscyamus. — When attended with cephalalgia, sleepless- 
 ness, delirium, convulsions, syncope, enuresis, or diarrhoea. 
 
 Silicea. — Frequent micturition, obstinate constipation, 
 great thirst, nausea, vomiting, and other gastric derangements. 
 
 Veratrum vir. — Thermic fever, with great heat of skin, 
 persistent diarrhoea, violent dyspnoea from pulmonary en- 
 gorgement, convulsions, paralysis, or syncope. 
 
 Diet and Regimen. — Gastric derangements, disturbances 
 of the circulation, and various cerebral affections, such as 
 epilepsy, insanity and paralysis, resulting from the profound de- 
 pression of the nervous system, and consequent injury sustained 
 by the great nerve centres, are among the more persistent 
 symptoms of sunstroke, and give rise to great physical prostra- 
 tion, which often lasts for years ; calling for the exercise of 
 
86 PRACTICE OF MEDICINE. 
 
 sound discrimination and judgment as to diet, clothing, exer- 
 cise, climate, and other hygienic influences. The food should 
 be plain and of easy digestion, special regard being had to such 
 articles of diet as are rich in phosphorus, such as fresh scale 
 fish, raw oysters, corn and oat-meal pudding, Graham bread, etc. 
 The clothing should be carefully adapted to the season, and 
 the sensibility of the patient, being neither too thick and warm, 
 nor too thin, since both heat and cold are oppressive and injur- 
 ious.* For this reason, the patient should, if possible, go north 
 in summer, and south in winter; and this should be repeated, 
 if necessary, from year to year, until such time as the patient 
 can bear the varying temperature of his own home. If this is 
 impracticable, underclothing made of soft buck-skin, or fur, may 
 be worn in winter, and such other precautions taken against the 
 effects of cold and heat as the peculiar circumstances of each 
 case may require. Finally, the patient should be encouraged 
 by the assurance, that but few cases are so hopeless that time — 
 which, as already stated, is often an essential element of cure — 
 will not, in conjunction with suitable remedial measures, be at- 
 tended with entire relief. 
 
 CONCUSSION OF THE BRAIN. 
 
 We shall close our chapter on diseases of the brain, with a 
 few remarks on concussion, which though an injury instead of 
 a disease, requires medical treatment for its management, and 
 therefore belongs to the domain of medicine, rather than surgery, 
 where it is commonly placed. 
 
 Concussion may be defined to be, a shock communicated 
 to the nervous system by some external violence, such as a 
 blow or fall, whereby its functions are temporarily suspended, 
 and the vital powers more or less depressed. Sometimes the de- 
 pression is very slight, and the patient quickly recovers ; at 
 others, the shock is so severe as greatly to impede the circula- 
 
 * See Am. Horn. Obs., vol. ix, p. 210, et seq. 
 
CONCUSSION OF THE BRAIN. 87 
 
 tion and retard recovery; while at other times the depressed 
 condition continues, and the patient sooner or later sinks. In 
 the more severe cases, when the system rallies, vomiting is apt 
 to ensue ; this is a favorable sign, as it tends by equalizing the 
 circulation to promote recovery. 
 
 DEGREE OF INJURY. — As might be inferred, every degree 
 of injury has been observed in fatal cases. Sometimes actual 
 rupture occurs ; at others, a soft or semi-diffluent state is pro- 
 duced ; while in other cases, even in those in which the shock 
 and consequent depression are the greatest, no lesion whatever 
 can be discovered. In these cases, no doubt, the patient dies 
 from the effects of the shock alone ; while in the others, the in- 
 jury to the brain interferes with the circulation through it, and 
 though the effects of the concussion upon the general system 
 may be no greater, the character of the injury is such as to 
 permanently depress the vital powers,and death, sooner or later, 
 is the inevitable consequence. 
 
 FINAL RESULTS. — The final results of the injury are as 
 various as the immediate effects. As we have said, some cas- 
 es soon recover ; others rally slowly, the paralysed brain grad- 
 ually regaining its power and functions ; and the patient, after 
 remaining, it may be, for hours in a cold and semi-moribund 
 condition, slowly recovering his activity and senses ; but suffer- 
 ing for a longer or shorter period from headache, confusion of 
 thought, giddiness, and impairment of the mental powers. In 
 other cases, again, should the patient survive the immediate 
 effects of the injury, an irritable state of the brain may re- 
 main, or such an impairment of its functions, as to render it 
 liable to inflammation under the operation of almost any ex- 
 citing cause, such as excess in eating and drinking, mental 
 emotion, etc. 
 
 Symptoms — The symptoms of concussion are, generally, a 
 greater or less degree of pallor, coldness, flaccidity of the mus- 
 cles, and insensibility. Commonly, all power of motion is 
 
88 PRACTICE OF MEDICINE. 
 
 lost ; and if the patient is capable of being partially aroused, 
 he immediately relapses again into a stage of semi-unconscious- 
 ness or insensibility. In this stage the pulse is slow and feeble, 
 the pupils contracted, and the surface pale and cold. The sec- 
 ond stage is characterized by returning warmth and color, the 
 restoration of consciousness and the power of motion, and the 
 gradual re-establishment of the circulation. This stage is gen- 
 erally accompanied by more or less vomiting, depending upon 
 the severity of the concussion. The third stage is marked by 
 extreme physical prostration, a cold, clammy, semi-moribund 
 condition, continuing sometimes for hours, and at last gradually 
 yielding to recovery, or terminating in death. 
 
 Treatment. — This should be directed, first of all, to over- 
 coming, as speedily as possible, the depression of the vital pow- 
 ers, being careful at the same time not to over-stimulate 
 the circulation, but simply aiming at the re-establish- 
 ment of the normal condition. This can generally be best 
 effected by wrapping the patient in warm blankets, applying 
 friction to the surface, and using dry heat* to the extremities 
 etc. As soon as the patient is able to swallow, he may be al- 
 lowed to drink moderately of simple warm teas ; but alcoholic 
 stimulants should be carefully avoided, unless the depression is 
 so great as to imperatively demand their administration, when 
 the quantity should be regulated by the exigencies of the 
 case. 
 
 The chief remedies for concussion, together with the lead- 
 ing Therapeutic Indications, are given in the subjoined 
 table. Consult, also, Table XII, and the Therapeutic In- 
 dications, under the head of Apoplexy. 
 
 * In the case of young children, the warm bath, or hot foot bath, may be used with the 
 greatest advantage, care being taken to prevent the patient getting chilled during its administra- 
 tion ; but in the case of adults, dry heat is generally the handiest as well as the safest mode of 
 applying heat to the surface, the patient being surrounded by hot bottles, or some equivalent 
 substitute. 
 
CONCUSSION OF THE BRAIN, 89 
 
 TABLE XL 
 
 CONCUSSION. — SYNOPSIS OF TREATMENT. 
 
 i. Premonitory Symptoms. — Bell., Dig., Euphor., Hep. 
 Ign., Phos. ac, Rut., Sulph., Verat. 
 
 2. First Stage, — Arn., Ars., Cic, Cocc., Con., Laur., 
 Verat. 
 
 3. Second Stage. — Arn., Bry., Chin., Euphor, Hep., Ign., 
 Nux. v., Op., Phos., Rhus., Sulph., Verat. 
 
 4. Third Stage. — Ang., Cic., Cocc, Con., Dig., Ign., Iod., 
 Merc, Phos. ac, Rhus., Sulph., Zinc 
 
 5. Muscular System. — Ang., Calc, Euphor., Iod., Phos. 
 ac, Puis., Sulph., ac. ; trembling — Aug., Cic, Cin., Hep., Ign., 
 Nux. v. ; spasms — Arn., Ars., Cocc, Con., Laur., Rhus., Sulph., 
 Verat., Zinc ; paralysis — Ang., Calc, Cin., Euphor., Hep., Ign., 
 Puis., Rut., Sulph. ac. ; tendency to paralysis. 
 
 6. Sensorium. — Dig., Euphor., Hep., Ign., Phos. ac, Rut., 
 Sulph., Verat. ; giddiness — Aug., Cin., Con., Iod., Puis., Rhus., 
 Sulph. ac ; drowsiness — Arn., Ars., Calc, Cic, Cocc, Laur., 
 Merc, Zinc. ; insensibility and u/iconsciousuess. 
 
90 PRACTICE OF M EDICINE. 
 
 TABLE XII. 
 
 CEREBRAL DISEASES AND REMEDIES. 
 
 A. HYPEREMIA.— Acon., Arn., Bell., Bry., Coff., 
 Merc, Nux. v., Op., Puls., Rhus., Verat., Anac,Calc,Cham. y 
 Chin., Con., Dig., Dulc, Ign., Ipec, Lyc, Phos., Sil., Sulph., 
 Camph., Caps., Coloc, Hyos., Sep., Spig , Tart., e. 
 
 B. ANEMIA.— Ars., Chin., Fer., Nat., Puls., Staph., 
 Cafe, Carb. v., Cin., Hep., Kal., Lyc, Lack., Merc, Nat. m., Nux. 
 v., Phos., Phos. ac., Sep., Si/., Sulph., Verat., Arn., Bell., Bry., 
 Cham., Nit. ac, Rhus. 
 
 C. VERTIGO.— Acon., Arn., Bell., Bry., Lyc, Nat., 
 Nux. v., Petr., Phos., Rhus., Calc., Camph., Cann., Carb. v., 
 Cocc., Dig., Graph., Ipec, Nat. m., Nit. ac., Op., Puis., Sec. c, 
 Thuja., Verat., Amb., Merc, Mosch.. Phos. ac, Strain. 
 
 D. STUPOR.— Ant. t., Cro., Op., Verat., Ant. c, Bell., 
 Brom., Camph., Cic, Con., Hell., Lact., Later., Phos. ac, Puis., 
 Plumb., Stram., Zinc, Arn., Ars., Bar. c, Caus., Cocc, Dig., 
 Lach., Led., Phos., Sec. c, Sep. 
 
 E. INSOMNIA.— Calc, Camph , Cham., Chin., Coff., 
 Kal., Lyc, Merc, Mosch., Puls., Rhus., Sep., Ars., Bell., 
 Bry., Cin., Con., Fer., Hep:, Hyos., Nat., Sil., S?dph., Aeon., 
 Anac, Cann., Caus., Dig., Dulc, Ign., Lach., Led., Nat. m., Nit. 
 ac, Nux. v., Phos., Plumb., Sang., Spong., Thuja., Verat. 
 
 F. CEPHALALGIA.— Acon., Bell., Cim., Coloc, 
 Glon., Merc, Nux. v., Puls, Sang., Stram., Bry., Calc, 
 Cham., Chin., Igna., Ipec, Sep., Camph., Caps., Cupr., Con., 
 Dulc, Hyos., Op., Rhus., Sil., Spig., Sulph., Tart, e., Tong., 
 Verb., Vio. t., Ver. v. 
 
CEREBRAL DISEASES. 91 
 
 G. MENINGITIS.— Acon., Bell., Bry., Hel., Hyos., 
 Op., Stram., Sulph., Ars., Arn., Campli., Cauth., Chi., Con., 
 Cupr., Dig., Lack., Merc, Rhus., Coff, Crot., Glon., Nux. v., 
 Phosp., Puis., Sil. 
 
 H. CEREBRITIS.— Acon., Ars., Bell, Glon., Iod., 
 PLUMB, Am., Bry., Hyos., Hep., Sulph., Con., Merc., Phos., 
 Rhus., Crot, Coff, Nux. v. Puis, Ver. 
 
 /. ACUTE HYDROCEPHALUS.— Acon,, Arn, Ars, 
 Bell, Bry, Hel, Merc, Sulph, Cin., Con., Dig., Hyos., 
 Lach., Merc., Op., Stram., Coff., Nux. v. Puis, Ver. 
 
 J. CHRONIC HYDROCEPHALUS.— Ars, Calc, 
 Hel., Merc, Plumb, Sil. Sulph, Zinc, Apoc. a., Apoc. c, 
 Ascl. s., Collin, c, Dig., Equiset., Eup. p., Junip. Sumb. 
 
 K. APOPLEXY.— Arn, Bar. c. Bell, Cocc, Lach, 
 Nux. v. Op, Puls, Acon., Anac, Ant. t., Coff., Con., Dig., 
 Hyos., Ipec, Laur., Merc, Strain., Zinc, Ant. c, Ang, Calc.) 
 Cin, Ign, Iod, Verat. 
 
 L. COUP DE SOLEIL.— Acon, Ant. t. Bell, Bry, 
 Camph, Glon, Helleb., Hyos., Sil, Ver. v, Carb. v., Nux. 
 v.. Op., Thuj., Zinc, Amyl. n., Gels., Scut. 1. 
 
 M. CONCUSSION.— Arn., Ang., Ars., Bell., Calen, 
 Cic, Con, Euphor., Hep., Merc, Petr, Puls., Rhus., Rut., 
 Sulph., Verat., Calc, Cin., Cocc, Dig., Ign., Iod., Laur-, Op., 
 Coff-, Hyos., Ipec, Stram., Zinc. 
 
92 PRACTICE OF MEDICINE. 
 
 CHAPTER II 
 
 DISEASES OF THE PROSOPON, OR FACE. 
 
 SECTION I. 
 
 PROSOPALGIA, OR FACE-ACHE. 
 
 TIC DOULEUREUX; NEURALGIA TRIGEMINI. 
 As we shall find it most convenient to describe the various 
 forms of neuralgia in their anatomical, rather than in their 
 physiological relations, this will be the proper place to treat of 
 one of its most common and painful varieties, namely, prosopal- 
 gia, or, as it is generally termed, tic douleureux y or face-ache. 
 This is, for the most part, an affection of the trigeminus, or 
 fifth pair of nerves ; but inasmuch as the portio dura, after pass- 
 ing through the parotid gland, is connected with a twig of the 
 trigeminus, the pain is sometimes, though rarely, felt also in the 
 course of that nerve. Commonly but one branch of the trige- 
 minus, the superior maxillary of one side, is affected ; but not 
 unfrequently two, and sometimes all three of the branches are 
 involved ; and the pain, by implicating the opposite branches, 
 may even extend to the other side of the face. 
 
 Symptoms. — As already stated, the most frequent form of 
 prosopalgia is that involving the middle branch of the trigemi- 
 nus. The pain is generally first felt in or near the infraorbital 
 foramen ; and being seated in the nerve of that name, extends 
 to the inner canthus of the eye, the lower eyelids, the muscles 
 about the zygoma, those of the cheek, especially the buccinater, 
 the upper lip and the alae of the nose. Subsequently the trunk 
 of the nerve, and the branches given off from it in its passage 
 through the infraorbital canal, become affected, the pains being 
 felt in the palate, tongue, zygomatic fossa, the upper teeth and 
 the nasal cavity. As the disease progresses, the pain may ex- 
 tend, as in other forms of prosopalgia, to all parts of the face- 
 
PROSOPALGIA. 93 
 
 The pain is never continual, but occurs in paroxysms of greater 
 or less violence and duration. When fully formed, the 
 paroxysms are frequently attended by a copious salivation. 
 
 Next in order of frequency, the pain commences near the 
 supraorbital foramen, and extending outward along the branches 
 of the frontal nerve and its ramifications, is experienced in the 
 soft parts covering the anterior portion of the cranium ; or it 
 may extend in the opposite direction along the trunk of the 
 nerve, and be felt at the bottom of the orbit. Subsequently, 
 the tunica conjunctiva and adjacent parts become affected, pro- 
 ducing redness of the conjunctiva and lids, with more or less 
 lachrymation and swelling. Sometimes it causes extreme 
 photophobia, the eye becoming so exceedingly painful and 
 sensitive to light, that the patient can scarcely tolerate a single 
 ray. Finally, as in other cases, the pain passes beyond the 
 parts supplied by the frontal nerve, extending itself to the 
 supraorbital, the maxillary, and sometimes, through communi- 
 cating filaments, to the facial, temporal and occipital nerves. 
 
 Less common than either of the preceding, but, when con- 
 firmed, equally intense and obstinate forms of prosopalgia, is 
 that affecting the inferior maxillary nerve. The pain is gener- 
 ally first felt at or near the anterior mental foramen, and ex- 
 tends to the teeth, lower lip, chin, temple and neck. As in the 
 preceding forms of the disorder, the associated branches of the 
 trigeminus, as well as the portio dura of the seventh, frequently 
 become implicated, and then the paroxysms of pain become 
 more or less general over one side of the face and head. 
 
 When the motor nerves become implicated, the muscles 
 supplied by them twitch convulsively, producing distortion of 
 the features, and, in some cases, more or less spasmodic action 
 of more distant parts ; the latter being caused, doubtless, by the 
 extreme pain. The irritability of the affected nerves frequently 
 becomes so great during the paroxysms, that the impressions 
 produced merely by movement, as in talking, sneezing and 
 
94 PRACTICE OF MEDICINE. 
 
 chewing, or by currents of cold air, etc., are often sufficient to 
 renew the attacks. The pains are of a shooting, rending or 
 burning character ; and when the paroxysm is at its height, 
 they frequently become so intolerable, that the patient is utter- 
 ly unable to suppress his cries. 
 
 DIAGNOSIS. — Prosopalgia is very liable to be confounded 
 with hemicrania and rheumatism. From the former it may be 
 distinguished by the seat of the pain corresponding accurately 
 with the course and distribution of the affected nerves ; and 
 from the latter, by the exacerbation being provoked by the 
 slightest touch, by the limited duration of the paroxysm, and 
 by the intolerable character of the pain. From ordinary tooth- 
 ache it may be distinguished by the transient character and 
 rapid succession of the pains, the convulsive twitchings of the 
 muscles, and the coursing of the pains along the tracks of the 
 affected nerves. With reference to those cases in which the 
 portio dura of the seventh pair of nerves becomes implicated, 
 they are sometimes exceedingly difficult to distinguish from 
 those in which only the branches of the trigeminus are involved. 
 The chief difference is, the pains are no longer confined to the 
 course of the trigeminus, but, in consequence of its communica- 
 tion with the other nerves of the face, the agony soon becomes 
 general over the entire side of the head. 
 
 Etiology. — The causes of this affection are generally 
 very uncertain and obscure. Sometimes, particularly when 
 the main trunk is affected, it can be traced to tumors, or 
 bony growths, pressing upon the affected nerves ; and occa- 
 sionally the attack can be satisfactorily referred to such 
 causes as wounds, decayed teeth, the suppression of accus- 
 tomed discharges, rheumatism, gout, syphilis, poisonous 
 cosmetics, etc ; but in the majority of cases, no known cause 
 can be assigned. Even the most careful anatomical and 
 pathological investigations generally fail of eliciting any satis- 
 factory explanation. True, the affected nerves are sometimes 
 
PROSOPALGIA. 95 
 
 found red and inflamed, but the ordinary absence of fever, the 
 sudden, transient, and intermittent character of the attacks, 
 their frequent occurrence in debilitated states of the system, 
 and the usual absence of tenderness on pressure, are suffi- 
 cient proofs that the cause, whatever it may be, is not gen- 
 erally of an inflammatory character. Probably the most fre- 
 quent exciting cause is cold. Next to this, those causes which 
 induce cephalagia, such as mental emotion, severe mental and 
 physical labor, excess in eating and drinking, the abuse of 
 spirituous liquors, tea, coffee and tobacco, excessive venery, 
 etc., no doubt contribute greatly to produce it in those who are 
 predisposed to the affection. What particular class of persons 
 are predisposed to it, however, is not so clear. It is doubtful 
 whether sex has any special influence in this direction, as some 
 suppose, though there are peculiarities in the female constitu- 
 tion which undoubtedly predispose it to other forms of neural- 
 gia, especially such as have their origin in the spine. Probably 
 what is called the nervous temperament, or an excitable dispo- 
 sition, furnishes as strong a predisposing cause as any of which 
 we have any knowledge. 
 
 PROGNOSIS. — The possibility, or even the probability of 
 a cure, depends upon a variety of circumstances. When caused 
 by malarious influences, general debility, pernicious habits, or 
 by cold, a cure is generally easily effected ; but when, on the 
 other hand, structural changes, such as tumors and other morbid 
 growths, give rise to it, there is but little hope of relief. Even 
 in the milder forms of the disease, the patient frequently re- 
 mains more or less subject to the complaint as long as he lives. 
 Death very seldom results from the attacks, however severe 
 the paroxysms ; but it always has a more or less pernicious 
 effect upon the system, undermining the general health, and 
 rendering the mind feeble and the nervous system extremely 
 sensitive and irritable. 
 
96 PRACTICE OF MEDICINE. 
 
 Treatment. — It follows from the purely subjective char- 
 acter and limited range of the symptoms, that the treatment of 
 prosopalgia needs to be conducted with special reference to 
 the cause. Hence it becomes necessary, first of all, to institute 
 a careful scrutiny into the general state of the patient's health, 
 his habits and surroundings, traveling, as it were, beyond the 
 boundaries of the symptomatic indications,in order to ascertain, 
 if possible, the true cause of the malady. In this way the pre- 
 scriber is enabled to make his anatomical, physiological and 
 pathological knowledge contribute not only to the diagnosis, 
 but, in a large proportion of cases, to the cure of this obscure, 
 obstinate and very painful disease. Even with all the light 
 which can be thrown upon it in this manner, the practitioner 
 will often have great difficulty in selecting a suitable remedy, 
 and will as frequently be disappointed ; but it is evident that 
 in no other way, in many cases, can there be any reasonable 
 hope of success. Thus directed, however, the symptomatic in- 
 dications are generally sufficiently definite to suggest the prop- 
 er remedy ; and, as a consequence, homoeopathy has produced 
 many brilliant cures in the domain of this opprobium medicorum 
 of the old school. 
 
 THERAPEUTIC INDICATIONS. 
 
 Arsenicum. — Burning, stinging, or tearing pains in the tem- 
 ples and around the eyes ; inflammation of the conjunctiva ; 
 watering of the eyes ; great restlessness, distress and prostra- 
 tion ; paroxysms occur, or are aggravated, in the evening or at 
 night. 
 
 This remedy is particularly useful when the attacks occur 
 periodically, or when they are caused by miasmatic influences. 
 
 Bellado7ina* — Pains of a cutting or tearing character, es_ 
 pecially when following the course of the infra-orbital nerve, and 
 
 * See Am. Horn. Observer, vol. ii., p. 108; also vol. iii, p. 66. 
 
PROSOPALGIA. 97 
 
 more particularly when associated with symptoms of vascular 
 excitement, such as heat, redness and swelling of the face and 
 eyes, flashes of light before the eyes, and lachrymation ; also 
 when there are convulsive twitchings of the facial muscles, stiff- 
 ness of the neck, shooting pains in the jaws, zygomatic process 
 and nose. The pains are excited or aggravated by rubbing the 
 affected parts and by movement. 
 
 Belladonna is especially applicable to cases caused by con- 
 gestion or inflammation, particularly when produced by the 
 abuse of mercury. 
 
 Chininum Sulph. — This remedy is preeminently adapted 
 to cases pending upon miasmatic influences. Hempel says of 
 it in these cases. "Say what you please against Quinine, it is 
 one of the most indispensable antidotes to the intermittent 
 type of paroxysms resulting from the influence of malaria. We 
 have so often and so satisfactorily cured prosopalgia with five 
 or ten grains of Quinine, administered in grain doses every two 
 hours during the apyrexia, that we can recommend its use to 
 homoeopathic physicians with all the earnestness of one whose 
 knowledge is based upon the most unimpeachable experience, 
 and we advise our friends not to mind the absurd twaddle of a 
 few antiquated ignoramuses, who would fain confine homoeo- 
 pathy to the narrow horizon of their own childish folly." 
 
 Although a firm believer ourself in the homoeopathic prin- 
 ciple or cure, and, as a general rule,* in the adequacy of small 
 doses to overcome diseased action, we can nevertheless heartily 
 subscribe to these views of Prof. Hempel, deeming them by no 
 means inconsistent with rational, that is to say, homoeopathic 
 practice. On the contrary, as before inculcated, ( See the 
 INTRODUCTION to this work ; also, remarks under the head of 
 Diphtheria,) we should be greatly wanting in consistency, and 
 
 * We say "as a general rule," because diseases depending upon mechanical, chemical 
 and toxicological influences, frequently so overpower the vital force, as utterly to preclude 
 the possibility of exciting in the system any permanent reaction, so long as the exciting 
 cause contimies to act upon it. In such cases, it is just as absurd to expect the dynamic forces 
 alone to conquer as it is for a stream of water to seek a higher level than its source. 
 
 13 
 
9$ PRACTICE OF MEDICINE. 
 
 also, as we conceive, in a proper estimate of the true sphere 
 of homoeopathy, did we not strongly endorse all that he says 
 on this subject. For whether the nervous system be primarily 
 affected in this condition or not, it is generally admitted that, 
 like a string of a puppet, its action corresponds, both in charac- 
 ter and duration, to the special influences operating upon it. It 
 is also admitted that Quinine is an antidote to the miasmatic 
 poison. It follows, therefore, that it should be administered in 
 sufficient quantity to antidote, or, if any one likes the expres- 
 sion better, to counteract the poisonous principle, whether it be 
 mild or severe. Nor does it alter the question, so far as the 
 matter of dose is concerned, whether, the action of the poison 
 on the nervous system is mediate or immediate ; whether, in 
 fact, the poisonous principle acts primarily upon the blood, and 
 through it upon the nervous system, thus derangeing its func- 
 tions, or whether it acts in some other and more occult manner ; 
 it is sufficient for us to know that a poison, sui generis, is affect- 
 ing the constitution, and that a true and sufficient antidote is 
 needed for it. 
 
 Colocynthis. — Darting and tearing pains particularly on 
 the left side of the face, with redness and swelling of the affect- 
 ed parts ; aggravated by the slightest touch, by cold, and by 
 movement of the facial muscles. 
 
 This medicine is of great use in catarrhal cases, or when 
 caused by mortified feelings, (Hartman), or by cold. 
 
 Gelseminum. — Darting pains, especially around the eye, 
 or in the course of the infraorbital nerve and dental branches ; 
 also when there are twitchings and contractions of the facial 
 muscles, particularly of the eyelids ; or where there is great 
 nervousness, a semi-paralyzed condition of the voluntary mus- 
 cles, or a distorted appearance of the eye. 
 
 This remedy has been employed with marked success in 
 periodical cases, especially of the quotidian type, (LlJDLAM.) It 
 is equally valuable in catarrhal cases, if used low. 
 
 Hepar Sulph. — Drawing and tearing pains in the cheek 
 
PROSOPALGIA. 99 
 
 and temple, sometimes extending into the ears, and aggravated 
 by pressure and by warmth ; also, pains in the teeth, aggravat- 
 ed by contact or by eating. 
 
 Hepar sulphuris is suitable for cases caused by the abuse of 
 mercury, as in salivation. 
 
 Iris Versicolor. — Prosopalgia involving all or any one of 
 the branches of the trigeminus, especially when associated with 
 "sick-headache," beginning in the morning and subsiding at 
 night. 
 
 Kalmia* — Violent rending and drawing pains in the 
 cheek, with redness ; darting pains in the jaws and teeth ; and 
 throbbing pains in the head. 
 
 This medicine is said to have acted with magical effect in 
 many cases of prosopalgia where all the usual remedies had 
 failed, (SNELLING.) 
 
 Mercurins. — Tearing, stinging or stitching pains, occur- 
 ring in the evening or at night, and aggravated by the warmth 
 of the bed ; also, facial pains caused or aggravated by carious 
 teeth, or by cold, particularly if accompanied by great rest- 
 lessness, wakefulness, swelling, ptyalism, or perspiration of 
 the face and head. 
 
 Mercurius is an appropriate remedy in catarrhal cases; 
 also in those of an inflammatory character. 
 
 Mezereum. — Stupefying and pressive pains, chiefly in the 
 left zygomatic region, occurring in paroxysms, and extending 
 over the face, head and shoulder. The pains are accompanied 
 by twitching of the facial muscles ; and are aggravated or re- 
 newed by warmth, especially by eating anything hot. 
 
 This remedy is particulary applicable to cases of a syphili- 
 tic origin, and also to cases arising from the abuse of mer- 
 cury. 
 
 Nux Vomica. — Rending and drawing pains in the infra-or- 
 bital region, sometimes extending into the ear, with redness of 
 
 * See Am. Horn. Obs., vol. i, p. i( 
 
100 PRACTICE OF MEDICINE. 
 
 the face, or of one of the cheeks ; tingling and twitching of the 
 facial muscles, lachrymation, and more or less numbness of the 
 affected parts. 
 
 Nux vomica is very suitable for coffee drinkers, particular- 
 ly those of an irritable disposition ; also for cases occurring 
 after a debauch, severe mental labor, watching, etc., especially 
 when attended by constipation, or by derangement of the diges- 
 tive organs. 
 
 Platina. — Creeping pains, with a feeling of coldness and 
 numbness, especially on the right side of the face ; renewal or 
 aggravation of the sufferings at night, and during rest. 
 
 Platina is well adapted to hysteric females, especially when 
 troubled with anguish of the heart, or palpitation, or when the 
 catamenia are deranged. 
 
 Rhus Tox. — Rending, stinging, burning or drawing pains, 
 especially in the supra-orbital and superior maxillary nerves; 
 renewal or aggravation of the pains at night, and increased by 
 the warmth of the bed, or by rest. 
 
 This remedy is suitable to catarrhal cases, or such as are 
 caused by exposure to cold and dampness. 
 
 Sepia. — Tearing, drawing or aching pains in the face and 
 nose, with swelling of the cheeks, and with or without redness 
 or flushing of the affected parts. The pains frequently extend 
 through the ear, especially the left, and are aggravated or re- 
 newed by either hot or cold things taken into the mouth. 
 
 This is one of the most useful remedies in the prosopalgia 
 and toothache to which delicate, sensitive, nervous females are 
 subject, particularly when the uterine functions are disturbed. 
 
 Spigelia* — Violent tearing, shooting and jerking pains in 
 the supra-orbital, orbital and malar regions, excited or aggravated 
 by motion, contact, cold and dampness, occurring in paroxysms, 
 and sometimes periodical. The pains are accompanied by more 
 or less precordial anguish, lachrymation, and glossy swelling 
 of the affected parts. 
 
 Spigelia is one of the most useful remedies in prosopalgia 
 especially in cases of a catarrhal or rheumatic character. 
 
 Verbascum. — Flashing, stupefying or jerking pains, seated 
 chiefly in the left zygomatic region, and aggravated by motion, 
 contact and exposure to cold. The paroxysms are short but 
 violent, and are often renewed by the slightest touch, and even 
 by talking, chewing or sneezing. 
 
 * See Am. Horn. Ois., vol. x, p. 237, 3d. 
 
PROSOPALGIA. IOI 
 
 Consult also the following table. 
 
 TABLE XII.— Prosopalgia/ 
 
 Arthritic— COLOC, Merc, RHUST., Canst, Nux. v., Spig, 
 Bell., Bry., Calc., Hep. s., Igna., Lye., Puis., Sep., Staph., 
 Sulph. 
 
 Catarrhal. — Bry., Coloc, Gels., Lyc, Merc, Nux. v., 
 Rhus, t., Sep., Spig., Calc, Chin., Cin., Graph., Staph., Aeon., 
 Caust., Cep., Cham., CofF., Phos., Puis., Sulph. 
 
 Hysteric — Bell., Gels., Igna., Plat., Aur., Lach., Puis., 
 Sep., Calc., Carb. v., Caust., Iris v., Kal., Phos., Sab., Staph., 
 Sulph., Verbas. 
 
 Inflammatory. — AcON., Arn., Bell., Bry., Merc., Phos., 
 Staph., Sulph., Bar. c, Lach., Plat, Thuj., Ver. a., Calc., 
 Cham., Hyosc, Nux. v., Puis. 
 
 Mercurial.— Carb. v., Chin., Hep. s., Mez., Aur., Bell., 
 Nit. ac, Sulph:, Puis., Staph: 
 
 Nervous. — Bell., Iris, v., Kal:, Lach., Nux. v., Plat,, 
 Spig., Verbas:, Caps., Hyos., Lyc, Sep., Sol. n., Aeon., Caust., 
 Cham., Chelid. m., Coff., Coloc., Kal. bic. 
 
 Odontalgic — Bell:, Cham., Gels., Merc, Nux. v., Aeon., 
 Ars., Coff., Hyos., Igna., Rhus, t., Sep., Spig., Calc, Carb. v., 
 Caust., Chin., Phos. ac., Sab., Staph. 
 
 Periodical. — Ars., Chin, s., Gels., Bry., Caps., Ced., Chin., 
 Nux. v., Puis., Aeon., Arn., Bell., Cauth., Calc., Carb. v., 
 Caust., Coff., Con., Merc., Rhus t., Sep., Sulph. 
 
 Rheumatic — ACON., Arn., Bry., Merc, Mez., SULPH., 
 Caust., Chin., Hep. s., Lach., Nux. v., Cim. r., Phos., Puis., 
 Spig., Ver. a. 
 
102 PRACTICE OF MEDICINE. 
 
 SECTION II. 
 
 DISEASES OF THE EYE. 
 
 Ophthalmic diseases, especially those of an inflammatory 
 character, have hitherto, for the most part, been regarded by 
 us, as well as by many allopathists, as a single affection, where- 
 as the structures which enter into the composition of the eye 
 are, like those of the encephalon, so diverse as to require sepa- 
 rate consideration. For what resemblance, except in a general 
 way, is there between conjunctivitis, iritis, scleritis and retinitis, 
 to say nothing of the various forms which even the first men- 
 tioned disease assumes in different cases ? We do not propose, 
 however, to describe, much less to enter into any considerable 
 detail concerning many diseases to which this organ is subject — 
 this must be left to special treatises — but simply to describe 
 the more common forms of inflammatory and other diseases of 
 the eye, in a manner sufficiently ample and accurate to enable 
 one, by means of the symptomatic indications, to treat diseases 
 of this organ with the same scientific precision that characteris- 
 es our treat; nent of other diseases. For it must be confessed 
 that, until within a very recent period, ophthalmic medicine in 
 our school has not kept pace with the general advance of homoe- 
 opathic practice. On the contrary, it has hitherto remained, for 
 the most part, in its very infancy ;* so that our ophthalmic 
 literature furnishes but a modicum of pure grain, in comparison 
 with the large amount of chaff with which it abounds. This 
 arises, however, from no defect in our system of practice, since 
 the success which has attended the treatment of eye diseases 
 under the law of similia y has been much greater than that 
 
 * The only work we now have is Angell's " Treatise on Diseases of the Eye" the fourth 
 edition of which, just published, is, I regret to say, very deficient both in description and treat- 
 ment ; especially the latter. 
 
DISEASES OF THE EYE 103 
 
 under allopathic treatment, as evidenced by the fact that the 
 authorities have substituted the former for the latter in some of 
 the great public charities ;* and also by the fact that certain 
 diseases not amenable to allopathic treatment, such as incipient 
 cataract, have in some instances unquestionably yielded to 
 homoeopathic medication. Perhaps this very success has been 
 the meansof retarding, rather than advancing.this special branch 
 of medicine among us, by satisfying the demands of the public 
 with less than what would have satisfied it, had the result of 
 allopathic treatment been greater. 
 
 The chief difficulties under which we labor in these cases are 
 two-fold ; first, the limited number of symptoms pertaining to 
 the disease, depending for the most part upon the purely local 
 character of the affection ; and, secondly, the defects of our 
 Materia Medica, so far as the eye symptoms are concerned, 
 arising from the incomplete, careless and imperfect character of 
 our provings. The latter only can be remedied, and is there- 
 fore the principal road to improvement in this branch of medi- 
 cal science. If under such adverse circumstances the superior- 
 ity of the homoeopathic ophthalmic practice is manifest, what 
 brilliant results may we not justly expect, when our Materia 
 Medica shall be freed from its incomplete and unreliable symp- 
 toms, and indications based upon scientific observations, be sub- 
 stituted in their place ? Meanwhile, and as a humble initiatory 
 effort in this direction, we shall attempt to make such use of the 
 materials before use, as will fairly represent the existing state of 
 our knowledge on this important subject. 
 
 ANATOMY OF THE EYE. 
 
 It is not necessary, nor would this be the proper place, to 
 give even a general description of the anatomy of the eye, as 
 every physician is supposed to be sufficiently acquainted with 
 
 See Am. Horn. OZ>s., vol. iv, p. 386. 
 
104 
 
 PRACTICE OF MEDICINE. 
 
 both its structure and physiology. It will be well, however, 
 before entering upon the study of the various affections which 
 we shall have to consider under this head, to refresh the mem- 
 ory by means of the following diagrams, which, in connection 
 with the explanatory references, will be found to be of far 
 greater practical value than the most labored description. 
 
 i. Sclerotic coat, or sclera, 
 consisting of a white, fibrous, 
 dense, and somewhat elastic 
 membrane, covering the pos- 
 terior five-sixths of the globe, 
 and giving shape and firmness 
 to the organ. 
 
 2. Chotoid, or second tunic. 
 This is a thin vascular coat, 
 which, like the sclera, covers 
 the posterior portion of the 
 eye, and is pierced near the 
 centre to admit the optic 
 
 In front it unites with, and 
 
 HORIZONTAL SECTION OF THE RIGHT BYE. 
 
 nerve and vessels of the retina, 
 forms a part of the ciliary body and iris. The outer portion of 
 this coat consists of the larger vessels, connected by a delicate 
 cellular tissue, and an abundance of brownish pigment ; the 
 inner portion consists of the capillary vessels of the mem- 
 brane. 
 
 3. The cornea, or "window" of the eye,* consisting of a 
 transparent fibrous membrane, similar in structure to the sclera, 
 covering the anterior sixth of the globe. It is composed of five 
 layers ; an outer epithelial layer ; the elastic layer of Reichert ; 
 the true cornea ; the layer of Descemet ; and an internal epithe- 
 lial layer ; the two latter constituting the anterior or corneal 
 
 * This is popular language only, since the pupil is the only true window, or opening of 
 the eye. 
 
DISEASES OF THE EYE. 10 5 
 
 portion of what is generally known as the membrane of the 
 aqueous humor. The cornea, though largely supplied with 
 nerves, contains no blood vessels ; consequently it never exhibits 
 any appearance of vascularity, except when diseased . 
 
 4, 5- The membranes of Descemet and Reichert. (See 
 Cornea.) 
 
 6. The iris. This is a beautifully colored vertical mem- 
 brane, or curtain, attached by its margin to the ciliary processes, 
 having an opening near its centre called the pupil. Its struc- 
 ture is similar to that of the choroid coat, of which it may be 
 regarded as an extension, just as the cornea may be considered 
 an extension of the sclera ; it differs, however, from the choroid 
 in being more muscular, having a circular set of muscular 
 fibres for diminishing, and a radiate set for enlarging, the pu- 
 pillary opening. It is abundantly supplied with nerves as well 
 as blood vessels ; and is covered posteriorly with a pigment 
 layer, called the uvea. 
 
 7. The canal of Fontana or Schlemm, giving passage to a 
 plexus of veins ; and generally known as the circular venous 
 sinus of the iris. 
 
 8. The conjunctiva ; a transparent and highly vascular 
 mucous membrane covering the anterior portion of the globe, 
 and reflected from the globe to the internal surface of the lids, 
 at the ciliary margin of which it is perforated by the ciliary 
 ducts. The former portion is called the occular conjunctiva ; 
 and the latter the palpebral ; the posterior portion, where it is 
 reflected from the globe to the lids, is frequently called the 
 retro-tarsal fold\ the ciliary edge of the membrane being 
 known as the tarsal conjunctiva. The entire membrane forms 
 a sac, the opening of which corresponds to the edge of the 
 lids. It is abundantly supplied with nerves as well as blood- 
 vessels, the former being derived chiefly from the first, or 
 ophthalmic branch of the trifacial. The palpebral portion is 
 
106 PRACTICE OF MEDICINE. 
 
 thickly studded with papillae, which, when enlarged by disease, 
 give to the membrane a villous or granular appearance. 
 9. Vena vorticosa ; 10. Optic nerve. (See retina.) 
 11. Intervaginal space ; 12. Lamina cribrosa. 
 
 13. The retina, or occular expansion of the optic nerve, 
 forming the internal, or third principal membrane of the eye. 
 It is divided by recent anatomists into no less than ten layers, 
 the principal of which are : the layer of nerve fibres, the layer 
 of rods and cones, and the pigment layer. The first of these 
 is but a simple expansion of the optic nerve fibres, being thick- 
 est at the optic disc, where the expansion begins, and gradually 
 thinning down as it approaches the ciliary processes in front. 
 It lies next the internal limiting layer or surface of the retina, 
 and forms the conducting layer, as that of the rods and cones 
 constitutes the perceptive layer. 
 
 14. The macula lutea, or central transparent spot of the 
 retina, having in its centre a depression called the fovea 
 centralis. 
 
 15. The or a serrata, or posterior edge of the ciliary pro- 
 cesses. The engraver has represented this with a regular curve 
 line, whereas it should be serrated, to correspond with the name. 
 
 16. The zonule of Zinn, or suspensory ligament of the lens. 
 
 17. The crystalline lens, a double convex body, suspended 
 from the ciliary processes immediately behind the iris. It is en- 
 closed in a transparent capsule, the anterior and posterior por- 
 tions of which are denominated the anterior and posterior 
 capsules. The lens is transparent, laminated, and increases in 
 density or hardness towards the centre, or nucleus, where it has 
 about the consistency of soft wax. At birth it is perfectly 
 colorless, but as age advances it acquires more or less of an 
 amber tint, impairing to some extent its transparency. 
 
 18. Ciliary processes. The ciliary processes are some 
 seventy-five or eighty in number, and constitute what is known 
 as the ciliary body. This is composed chiefly of the ciliary 
 muscle, covered by the choroid and pigment layer. (See 
 choroid.) The ciliary muscle is composed of two sets of fibres ; 
 
DISEASES OF THE EYE. 
 
 07 
 
 an anterior set which are circular, and a posterior which are 
 radiating or meridional. 
 
 19. The anterior chamber, or concavity, bounded by the 
 cornea and iris. 
 
 20. The posterior chamber, bounded anteriorly by the uvea, 
 and posteriorly and laterally by the lens, a portion of the 
 zonula, and the ciliary processes. The anterior and posterior 
 chambers communicate by the pupil ; and are filled with a 
 transparent watery fluid, called the aqueous humor, which 
 readily escapes whenever the cornea is punctured, but is rapidly 
 restored by secretion. 
 
 21. The vitreous humor. This is a transparent, jelly-like 
 substance, containing neither vessels nor nerves, which occupies 
 the entire cavity of the retina. So far as simple appearance is 
 concerned, it bears a striking resemblance to glass, whence it 
 derives its name. It consists of a loose cellular texture, con- 
 taining water in its interstices, the latter constituting some 
 ninety-eight per cent, of its bulk. The membrane inclosing the 
 vitreous body, and which is but an external condensation of the 
 cellular mesh-work, is called the hyaloid membrane, so named 
 by its discoverer, Fallopius. 
 
 Lachrymal organs.* 
 a, a, Puncta lachry7nalia y or 
 openings of the lachrymal 
 canals, in the lids. 
 
 a, b y c t d, Lachrymal canals- 
 
 b, b. Blind dilatations, or 
 small culs-de-sac, at the orbital 
 extremities of the lachrymal 
 canals, where they turn inward 
 to the lachrymal sac. 
 
 e > fy g- Lachrymal sac. 
 
 THE LACHRYMAL APPARATUS.. 
 
 * After Sommering;. 
 
108 PRACTICE OF MEDICINE. 
 
 e. The blind end of the lachrymal sac. 
 
 g. Termination of the lachrymal sac, at which point there 
 is a slight contraction which serves to distinguish between the 
 sac and duct. 
 
 h, i. The ductus ad nasum, or nasal duct. 
 
 i. Opening of the nasal duct into the nose. 
 
 k, I. Lachrymal gland. This is a small conglomerate 
 gland situated just within the orbit, near the external angular 
 process of the frontal bone. It communicates with the surface 
 of the conjunctiva by means of seven or eight small excretory 
 ducts, which open just above the external angle of the eye. 
 
 DIV. I.— OPHTHALMIC INFLAMMATION. 
 
 ART. I. — CONJUNCTIVITIS. 
 
 Of the various forms of ophthalmic inflammation, we shall 
 first describe Conjunctivitis, as that is not only the most fre- 
 quent, but also the most important affection of the eye which 
 the busy practitioner is called upon to treat. It is referred to 
 under different names — Ophthalmia, Ophthalmitis, Conjunc- 
 tivitis, etc., the first of which is the most common, the last the 
 most correct. As the name implies, it is simply an inflammation 
 of the conjunctival mucous membrane. This membrane is not 
 only the most exposed to atmospheric influences, but also to 
 direct external injuries, to irritations arising from the pressure 
 of dust, cinders, and other extraneous substances in the eye, to 
 inverted or misdirected cilia, and to tumors, changes in the lids, 
 etc. ; all of which excite more or less inflammation of the con- 
 junctiva. It may also arise indirectly from scrofulous, syphi- 
 litic, or other unhealthy states of the constitution, or as a con- 
 sequence of other inflammations, either simple or specific, in 
 other organs or in other parts of the same organ. The simple 
 form, conjunctivitis simplex, does not differ in any essential par- 
 ticular from the catarrhal, so that it is unnecessary to describe 
 it separately. The treatment, also, is similar, the special indi- 
 cations depending chiefly upon the intensity of the inflammation ; 
 these, in severe cases of simple conjunctivitis, being identical 
 with those of the milder varieties of catarrhal ophthalmia. 
 
DISEASES OF THE EYE. 
 
 I09 
 
 FIG 3. 
 
 I.-CATAEEHAL CONJUNCTIVITIS. 
 
 CATARRHAL OPHTHALMIA; MUCOUS OPHTHALMIA. 
 
 This is a simple inflammation of 
 the conjunctiva, resulting from ex- 
 posure to cold and damp. When 
 the inflammatory process extends 
 to the sclera, catarrhal conjunc- 
 tivitis becomes either catarrJw- 
 ■rheumatic or catarrho-arthritic con- 
 junctivitis ; and when it involves 
 the lids, the affection is called 
 blepharoconjunctivitis, or simply 
 
 CATARRHAL CONJUNCTIVITIS. bUfkaHHS. 
 
 Symptoms. — Dryness, itching, smarting and stiffness, with 
 more or less redness, lachrymation, sensitiveness to light, and a 
 feeling as though sand or some other foreign object had gotten 
 into the eye. Sometimes this is really the case, even in catarrhal 
 conjunctivitis, but it is much more apt to occur in the simple 
 form of the affection, since it is in that manner that simple con- 
 junctivitis is generally exdted. The symptom in question is 
 generally due to the roughness of the conjunctival surface, 
 caused by the enlarged and tortuous vessels which characterize 
 the inflammation. Vision is often impaired, especially towards 
 evening, on account of the abundance of mucus secreted at 
 that time and deposited upon the cornea. The palpebral con- 
 conjunctiva is of a bright vermilion hue, frequently flecked with 
 slightly ecchymosed patches of a deeper color, and is sometimes 
 so much increased in extent by relaxation, especially the great 
 fold of the membrane, as occasionally to be twice its usual 
 volume. In some cases, slightly diaphanous granulations, of a 
 lighter color than the general surface, may be perceived upon 
 the general surface, particularly of the upper lid.* Sometimes 
 
 *This is agreeable to most authorities, and is undoubtedly true of the chronic variety, 
 in which alone granulations form a prominent feature; but in the more simple subacute 
 forms, I have generally found them to be most conspicuous upon the lower lid, or rather 
 in the conjunctival folds between the lid and the globe, and such also appears to have 
 been the experience of Eble. 
 
110 PRACTICE OF MEDICINE. 
 
 also little vesicles, or pustules, consisting of slight elevations of 
 the mucous membrane, and containing a serous fluid,* are situ- 
 ated about the margin of the cornea. The eyelids generally 
 participate more or less in the inflammation, whenever the con- 
 junctivitis is of an active character. 
 
 Diagnosis. — The vessels of the occular conjunctiva have a 
 more or less regular distribution (See Fig. j.) ; their trunks are 
 turned towards the circumference of the globe, from which they 
 run forwards in a slightly tortuous, but nearly parallel course, 
 subdividing and inosculating as they approach the cornea, and 
 terminating in very fine points at the distance of about two 
 lines from the outer edge of the cornea, leaving a space around 
 it in the form of a band which is free from redness. The dis- 
 tended vessels are quite superficial, and may easily be displaced 
 by moving the lids. This form of inflammation seldom causes 
 much swelling of the mucous membrane, and is not to be com- 
 pared with the chemosis associated with the more acute inflam- 
 mations of the conjunctiva. In addition to these diagnostic 
 signs, other mucous surfaces suffer when the conjunctivitis is 
 severe, producing more or less coryza, headache, and catarrhal 
 fever. The symptoms, both local and general, remit in the 
 morning, and undergo exacerbation at night. 
 
 Prognosis. — Catarrhal conjunctivitis if properly treated 
 undergoes resolution, and is therefore, generally speaking, free 
 from danger ; but if violent, and especially if wholly neglected, 
 or improperly treated, it may extend to the cornea and sclera, 
 producing opacity and ulceration of the former, granulation 
 and ulceration of the conjunctiva, and other serious conse- 
 quences. 
 
 ETIOLOGY. — Cold and damp are the chief exciting causes 
 of catarrhal ophthalmia as they are of catarrhal affections 
 in general. Great and rapid atmospheric changes, especially 
 from heat to cold, often produce an attack ; so also do cold 
 
 *And therefore not true pustules, though frequently so called. 
 
DISEASES OF THE EYE. Ill 
 
 winds, especially when combined with rain or snow. Changes 
 of clothing, especially such as favor a chill of the surface, 
 are capable of producing it, particularly if the head itself is 
 exposed. Getting wet, either partially or generally, expo- 
 sure to drafts of air, and whatever causes a chill of the body, 
 may all give rise to it ; it is also sometimes caused, appar- 
 ently, by certain atmospheric influences, the nature of which 
 has never been satisfactorily explained. 
 
 Treatment. — The proper treatment for catarrhal con- 
 junctivitis is that which is best adapted to catarrhal inflamma- 
 tions in general, and particularly to coryza, with which it is fre- 
 quently associated. Hence the principal remedies are : 
 
 Aconite* especially at the beginning of the attack. This 
 remedy alone will frequently allay the inflammation, provided 
 no untoward complications exist. 
 
 Apis mel. — This remedy is often associated with Aconite, 
 especially in the first stage, and, not unfrequently, with great 
 apparent benefit. 
 
 Belladonna* — This medicine is best adapted to the more 
 violent forms of catarrhal conjunctivitis, particularly when there 
 exists considerable sensitiveness to light. 
 
 Euphorbinm. — This is often a very efficient remedy in 
 violent forms of the disorder ; also in chronic catarrhal con- 
 ditions, with dryness and itching of the lids and canthi. 
 
 Euphrasia is an excellent medicine, similar in its action to 
 Belladonna, and especially adapted to cases complicated with 
 coryza, or with copious mucous discharges from the nasal pas- 
 sages. It also generally has an excellent effect when applied 
 locally in suitable cases. 
 
 Hepar Sulph. — This remedy is best adapted to the sub- 
 acute forms of catarrhal inflammations ; also in the acute after 
 Aconite and Belladonna, particularly the latter. 
 
 Mercurius.. — This is one of our most efficient remedies in 
 
 *See Am. Horn. Obs., vol. iv., p. 440, (sub-acute; A, 1-10,) 
 
112 PRACTICE OF MEDICINE. 
 
 obstinate cases, especially when associated with a general 
 catarrhal condition of the system. 
 
 Rhus Tox. has also been found useful in bad cases of 
 catarrhal ophthalmia, attended with more or less cedematous 
 swelling of the conjunctiva. 
 
 The chief remedies for the more chronic forms of catarrhal 
 conjunctivitis are : 
 
 A rsenicum, especially when there is ulceration of the cornea 
 and the margin of the lids ; also when there is oedema, lachry- 
 mation, and nightly agglutination. 
 
 Calcarea. — This remedy is particularly useful in cases 
 similar to the above, and of long standing, especially if aggra- 
 vated by reading or sewing. 
 
 Hydrastis Canaden. — This medicine may be used to ad- 
 vantage, both locally and generally, in chronic catarrhal con- 
 junctivitis, especially when attended with ulceration ; it is also, 
 like Hepar Sulph., frequently useful in the acute and sub-acute 
 forms. 
 
 Iodinm. — This remedy is suitable to obstinate cases occur- 
 ring in lymphatic constitutions, and in which there is more or 
 less redness and swelling of the eyelids, with nightly aggluti- 
 nation. 
 
 Phosphorus. — In cases similar to the above, associated with 
 coryza, or with a more general catarrhal condition of the system. 
 
 Staphysagria. — This medicine is well adapted to cases 
 which have become complicated with inflammation of the lids, 
 especially when the meibomian glands are implicated. 
 
 Sulphur. — This remedy is suitable to almost every form of 
 chronic catarrhal inflammation, especially when attended with 
 ulcerations of the margins of the lids, with swelling of the con- 
 junctiva or with opacity or ulceration of the cornea. 
 
 Thuja.— This remedy is found useful in the most violent 
 forms of chronic catarrhal conjunctivitis, attended with thicken- 
 ing and granulation of the lids. See Chronic Purulent Con- 
 junctivitis •, § 2 (2). 
 
DISEASES OF THE EYE. 1 13 
 
 Although the above list of remedies is amply sufficient for 
 the successful treatment of every variety of catarrhal conjunc- 
 tivitis, additional remedies, together with their symptomatic in- 
 dications, will be given after the other forms of ophthalmia have 
 been described. See Tables XIV. and XV.; also Therapeutic 
 Indications at the end of the Section on Ophthalmic Diseases. 
 
 Local Treatment. — Topical treatment, under homoe- 
 opathic medication, is seldom required in either the acute or 
 sub-acute forms of catarrhal conjunctivitis. If, however, owing 
 to constitutional weakness, or other causes, the inflammation, in 
 spite of the indicated constitutional remedies, runs very high, 
 and especially if there be much chemosis, or swelling, cold com- 
 presses will generally give great relief, and aid materially in 
 bringing about speedy resolution. Irritating collyria, however, 
 are never admissible during this stage. It is not until the in- 
 flammation has been somewhat subdued, or else is disposed to 
 linger, or become purulent, that collyria are beneficial ; and 
 then they should be of the most simple character, such as a 
 solution of one grain of nitrate of silver, one or two of the 
 sulphate of copper or zinc, two or three of alum, the same 
 quantity of the acetate of zinc, or five or six grains of borax, 
 to the ounce of distilled water. These should be interchanged 
 from time to time, using such only as are found to be most 
 beneficial and agreeable to the patient, and either discontinued 
 altogether or conjoined with the use of the cold compress, 
 whenever active inflammatory symptoms supervene. If the 
 collyrium, however weak it may be (and it should never be very 
 strong in the early stages of the disease), causes much pain, it 
 should either be abandoned, or greatly reduced in strength, as 
 
 experience shows that such washes generally do more harm than 
 good under such circumstances. By carefully adapting them, 
 however, to the requirements of each particular case, they may 
 be made to contribute to both the comfort and benefit of the 
 patient. If the inflammation prove obstinate, and especially if 
 the discharge assume a purulent character, the case should be 
 treated as directed in the following section. 
 
 is 
 
114 PRACTICE OF MEDICINE. 
 
 2 -PURULENT CONJUNCTIVITIS. 
 
 CONJUNCTIVITIS BLENNORRHOICA ; PURULENT OPHTHALMIA. 
 We propose to describe under this head the varieties of 
 conjunctival ophthalmia originating in the mucous membrane of 
 the eye, and oft^n confined to it, characterized by an increased 
 secretion of a purulent or puriform character. They are : 
 
 a. Conjunctivitis neonatorum, or purulent ophthalmia of 
 newly born infants. 
 
 b. Conjunctivitis purulenta, or purulent ophthalmia in the 
 adult. 
 
 c. Conjunctivitis gonorrhoica, or acute gonorrhceal ophthal- 
 mia. 
 
 These varieties of conjunctivitis are strikingly similar in 
 their symptoms, course and terminations, are all very destruc- 
 tive to the integrity of the organ, and are chiefly distinguishable 
 from each other by the age of the patient, or by the nature of 
 the exciting cause. 
 
 A— Conjunctivitis Neonatorum. 
 
 PURULENT OPHTHALMIA OF INFANTS. 
 
 Symptoms. — This form of conjunctivitis generally sets in 
 about three days after birth, but it sometimes begins at an 
 earlier and sometimes at a later period. At first it is limited to 
 the palpebral conjunctiva, which is red and velvety ; the edges 
 of the lids, also, are somewhat red, particularly at the corners, 
 where they adhere slightly to each other, the adhesion arising 
 from their being kept closed in consequence of pain experienced 
 on exposure to light, and to the secretion by the inflamed mem- 
 brane of a small quantity of white mucus, which may be seen 
 
PRACTICE OF MEDICINE. 115 
 
 on everting the lower lid. This blepharo-blennorrhcea, or bleph- 
 aritis, as it is termed, constitutes what is called the first stage. 
 
 The second stage is marked by the extension of the disease 
 to the ocular conjunctiva, the redness and inflammation being 
 greatly increased, and the inflamed membrane pouring out a 
 copious puriform secretion, which causes adhesion of the palpre- 
 bal edges, and the accumulation between the swollen and 
 inflamed lids of more or less of the purulent matter. In this 
 stage, there is always considerable tumefaction both of the lids 
 and conjunctiva, the loose folds of the latter being distended 
 into fiery rolls, having a finely granulated or villous appearance, 
 and producing in many cases temporary ectropium of one or 
 both of the lids. Photophobia is always great, and generally 
 extreme, the child contracting its brow, and resisting as much 
 as possible every attempt at exposure to the light. Whenever 
 the lids are separated, especially in the morning, a profuse 
 purulent discharge generally gushes out, and pours over the 
 face of the child ; and in all cases the puriform secretion is 
 sufficiently abundant to agglutinate the lids, and, when sepa- 
 rated, to conceal from view the inflamed surfaces. The dis- 
 charge is of different degrees of consistency, and of various 
 shades of color, being generally of a purulent or muco-purulent 
 character, but sometimes ichorous or sanious and even bloody. 
 
 The third stage stage is characterized by a gradual sub- 
 sidence of the inflammation ; the redness and tumefaction abate ; 
 the secretion is not only diminished in quantity, but altered in 
 quality, becoming bland and muculent; the photophobia sub- 
 sides, so that the child will even open its eyes when the light is 
 subdued; and the temporary ectropium, resulting from the 
 eversion and strangulation of the lids, disappears, so that the 
 eye can now be carefully examined. 
 
 RESULTS. — Opacity, ulceration and more or less sloughing 
 of the cornea, as well as adhesion of the iris to its inflamed or 
 ulcerated surface, may all occur in the second stage of the com- 
 
Il6 CONJUNCTIVITIS NEONATORUM. 
 
 plaint. When the whole cornea sloughs and the humors escape, 
 the eye shrinks greatly in size, appearing like a flattened tubercle 
 at the bottom of the orbit, when the humors are retained, the 
 front of the globe only is flattened. When, in consequence of 
 extensive sloughing of the cornea, the iris prolapses and becomes 
 adherent, staphyloma, either partial or general, commonly super- 
 venes; sometimes, however, the tumor thus formed gradually 
 diminishes until only a small brown point remains in the cornea, 
 impairing the vision more or less, according to its situation and 
 extent. The cicatrices *left after healing of the corneal ulcera- 
 tions are opaque, and consequently interfere more or less with 
 vision. Permanent opacity of the cornea, {leucoma albugo,) 
 resulting from a greater or less amount of interstitial deposition, 
 may be either partial or general; in such cases, of course, vision 
 is more or less permanently impaired ; but when the opacity is 
 superficial, or results from a slight degree only of interstitial 
 deposition, the effusion will ultimately be absorbed, and the 
 transparency of the cornea fully restored. 
 
 Prognosis. — When the disease is severe, neglected, or 
 badly treated, the danger to the eye becomes very great, and 
 vision is apt to be permanently injured. On the contrary, if 
 the case be taken in hand early, before the cornea becomes 
 seriously affected, the inflammation can almost always be sub- 
 dued in time to avert the dangers to which this form of con- 
 junctivitis is subject. Indeed, if the cornea remains clear, 
 even if the inflammation has extended to the ocular conjunc- 
 tiva, but little risk is incurred, provided the most prompt and 
 efficient means are employed. But if extensive ulceration or 
 sloughing of the cornea has occurred, or if inflammation has 
 extended to the deeper structures of the eye, producing adhe- 
 sion of the iris, {synechia anterior^) or impairing the transparency 
 of the humors, the loss of vision will be unavoidable. 
 
 ETIOLOGY. — Purulent conjunctivitis of new-born infants has 
 been proven in many instances to be contagious ; and the gen- 
 
PRACTICE OF MEDICINE. 117 
 
 eral appearance of the disease on the second or third day after 
 birth, taken in connection with the fact that, in a large propor- 
 tion of cases, the mothers have been observed to have a morbid 
 vaginal discharge, such as leucorrhoea or gonorrhoea, renders 
 the received notion of its contagious origin from contact of these 
 morbid secretions, highly probable, to say the least. On the 
 other hand, conjunctivitis neonatorum frequently attacks the 
 children of healthy mothers, or, at least, of such as appear to 
 be quite healthy, so that the question as to the contagious 
 origin of the complaint still remains to some extent unsettled.* 
 Whether contagious or non-contagious, however, one thing is 
 certain, namely, that those influences that excite other forms of 
 conjunctivitis are capable of producing this ; thus it is found to 
 be most frequent and destructive among weakly children, and 
 such as are inadequately and improperly nourished, clothed and 
 housed ; also, that it is more prevalent and destructive where 
 large numbers are collected together, as in foundling hospitals, 
 especially those which admit children of the lowest class, the 
 mothers of which are frequently affected with leucorrhceal or 
 other vaginal discharges, and whose infants are often puny, 
 premature and badly nourished. 
 
 Treatment. — In order to avoid unnecessary repetition, 
 we shall mention in this place only a few of the leading medi- 
 cines adapted to this variety of ophthalmic inflammation, refer- 
 ring to Tables XIV and XV, and also to the Therapeutic 
 Indications at the end of the Section on Ophthalmic 
 Diseases, for such additional remedies as may be required in 
 exceptional cases. 
 
 Aconite. — This medicine appears to be incapable of causing 
 a true inflammatory exudation of plastic lymph or pus, and is 
 therefore of no value in this form of inflammation, except 
 
 *It is true, the most recent authorities regard every form of purulent conjunctivitis, even the 
 catarrhal, as somewhat contagious, and this is no doubt true ; but our own experience, no les 
 than that of many others, to say nothing of the general history of the disease, is not such as to 
 warrant us in giving an unqualified opinion on the subject in question. 
 
Il8 CONJUNCTIVITIS NEONATORUM. 
 
 during the first stage of the complaint, and even then it will be 
 most useful if given in alternation with Argent, nit, or Bella- 
 donna. 
 
 Argentum nit. — This remedy enjoys the reputation of being 
 a specific for this form of conjunctivitis ; it is well to alternate 
 it with other medicines whenever special symptoms demand a 
 change of remedies. 
 
 Belladonna. — This remedy is well adapted to the first stage 
 of conjunctivitis neonatorum, especially in the less acute grades 
 of the disease ; its use, however, should not be persisted in after 
 the secretion has become thick and copious, but the practitioner 
 will do well, as a general rule, to resort at once to 
 
 Bryonia: — This medicine is adapted to the second stage, 
 when the conjunctiva has become more or less infiltrated, the 
 secretion being thick and slimy and the lids agglutinated ; but, 
 unless improvement rapidly follows, resort should be had to 
 
 Hepar Sulph., or to the Muriate of Hydrastia, either singly, 
 or in alternation with Bryonia or 
 
 Mercurius. — This is perhaps the most reliable remedy after 
 the second stage has become fully established and plastic exu- 
 dation has taken place, especially if pustules or ulcers have 
 already formed on the cornea. 
 
 Rhus tox. — This medicine is also well adapted to the second 
 stage of the disorder, especially when there is very great swell- 
 ing of the lids and conjunctiva, with redness and hard swelling 
 of the tarsal edges. 
 
 Thuja. — This remedy, which is better adapted to severe 
 forms of catarrhal conjunctivitis, has been recommended chiefly 
 on theoretical grounds ; yet it has been proven to be of consid- 
 erable value in many cases, especially when there is very 
 high inflammation, with great redness and swelling of the lids 
 and ulcerations of the tarsi and cornea. 
 
 Auxiliary Treatment. — Great care should be taken to 
 cleanse the eyes, as often as may be needed, with warm milk 
 
PRACTICE OF MEDICINE. 119 
 
 and water, by means of fine old linen rags, never using the 
 same piece twice, and never opening the lids without first soak- 
 ing them until the dried and glutinous matter is entirely 
 removed. A light linen compress, saturated with a solution of 
 Belladonna or Thuja, of the strength of fifteen or twenty drops 
 of the mother tincture to the glass of water, and frequently 
 changed, may be used to advantage in the first and second 
 stages respectively ; and a solution of A rgentum Nitratum, one 
 grain to the ounce of distilled water, and kept in the dark, may 
 be dropped into the eye, or applied to diseased surfaces, every 
 six hours during the suppurative stage, by means of a camel's 
 hair pencil, being careful to cleanse the pencil with warm water 
 every time it is used. This application not only destroys the 
 contagious character of the secretion, but acts favorably upon 
 the inflammation, by limiting the exudative process and pro- 
 moting the absorption of the exudation ; and, if carefully and 
 timely applied, it will insure resolution of the inflammation, by 
 preventing disorganization of the ocular structures and conse- 
 quent loss of vision. 
 
 Diet and Regimen. — From what has been said respect- 
 ing the nature and causes of this disease, it is evident that the 
 nutrition of the infant is a matter of the highest importance ;* 
 and for this purpose, healthy maternal breast-milk should, if 
 possible, be obtained. If, however, the babe must be fed with 
 artificial food, well-cooked oat-meal, prepared with half water 
 and half milk, and strained, will, as a general rule, be found to 
 be the best substitute. Due attention to cleanliness, the use of 
 a proper amount of warm, clean clothing, and a plentiful supply 
 of pure air, are matters also which the practitioner should be 
 careful to enjoin. 
 
 * To those practitioners who are accustomed in this complaint to rely wholly on medi- 
 cation, these directions may appear both antiquated and unnecessary; but an experience of 
 many years in its treatment, and the disastrous results which in many cases we have 
 observed to follow the neglect of suitable hygienic measures, especially in public institutions, 
 not only authorize, but demand, we think, their observance in all cases. 
 
120 PRACTICE OF MEDICINE. 
 
 B— Conjunctivitis Punilenta. 
 
 PURULENT OPHTHALMIA OF THE ADULT ; MILITARY OR 
 CONTAGIOUS OPHTHALMIA. 
 
 This form of conjunctivitis is of different degrees of severity, 
 according as it occurs in civil life and under favorable circum- 
 stances, or in the army, in over- crowded barracks, hospitals, etc. 
 In the former case, it is generally a comparatively mild affec- 
 tion, differing in no respect from the milder form of conjuncti- 
 vitis neonatorum just described, except as modified by age and 
 other accidental circumstances. Indeed, there is reason to 
 believe that in some instances it is nothing more than a severer 
 and more dangerous form of the catarrhal. In the latter case, 
 however, owing doubtless for the most part to exposure, a scor-' 
 butic state of the system and want of cleanliness, it has proven 
 exceedingly destructive, no less than eleven hundred cases of 
 blindness having occurred in the Prussian army out of thirty 
 thousand attacked. Sometimes, also, the ravages of the disease 
 are alarming even in civil life, as when it breaks out in asylums 
 and large schools, or when, through neglect of sanitary precau- 
 tions, or the non-observance of suitable hygienic measures, it 
 becomes epidemic. The latter constitutes what is generally 
 known as 
 
 (I.) — ACUTE PURULENT CONJUNCTIVITIS. 
 
 Symptoms. — As in ophthalmia neonatorum, the redness 
 and inflammation are at first confined to the palpebral conjunc- 
 tiva ; there is also more or less lachrymation, stiffness of the lids, 
 and accumulation of whitish mucus on the inflamed membrane. 
 This is the first stage, or blepharo blennorrhea. The inflamma- 
 tion soon extends to the conjunctiva oculi, producing great 
 redness and swelling of the affected membrane, and copious 
 discharge. At first there is simple stiffness of the globe and 
 lids, but this is soon followed by a feeling as though sand or 
 cinders were in the eye. The lachrymation of the first stage is 
 succeeded by a puriform discharge, so copious as to frequently 
 
DISEASES OF THE EYE. 
 
 121 
 
 fig. 4- overflow the lids and face. Che- 
 
 mosis, from swelling of the ocular 
 conjunctiva, becomes so great as 
 frequently to overlap and nearly 
 cover the cornea, forming with the 
 swollen membrane of the lids, two 
 large pinkish rolls or protuberances, 
 which so effectually close the eye 
 as to render a satisfactory view of 
 the cornea quite impossible. When the inflammation extends 
 to the sclera, the pain is greatly augmented, becoming at times 
 almost intolerable ; the constitution also sympathises with the 
 affection, producing a feverish state of the system, attended by 
 headache, throbbing in the temples, loss of appetite, etc. The 
 vascular exitement and suffering remit or abate from time to 
 time, generally in the morning, and sometimes they become 
 distinctly periodical. This is the second stage, commonly called 
 ophthalmo-blennorrhoea. The third stage is marked, by a general 
 subsidence of the foregoing symptoms ; the pain, swelling and 
 discharge diminish, leaving however for a considerable period 
 more or less eversion of one or both of the lids. 
 
 Results. — Among the effects sometimes resulting from 
 acute attacks of purulent ophthalmia, we have opacity, rupture, 
 sloughing, suppuration and ulceration of the cornea, interstitial 
 deposition into and between its laminae, prolapsion and adhesion 
 of the iris, vascularity, thickening and separation of the mucous 
 membrane covering the cornea, staphyloma, ectropium, en- 
 tropium, and enlargement or collapse of the globe. Even when 
 no such effects follow the inflammation, a certain degree of 
 impaired vision (amblyopia) sometimes remains, owing to - 
 changes in the lens, choroid coat, vitreous humor, and vessels of \ 
 the orbit and brain. 
 
 Diagnosis. — The violence of the disease, the purulent char- 
 
 16 
 
122 PRACTICE OF MEDICINE. 
 
 acter of the secretion, and the changes above-mentioned, 
 especially the chemosis, which, as a dropsy of the conjunctiva, 
 is not to be compared with the swelling of the conjunctiva in 
 catarrhal ophthalmia, will serve to distinguish it from the latter, 
 with which alone it is liable to be confounded. Severe cases of 
 catarrhal ophthalmia, attended by puriform secretion, some- 
 times bear a close resemblance to this disorder, and, as already 
 stated, may perhaps be properly regarded as mild cases of the 
 disease ; but the fact that the inflammatory process commonly 
 affects the whole conjunctival surface at once, instead of being 
 confined for a time to the palpebral conjunctiva alone, as in 
 purulent ophthalmia, will, in connection with the history and 
 progress of the case, generally serve to establish a satisfactory 
 diagnosis between them.* 
 
 PROGNOSIS. — Notwithstanding the formidable character of 
 the inflammation, if the cornea be unaffected, suitable treat- 
 ment will generally arrest the disorder ; but if the cornea, and 
 especially the globe, be involved in the inflammation, the event 
 is more or less doubtful. Interstitial deposition, suppuration, 
 and even ulceration, unless considerable, and occurring in a bad 
 state of the system, do not necessarily involve the loss of vision, 
 much depending, of course, on the extent and situation of the 
 changes ; if the centre of the cornea, or any considerable por- 
 tion of it, remains clear, the sight is not likely to be greatly im- 
 paired. The general prognosis depends, of course, on the more 
 or less rapid progress of the inflammation ; the more rapidly it 
 passes through its several stages, the more danger we shall have 
 to fear. Whenever the true nature of the exciting cause can be 
 determined, we shall have still surer ground upon which to base 
 the probable results. Thus, if the blenorrhcea depends upon 
 
 * The following is the diagnosis of Prof. Arlt, Vienna : " The upper lid is to be everted, 
 and if the conjuctiva is sufficiently transparent for us to see the lines of the meibomian glands 
 running toward the eye, of the tarsus, we have a catarrh; if the infiltration is so great as to 
 hide these glands, we have no longer a catarrh, but either a purulent or some graver form of 
 ophthalmia."~ANGELL on Diseases of the Eye, p, 28. 
 
PURULENT CONJUNCTIVITIS. 1 23 
 
 infection, forty-eight, or even thirty-six hours may be sufficient 
 to produce irreparable injury to the cornea, and consequently 
 to vision. 
 
 ETIOLOGY. — Severe catarrhal and mild purulent ophthalmia 
 are so closely related, that it cannot be positively denied tftat 
 the latter may sometimes originate in the same causes that give 
 rise to the former ; but it is generally admitted to be of an in- 
 fectious origin and nature; indeed, in most cases it can be traced 
 directly to some contagious or blenorrhceic secretion, emanating 
 either from the eyes or from the genital organs. The contagion 
 is promoted, of course, by everything which tends to favor it, 
 such as the crowding together of large numbers in the same 
 apartment, thus accounting for its comparatively frequent oc- 
 currence in asylums and large schools, and in army hospitals. 
 The same circumstances, likewise, superadded to exposure, 
 want of cleanliness, and a scorbutic or psoric condition of the 
 system, greatly facilitate the spread of the contagion, and hence 
 the fearful ravages which the disease sometimes makes in the 
 army. 
 
 In proof of its contagiousness, it is only necessary to cite 
 the fact that it has frequently been communicated by direct in- 
 oculation, not only accidentally in persons, but intentionally in 
 animals, the disease having been repeatedly produced in dogs 
 and cats by the application of the purulent secretion to their 
 eyes. Additional confirmation is found in the fact that, being 
 endemic in Egypt, it was first brought to Europe by the English 
 and French armies — whence the name of Egyptian Ophthalmia, 
 by which it is sometimes known — and from this source its pro- 
 gress was traced from the infected to the uninfected, until the 
 Europeon surgeons were, with but few exceptions, cgnvinced of 
 its contagious character. On the other hand, as Lawrence 
 observes, " this notion of a specific contagion, imported from 
 Egypt, originated in Europe, never having occurred in the sup- 
 posed birth-place of the virus. Assalini, and the other medical 
 
124 PRACTICE OF MEDICINE. 
 
 observers who actually witnessed the affection in Egypt, refer 
 it to the ordinary causes of ophthalmic disease." In confirma- 
 tion of the latter opinion, it may be stated, that where collec- 
 tions of individuals affected by it have been separated, the 
 disease, instead of being propagated to others, generally abates. 
 The only rational conclusion, therefore, that we can come to on 
 this subject, is, that as a general rule, when the disease breaks 
 out in over-crowded, filthy, and disease-producing situations, 
 the malady becomes highly contagious and virulent ; while on 
 the other hand, in situations and under circumstances favorable 
 to health, it soon undergoes amelioration, generally losing, to a 
 great extent, at least, its contagious character, and becoming 
 milder and more manageable.* This will satisfactorily account 
 for the milder form which the disease often assumes, not only 
 in civil life, but also in the army, whenever suitable hygienic 
 regulations are observed. 
 
 Treatment. — This should be similar to that recommended 
 for ophthalmia neonatorum, only, as the inflammation is gener- 
 ally of a higher grade, the treatment should, if possible, be still 
 more energetic. As the same indications exist, the same reme- 
 dies will be found applicable, and it will therefore be uneces- 
 sary to repeat them here. See Treatment of Conjunctivitis 
 Neonatorum, and consult also the remedies mentioned in Table 
 XIV, at the end of the section on Ophthalmic Diseases. 
 
 Local Treatment. — Most authors recommend ice and 
 ice water compresses for external use, and when well-borne and 
 regularly and judiciously applied, they are found to be a very 
 efficient means of subduing the inflammation, but it should be 
 remembered that such applications are extremely hazardous in 
 unreliable* and inexperienced hands. We have often obtained 
 much better results from water of a moderate coldness only, 
 applied constantly by means of light linen rags, frequently 
 renewed, taking care to cleanse the eyes from time to time with 
 
 * See Am. Horn. Obs., vol. il, p. 309, et seq. 
 
PURULENT CONJUNCTIONS. 125 
 
 fresh portions of the same. Sometimes even this degree of 
 cold cannot be borne without great pain, in which case it should 
 be used tepid, or else omitted altogether, except for purposes of 
 ablution. 
 
 After the redness and swelling of the inflamed membrane 
 have somewhat subsided, and the pain and soreness have 
 mostly disappeared, astringent washes, composed of such sub- 
 stances as we have already mentioned, will prove most beneficial, 
 especially when used in conjunction or alternation with a solu- 
 tion of Argentum Nitratum, of the strength of from three to 
 eight grains to the ounce, according to the severity of the case, 
 applied by means of a camel's hair pencil, in the manner 
 recommended for the purulent conjunctivitis of infants ; 
 remembering always to rinse the lids immediately after making 
 the application, and not to repeat it oftener than twice a day 
 If the caustic applications are made prematurely, before the 
 inflammation is sufficiently reduced, they will aggravate the 
 complaint, and should at one be suspended, until, by the use of 
 Aconite internally and cold compresses externally, the inflam- 
 mation is so far lessened that they can be resumed with benefit. 
 
 DIET AND REGIMEN. — If the general*health of the patient 
 is good, the diet should be very light, consisting only of farina- 
 ceous food, wholesome fruits, and light, unstimulating drinks ; 
 but if weak and emaciated, and especially if there is a scroful- 
 ous or scorbutic state of the system, the diet should be liberal 
 and nutritious. Should the case linger from any cause, as it is 
 frequently apt to do in a depraved state of the constitution, and 
 especially if the loss of vision be threatened by progressive 
 ulceration of the cornea, such articles as milk, eggs and beef 
 should be prescribed, and if necessary even a moderate amount 
 of port wine should be allowed ; since, in these cases, notwith- 
 standing the inflammation, the danger to the integrity of the 
 organ arises rather from under than from over stimulation. But 
 before resorting to even the mildest stimulative measures, the 
 practitioner should be certain that he has correctly interpreted 
 the constitutional state ; otherwise irreparable mischief will be 
 the consequence. 
 
126 PRACTICE OF MEDICINE. 
 
 GEANULAR CONJUNCTIVITIS. 
 
 CHRONIC PURULENT OPHTHALMIA ; TRACHOMA. 
 
 Fig - 5 - This much the most 
 
 commen form of Puru- 
 lent Ophthalmia, espec- 
 ially in civil life. It is 
 distinguishable from the 
 acute form just describ- 
 ed, chiefly by its being 
 confined, except in very 
 rare instances, to the 
 palpebral conjunctivia ; 
 
 GRANULAR CONJUNCTIVITIS. , ,, 
 
 by its generally running 
 a comparatively mild and very chronic course; and by a gradu- 
 al change of the mucous lining of the lids, especially of the 
 lower, which, after the lapse of several weeks or months, are, so 
 to speak, over-run with patches of minute fleshy growths, or 
 vegetations, called " granulations," which give to the affected 
 membrane a rough, mulberry like appearance, (trachoma)) The 
 size and color of the granulations are generally proportioned to 
 the intensity of the inflammation ; when the conjunctivitis is 
 most intense, they are commonly of a deep red or garnet color, 
 and of a rough, warty, or condylomatous appearance ; but 
 when the inflammation is less violent the palpebral conjunctiva 
 is paler, and appears as if sprinkled with dust or fine sand. At 
 first the granulations are soft and tender, and bleed easily ; 
 afterwards they become more and more indurated, and give to 
 the conjunctiva a somewhat seamed or cracked appearance.* 
 
 SYMPTOMS. — The disease often sets in so gradually as 
 scarcely to attract attention. Commencing with the symptoms 
 
 * It is important to distinguish between granulations , properly so called, and enlarged 
 papillce. The latter ordinarily accompany the former, but are more superficial ; granulations, 
 proper are an inflammatory product, appearing, even before changing into cacatricial tissue, 
 as distinct formations, like grains of sand, lying immediately under the conjunctiva. 
 
PRACTICE OF MEDICINE. 1 27 
 
 of catarrhal ophthalmia, the patient experiences more or less 
 uneasiness in the eye, attended with a feeling of heat or burn- 
 ing, especially of the tarsal edges, which exhibit more or less 
 redness ; sometimes the inflammation is confined to the tarsal 
 portion of the lids for a considerable period ; afterwards, when 
 the inflammation has spread towards the globe, the patient 
 complains of a feeling of dryness and roughness in the eye, as 
 if caused by particles of foreign matter beneath the lids. There 
 is now an increased secretion of tears and of mucus, but little or 
 no pain. The disease may continue in this mild form for two 
 or three weeks, and then terminate under proper treatment? 
 or, in consequence of unfavorable circumstances, it may increase 
 in intensity until it reaches a higher grade, the conjunctiva be- 
 coming redder and more swollen, and secreting a thick, glutin- 
 ous, or puriform matter. The affected membrane now takes 
 on the characteristic granulated appearance ; the lids partici- 
 pate in the general swelling ; and the pain becomes more con- 
 siderable. This, the most inveterate form of the complaint, 
 may last for several weeks or months before it terminates, eith- 
 er by resolution, or, which is more common, by reaching a still 
 higher degree of intensity — a grade which, like the former, it 
 may assume from the beginning. This stage or degree of the 
 inflammation generally supervenes suddenly on the condition 
 just described ; and from its great violence may work irrepara- 
 ble mischief to the organ within a few hours. The pain is now 
 severe, and of a burning, aching or stabbing character ; the 
 granulations become warty and luxuriant ; the lids swell enor- 
 mously ; the purulent discharge becomes profuse ; and a condi- 
 tion of the palpabral conjunctiva succeeds similar to what oc- 
 curs in the third stage of acute purulent ophthalmia, except as 
 modified by the granulated state of the lids. 
 
 RESULTS. — The ordinary and characteristic results of 
 chronic purulent ophthalmia, are such as arise from the thick- 
 ening and granulation of the lids. Even after the removal of 
 
128 GRANULAR CONJUNCTIVITIS. 
 
 the symptomatic affections, so long as the granulations exist 
 there will remain more or less weakness of vision, arising from 
 irritation, together with swelling of the eyelids, a lessening of 
 the palpebral fissure, and, in some cases, more or less eversion 
 of the tarsi. 
 
 In addition to these changes, there is commonly more or 
 less vascularity and opacity of the cornea, generally of its 
 upper half, arising from the friction of the granulated surface of 
 the conjunctiva, which is chiefly limited to the upper lid. The 
 vascularity of the mucous covering of the cornea may become 
 so great as to constitute what is technically termed pannus. As 
 the results of severe inflammation, we may also have ulcer, 
 leucoma, prolapsion and adhesion of the iris, and staphyloma. 
 
 Prognosis. — This is generally favorable ; though there 
 will always remain great liability to relapse, the weakened ves- 
 sels of the conjunctiva becoming congested by very slight caus- 
 es. The constitution, habits and occupation of the patient, as 
 well as the state of tne weather, and other accidental circum- 
 stances, will have much to do with the progress and termina- 
 tion of the case. The disease which appears greatly improved 
 to-day, may be greatly aggravated to-morrow. In this way 
 months and even years sometimes elapse, the superficial and 
 interstitial changes of the palpebral conjunctiva gradually be- 
 coming greater and greater, until it is even doubtful in some 
 cases whether the affected membrane can ever be fully restored 
 to a healthy state. 
 
 Etiology. — The causes of chronic purulent ophthalmia 
 are the same as those which give rise to the acute form,and need 
 not therefore be repeated. Less commonly, the disease suc- 
 ceeds to the acute form ; the latter, owing to bad management, 
 or some vice of the constitution, not undergoing complete reso- 
 lution. , 
 
 Treatment.* — As surgeon in charge of the Ophthalmic 
 
 *See Am. Ho7n. Obs., vol. ^., p. 466. 
 
PRACTICE OF MEDICINE. 120, 
 
 Department of Brown General Hospital, our experience in the 
 treatment of this disease during the late war was by no means 
 inconsiderable ; and as the result of that experience, and of 
 over twenty years practice in civil life, we desire at the outset 
 to express our emphatic disapproval, except in the inveterate 
 form called trachoma ficosa, of the escharotic method of treat- 
 ment. We are convinced that the indiscriminate use of power- 
 ful escharotics in every form and stage of the complaint, has 
 been the means of practicing, and, in many cases, of confirm- 
 ing this formidable affection ; (1) by aggravating the local ex- 
 citement ; (2) by increasing the tendency to relapse ; (3) by 
 renewing and increasing the inflammation ; and (4) by taking 
 the place of more rational and efficient treatment. So far as 
 local measures are concerned, the following distinctions will be 
 found to be of great practical importance : 
 
 1. When the conjunctiva, instead of having its natural pol- 
 ished surf ace, is villous or velvety, or when the gra7iulations are 
 small, pale, and sand- like ; in short, when the so-called granula- 
 tions are quite recent, or when they consist simply in a swollen 
 or hypertrophied state of the conjunctival papillce escharotics 
 are unnecessary, and generally harmful. In these cases, the ap- 
 plication of cold salt-water compresses, whenever demanded by 
 an increase of inflammatory action, and the employment, in the 
 intervals, of mild astringent lotions, such as we have recom- 
 mended for the acute form, with due attention to diet, pure air, 
 and exercise, with repose and protection of the organ,* will 
 generally be found to give the most prompt, marked and per- 
 manent relief. 
 
 2. When the granulations are large, flabby, and easily 
 torn y the above treatment, aided by internal remedies, may still 
 hold them in check, and even promote their absorption ; if not, 
 
 * Dr. Dobrowelski, of St. Petersburg, in Annates a Oculistique, pointr out the com- 
 parative value of blue, and grey or smoked glasses as a protection against the sun's rays, 
 giving the preference to the latter. See Am. Horn. Obs., vol. xi. p, 555. 
 
130 GRANULAR CONJUNCTIVITIS. 
 
 it may be aided by a wash of Kali HYDRIODICUM, or by touch- 
 ing them with a crystal of the Sulphate of Copper, the lat- 
 ter being used only to suppress the exuberance of the granula- 
 tions. 
 
 3. When the granulations have a firm, pale, zvart-like 
 appearance, and cnt like cartilage, escharotic treatment is not 
 only admissable, but required. In these cases we have derived 
 the greatest benefit from passing a pencil of Argent. CUM, 
 CALCE freely over the granulated surface, being particular be- 
 fore restoring the lid to its natural position, to wash it carefully 
 with water or diluted vinegar, in order to prevent any farther 
 action of the escharotic. (See Fig. 5.) This application should 
 never be repeated oftener than once a week, nor the sulphate of 
 copper oftener than once in two, three or four days, according to 
 the amount of local excitement produced by it ; remembering in 
 all cases that, whenever local treatment causes any aggravation 
 of the symptoms, the irritation and increased vascularity must 
 be allowed to subside before repeating it ; that some cases will 
 bear much stronger applications than others ; that when their 
 use is attended by a sense of relief, they are always beneficial ; 
 but when pain and increased vascularity are permanently ex- 
 cited by them, they will always do harm, especially if too fre- 
 quently applied. 
 
 The internal remedies especially adapted to this variety of 
 ophthalmic inflammation, in addition to those previously re- 
 commended, are : 
 
 Acidum nit. — This medicine is suitable for most cases of 
 chronic purulent ophthalmia, especially such as are associated 
 with a syphilitic or mercurial cachexia. 
 
 Graphites. — This medicine is especially indicated when 
 the edges of the lids are implicated, particularly the meibomian 
 follicles. 
 
 Iodium. — -This remedy is adapted to every stage of the 
 complaint, especially when there is a psoric state of the sys- 
 tem. 
 
PRACTICE OF MEDICINE. 13 1 
 
 Kali Hydriodicwn. — In cases similar to those for which 
 Iodium is recommended. 
 
 Lycopodium. — Specially adapted to casrs attended with 
 inflammation and ulceration of the tarsal edges. 
 
 Mercurius. — This remedy is no less useful in the chronic 
 than it is in the acute form of purulent ophthalmia. 
 
 Sulphur. — The same remark may also be applied to this 
 remedy, which is particularly adapted to the chronic form of 
 the complaint, especially when attended with ulceration. 
 
 Thuja. — We mention this remedy because it is strongly 
 recommended by others, and not because we have had any 
 experience with it ourselves. 
 
 For other medicines and for fuller details, see Tablts XIV. 
 and XV. ; consult, also Therapeutic Indicatioiis, at the end of 
 the Section on Ophthalmic Diseases. 
 
 Diet and Regimen. — As granular conjunctivitis is not 
 pnly contagious, but, like the simple form of purulent ophthal- 
 mia, is aggravated by squalor, impure air, want of cleanliness, 
 improper or deficient nourishment, over-crowding of apartments, 
 dampness, miasm, etc., it follows that too much attention can- 
 not be paid to hygienic regulations. Indeed, experience shows 
 that without due attention to these particulars, in the vast ma- 
 jority of cases the improvement, if any, will be slow and un- 
 satisiactory ; while on the other hand, good nutritious food, 
 clean clothing and comfortable surroundings contribute in no 
 small degree towards affecting a permanent cure. 
 
132 PRACTICE OF MEDICINE. 
 
 C,— Conjunctivitis Gonorrhoea. 
 
 ACUTE GONORRHCEAL OPHTHALMIA. 
 
 This variety of conjunctivitis differs in no essential respect 
 from the acute form of purulent ophthalmia already described, 
 except in the specific nature of the exciting cause, and in the 
 more violent and rapidly destructive character of the inflam- 
 mation. Instead, therefore, of giving a detailed description of 
 symptoms, which, for the most part, would be but a repetition 
 of those mentioned in the preceding article, we shall content 
 ourselves with merely pointing out the characteristic features 
 of the disease, by way of 
 
 DIAGNOSIS. — Gonorrhceal conjunctivitis in its most severe 
 form is, with perhaps a single exception, the most rapidly de- 
 structive form of purulent ophthalmia known ; frequently de- 
 stroying the eye, or producing irreparable mischief to the organ, 
 within a few hours. The disease, which at first is generally 
 confined to the conjunctiva, producing symptoms similar to 
 those of simple catarrhal or purulent ophthalmia, soon extends 
 to the globe, causing the most severe and agonizing pains in 
 the head and eye, accompanied with great chemosis, excessive 
 photophobia, and a more or less violent febrile movement of 
 the circulation. At this stage the tumefaction, both of the lids 
 and the orbital conjunctiva, is extreme, completely closing the 
 eye, and rendering a satisfactory view of the cornea utterly im- 
 possible. As the oedema declines, one or both of the eyelids 
 generally become everted, producing temporary ectropium. 
 
 As between the highest degree of catarrhal inflammation 
 and the milder form of simple purulent ophthalmia there is a 
 striking resemblance in the local symptoms, so between the 
 severest grade of purulent inflammation and acute gonorrhceal 
 ophthalmia there is a similar resemblance. The swelling of 
 the eyelids, which is always considerable, is generally more 
 marked in the former, while the chemosis, or oedema of the con- 
 
CONJUNCTIVITIS GONORRHOICA. 1 33 
 
 junctiva oculi, is greater in the latter; the discharge, also, is 
 generally of a brighter yellow, more creamy in consistence, and 
 more abundant. But the chief difference between them is that 
 the latter sets in suddenly with the greatest violence, and 
 proceeds with such rapidity as to terminate in a few hours or 
 days, either by resolution, or what is more common, by destruc- 
 tion of the organ. Again, gonorrhceal ophthalmia, with but 
 few exceptions, attacks only one eye, while the purulent or con- 
 tagious disease generally affects both. Finally, sloughing of the 
 cornea, which is a frequent consequence of gonorrhceal inflam- 
 mation; seldom or never occurs in simple purulent ophthalmia. 
 
 RESULTS. — The immediate results, unless relieved by treat- 
 ment, are : ulceration, suppuration, and more or less sloughing 
 of the cornea, together with interstitial deposition into and be- 
 tween its laminae. The more remote consequences are : corneal 
 opacity, synechia anterior, obliteration of the pupil, staphyloma, 
 and collapse of the globe. Sometimes the sloughing process, 
 though general, is limited to the anterior laminae of the cornea, 
 the posterior layer or membrane of the aqueous humour being 
 left, so that the anterior chamber is not exposed ; in which case 
 the front of the eye remains flattened, or is bulged forward by 
 the protruding iris, forming what is called stapliyloma racemo- 
 sum. 
 
 Prognosis. — In a large proportion of cases, vision is either 
 lost or seriously injured. Since the inflammation is not equally 
 violent in all cases, the prognosis chiefly depends upon its 
 comparative mildness or severity, and upon the state of the 
 cornea. If the latter should be clear, the sight may be saved ; 
 but if it has lost its transparency, and especially if the inflam- 
 mation is of the most acute character, vision will probably be 
 lost or seriously impaired. On the other hand, if the inflam- 
 mation be subdued before extensive sloughing or ulceration 
 occurs, the sight may be restored. 
 
 ETIOLOGY. — This form of ophthalmic inflammation always 
 
134 PRACTICE OF MEDICINE. 
 
 arises from some kind of connection, either innoculative, con- 
 stitutional or metastatic, with the gonorrhceal virus. It has 
 been satisfactorily proven that the application of gonorrhoeal 
 matter, either from the patient's own urethra or from that of 
 another person, is capable of exciting the disease in its most 
 intense form. In a large proportion of cases, however, no such 
 direct application of matter can be traced ; and hence the in- 
 ference is unavoidable, that the disease frequently arises either 
 from metastasis, as orchitis or mammitis arises from mumps, or 
 else that it depends upon some peculiar condition of the con- 
 stitution, in the same manner that rheumatic or arthritic oph- 
 thalmia depend upon similar states of the system to those in 
 which they respectively occur. Probably the latter hypothesis 
 is the true one, since the urethral inflammation is never sup- 
 pressed by the transference of the disease to the eye, and 
 hence a true metastasis, or translation of the disease, cannot be 
 said to occur in these cases. Moreover, the sudden stoppage 
 of gonorrhoea by treatment is not followed by ophthalmic in- 
 flammation, and hence its origin cannot be referred to the cessa- 
 tion of the disease in the urethra. 
 
 Treatment. — The treatment, both local and general, 
 should be similar to that recommended for acute purulent oph- 
 thalmia. The first application should consist of a saturated 
 solution of Ar^entum Nitratum, which should be promptly 
 applied to the diseased surfaces, in the manner described under 
 the head of ophthalmia neonatorum. After the swelling and 
 other effects of the application subside, the remedy should be 
 repeated, observing to lessen the strength of the solution in 
 proportion as the purulent discharge diminishes and the inflam- 
 mation abates. As a general rule, one application per day will 
 be found to suffice, provided it be sufficiently thorough. It is 
 best made by everting the lids, and passing the camel's hair 
 pencil, loaded with the solution, quickly over the distended 
 conjunctiva, taking care to avoid touching the cornea, and to 
 
CONJUNCTIVITIS GONORRHOICA. 1 35 
 
 wash the lids afterwards with tepid water before returning 
 them, especially the first time the application is made. (See 
 
 Fig- 5-) 
 
 It should be borne in mind that the saturated solution of 
 Arg. nit. here recommended is required only in the severest 
 form of the disease. Many cases of gonorrhceal ophthalmia 
 are so mild as to resemble the simple purulent form of conjunc- 
 tivitis, and then require the same treatment. [See § B.) 
 
 Light linen rags wet with a weak solution of Alum en or 
 Muriate of Hydrastia, and frequently renewed, should be kept 
 constantly applied to the affected eye. 
 
 The internal treatment consists mainly of the following 
 remedies : 
 
 Acidum Nitricum. — This remedy is not only pathogen et- 
 ically appropriate, but its use in this form of ophthalmia has 
 been attended with the best results. 
 
 Cannabis sativa. — This medicine, used low, is useful in 
 every stage of the complaint, especially if there is opacity of 
 the cornea, or a spasmodic pressure of the lids. 
 
 Cantharis. — This remedy is indicated in the first stage, 
 when attended with violent stinging and burning pains in the 
 eye and urethra. 
 
 Clematis — This medicine is most useful in the latter 
 stages of the disorder, in cases similar to those for which Can- 
 tharis is recommended. 
 
 Hepar siilph. — This is one of our best remedies in gon- 
 orrhceal ophthalmia, especially in the second and third stages. 
 
 Mercurins. — The same remark applies to this remedy, 
 Mercurius being one of the best, if not the very best remedy 
 for this complaint ; it is more particularly adapted to the high- 
 est state of inflammatory action. 
 
 Additional remedies for this disorder are given in TABLES 
 XIV and XV ; consult also the THERAPEUTIC INDICATIONS 
 at the end of the Section on Ophthalmic Diseases. 
 
136 PRACTICE OF MEDICINE. 
 
 3.— Diphtheritic Conjunctivitis. 
 
 OPHTHALMIA DIPHTHERITICA; CONJUNCTIVIVAL CROUP. 
 
 Closely allied in some respects to gonorrhceal conjunctivi- 
 tis, but differing widely in others, is the diphtheritic. This 
 disease, which seldom occurs in an idiopathic form in this 
 country, and still more rarely in England and France, is not 
 uncommon at Berlin and in Holland. As it appears with us 
 it is most commonly associated with diphtheria in other parts, 
 especially the throat, from which it is transferred either by di- 
 rict contact of the irritating secretions, by sympathy, or by ex- 
 tension of the disease from the nasal passages through the 
 lachrymal canals.* The violence of the disease is such as to 
 render it extremely dangerous to vision ; and when secondary, 
 the danger is greatly increased by the liability to constitutional 
 infection. The idiopathic form is characterized by the follow- 
 ing 
 
 Symptoms. — The disease sets in suddenly, with heat, pain 
 and stiffness of the lids, which soon become distended, hard and 
 rigid, owing to a fibrinous exudation into the conjunctival 
 and episcleral tissues. There is also chemosis of the ocular 
 conjunctiva, from effusion of the same fibrinous material, the 
 pressure of which upon its vessels, by interfering with the cir- 
 culation, gives rise to scattered points of extravasated blood. 
 The discharges are at first thin, watery, and of a dirty gray 
 color, or yellowish and flocculent ; afterwards they become more 
 or less purulent, the pus globules being mixed with shreds of 
 fibrin and disintegrated false-membrane. On examining the 
 lids, the palpebral conjunctiva is found to be covered with a 
 firm fibrinous membrane, which manifests a disposition to sep- 
 arate at the edges, and may be easily detached with the for- 
 ceps. The rapidity with which it is reproduced is truly aston- 
 
 * See Am. Horn. Obs., vol. v, pp.70, 71. 
 
DIPHTHERITIC CONJUNCTIVITIS. 137 
 
 ishing, the false-membrane sometimes attaining a thickness of 
 two or three lines in the course of twenty-four hours. 
 
 Etiology. — The exciting causes of diphtheritic conjunc- 
 tivitis are doubtless the same as those which give rise to diph- 
 theria in other parts ; hence it is found to prevail during the 
 cold and damp seasons of the year Although adults are 
 sometimes attacked, it is generally confined to children between 
 two and ten years of age. According to Williams, some fam- 
 ilies exhibit a constitutional predisposition to the complaint, 
 the children being successively attacked on reaching a certain 
 age. 
 
 Prognosis. — The result, notwithstanding the greatest care 
 and attention, is apt to be unfavorable. The chief danger lies 
 in the great liability to ulceration and sloughing of the cornea 
 from defective nutrition, the corrosive action of the secretions, 
 and the strangulation of the implicated tissues. As an ultimate 
 consequence, we sometimes have entropium, the result of con- 
 traction and other structural changes in the conjunctiva and 
 tarsal cartilages. 
 
 Treatment. — The local treatment should be similar to 
 that already recommended for Acute Purulent Conjunctivitis, 
 using, when well borne, ice and ice-water compresses in the first 
 stage, to which may be added a solution of Kal. chl., 3ij to Oj. 
 In the second stage, when the discharge becomes thick and 
 purulent, the escharotic treatment recommended for Gonorrhe- 
 al Conjunctivitis, should be adopted. (Seethe previous section.) 
 If only one eye is affected, the other should be bandaged as a 
 precautionary measure. 
 
 The internal remedies which have given the greatest satis- 
 faction, and from which most benefit may be expected, are the 
 following: Aconite, Kali chl., Kali bich., Phytotacco dec, during 
 the first stage : Acidum nit., Argentum nit., Arsenicum, Hepar 
 sulph., Mercurius ; during the purulent and ulcerative stage 
 See also Tables XIV. and XV., and the Therapeutic Indica- 
 tions at the end of the Section on Ophthalmic Diseases. 
 18 
 
138 
 
 PRACTICE OF MEDICINE. 
 
 Diet and Regimen. — Cleanliness, which is of primary 
 importance in every form of contagious ophthalmia, should be 
 rigidly enforced in this, especially if but one eye is affected 
 since, should both eyes become involved, the danger to vision 
 will be proportionably increased. For this purpose an abund- 
 ance of soft clean rags should be kept on hand, which should, 
 be burned, or otherwise destroyed, as fast as used. Care 
 should be taken, also, to supply the patient with clean clothes 
 nutritious and easily digestible food, clean and comfortable bed- 
 ding, and an abundance of fresh pure air. If, as frequently is 
 the rooms are small or over-crowded, a liberal use of Carbolic 
 Acid, or other suitable disinfectant, should be made, while at 
 the same time the freest possible ventilation should be secured. 
 
 4.-SCR0FUL0US CONJUNCTIVITIS. 
 
 SCROFULOUS OR PHLYCTENULAR OPHTHALMIA. 
 
 Fig - 6 - Scrofulous ophthalmia, as 
 
 its name imports, is an in- 
 flammation of the eye occur- 
 ring in scrofulous subjects. 
 Its principal seat is the con- 
 junctiva oculi, but it also af- 
 fects, the episcleral tissue 
 and cornea ; and sometimes, 
 scrofulous conjunctivitis. in complicated cases, it ex- 
 
 tends to the choroid coat and iris. The disease is almost en- 
 tirely confined to childhood ; it is said never to occur in infants 
 at the breast, and it is rarely seen after puberty. 
 
 Symptoms. — The disease seldom occurs in a purely 
 simple form, but as already stated, is generally associated 
 with more or less inflammation of the cornea and epis- 
 cleral tissue, constituting what is called scrofulo-rheumatic 
 ophthalmia. It is chiefly characterized by a number of 
 
SCROFULOUS CONJUNCTIVITIS. 1 39 
 
 vessels occupying a circumscribed part of the orbital con- 
 junctiva, generally that which borders upon the commissures 
 of the eyelids, pursuing nearly a parallel course towards the 
 cornea, and forming with each other fasciculi or bundles, which 
 terminate abruptly near the edge of the cornea, without going 
 beyond it. (See Fig. 6.) When, however, the disease is com- 
 bined with catarrhal inflammation, the vessels may extend be- 
 yond the border of the cornea, where they assume the fascicular 
 form characteristic of the scrofulous injection. These fasciculi 
 generally terminate in one or more small vesicles, called phlyc- 
 taena, which, though not belonging exclusively to this affection, 
 are nevertheless so characteristic of the disease, as almost to 
 justify the term phlyctenular ophthalmia, by which it is some- 
 times called. The vesicle or phlyctaena generally appears first, 
 and afterwards the vessels which run towards it become inject- 
 ed. The vesicle either dries up and disappears, or else breaks, 
 leaving a superficial ulcuscle, which extends itself by ulceration. 
 Sometimes the cornea, instead of being ulcerated, takes on a 
 mammillated nebulous appearance, becoming as it were sanded 
 or dotted over with a number of extremely fine points ; (non- 
 vascular or diffuse keratitis ;) or a papulous exudation arises, 
 (vascular keratitis) whichforms a grayish vascular covering to the 
 cornea, giving rise to what is called pannus. 
 
 The external redness, unless the disorder is complicated 
 with catarrhal inflammation, is generally inconsiderable. On 
 the other hand, owing partly to its combination with keratitis, 
 and partly to nervous or ciliary irritation, the sensitiveness to 
 light is so extreme as to constitute a distinguishing feature of 
 the disease, under the name of photophobia scrofulosa. The 
 access of light to the eye is so extremely painful as to cause the 
 child to turn its head obstinately from the light, and, in severe 
 cases, to hide away in the dark, or bury its face in its mother's 
 lap, or in the bed. If the lids are forced open — which, how- 
 ever, need never be done, as both the pain and photophobia 
 
140 PRACTICE OF MEDICINE. 
 
 generally abate at dusk, when the child will open its eyes of its 
 own accord — although the cornea is turned up so as to hide the 
 pupil from view, the orbicularis palpebrarum muscle becomes 
 spasmodically contracted on the globe, producing so much 
 pressure as to cause the child to cry with pain. In uncomplica- 
 ted cases, neither pain nor tears accompany the disorder ; but, 
 as already stated, the complaint is generally associated with 
 keratitis, so that, in addition to the pain — which, as already 
 explained, depends partly upon inflammation of the cornea, 
 and partly upon sympathetic or nervous irritation — there is 
 generally a copious flow of tears, especially at the commence- 
 ment of the disease. These greatly aggravate the complaint, 
 by excoriating the parts over which they flow, producing more 
 or less soreness and itching of the lids and face. This is still 
 farther augmented by scratching and rubb'ing, which inflame 
 the skin and sometimes give rise to an eczematous or impetig- 
 inous eruption, which not only incrusts the affected parts, but 
 may even extend over the head and body. 
 
 Owing to the scrofulous disposition of the patient, the dis- 
 ease has a natural tendency to become chronic, or at least to 
 be reproduced by every new influence of an exciting cause, so 
 that after one attack has been overcome, another frequently 
 takes its place, either in the same or the other eye, and thus the 
 disease may continue for months and years, and perhaps never 
 reach a permanent and satisfactory conclusion. 
 
 RESULTS. — The pustules or phlyctaena which form at the 
 extremities of vascular fasciculi, or near the junction of the 
 cornea with the sclerotica, frequently ulcerate, the ulcers some 4 
 times extending superficially, at others penetrating into the 
 corneal substance ; in the latter case they may open into the 
 anterior chamber, and cause prolapsion of the iris. In addition 
 tion to these results, we have in some instances, pannus, inter- 
 amellar effusions into the cornea, onyx, hypopion, leucoma, 
 synechia anterior, and staphyloma. When the inflammation 
 
SCROFULOUS CONJUNCTIVITIS. 141 
 
 extends to the choroid coat and iris, alterations, more or less 
 serious, of those membranes occur. 
 
 DIAGNOSIS. — Scrofulous ophthalmia is generally easily 
 distinguished by the great intolerance of light, the vesicular 
 elevations of the conjunctiva, the vascular fasciculi, and the co- 
 existence of scrofulous symptoms in other parts of the body. 
 When, as frequently happens, the absorbent glands of the neck 
 are inflamed and swollen, the alae of the nose red, swollen and 
 excoriated, and the ears sore and excoriated behind ; and when, 
 in addition to these symptoms, there is a disordered state 
 of the stomach and bowels, generally characterized by a fetid 
 breath, furred tongue, morbid appetite, swollen abdomen and cos- 
 tiveness, it is scarcely possible to mistake the affection. Indeed, 
 such is the severity of the ciliary irritation and consequent pho- 
 phobia in these cases, as of itself to constitute an almost certain 
 guide to the nature of the complaint. It is well to remember, 
 in this connection, that there is a troublesome form of ophthal- 
 mic inflammation occurring in strumous children, which is main- 
 ly dependent upon the state of the primae viae and skin, but 
 which does not exhibit, in any marked degree, the features of 
 ordinary scrofulous ophthalmia. There is generally more ex- 
 ternal redness, especially of the lids, and but little intolerance 
 of light ; still the disease is esentially scrofulous in its nature, 
 and, like other scrofulous diseases, is extremely obstinate, and 
 and continually apt to recur. 
 
 PROGNOSIS. — This, so far as vision is concerned, is gener- 
 ally favorable, provided the cornea remains clear, or, if opaque, 
 the opacity is merely superficial, or is simply owing to intersti- 
 tial deposition. Vascularity and inter-lamellar depositions gen- 
 erally disappear soon after the subsidence of the inflammation ; 
 even pannus, though it may last a long time, does not endanger 
 the sight. Ulceration produces more or less permanent opacity ; 
 and when extreme, especially if attended with prolapsion of the 
 iris, it generally causes serious injury to vision. Staphyloma 
 
142 PRACTICE OF MEDICINE. 
 
 and bursting of the cornea are of course always attended by 
 the most disastrous consequences. 
 
 Etiology. — The chief predisposing cause of scrofulous 
 ophthalmia is a strumous condition of the system. The excit- 
 ing causes are such as, by depressing the vital powers, are cal- 
 culated to call into action the scrofulous diathesis, such as cold, 
 damp and variable weather, inadequate clothing, poor and im- 
 proper nourishment, dark and unwholesome dwellings, insuffi- 
 cient exercise in the open air, disorders of the digestive system, 
 and an inactive state of the skin, bowels and uterine organs. 
 It likewise occurs, for the same reason, after any protracted ill- 
 ness, such as the various exanthemic fevers, whooping cough, 
 etc. On the other hand, if the strumous disposition be strong, 
 the disease may by provoked by mechanical injuries, excessive 
 use of the eyes, want of cleanliness, and even by a change of 
 season. Not unfrequently the disease alternates with other af- 
 fections, such as otorrhcea, cutaneous eruptions, etc. 
 
 Tteatment. — This should be general as well as special, 
 that is to say, the treatment should be directed against the gen- 
 eral unhealthy state of the system — the scrofulous diathesis — 
 as well as against the attack itself ; this is necessary in order 
 both to remove the local affection and prevent relapse. The 
 treatment should also have relation to the particular form of 
 the attack, whether as simple or complicated ; the former will 
 require, more especially, the antipsoric remedies, such as Calca- 
 rea, Hepar sulph., Sulphur, etc. ; while the latter will require 
 those best adapted to the particular complications, such as Bel- 
 ladonna, Mercurius, etc. 
 
 Cold applications are, as a general rule, injurious to scrofu- 
 lous sore eyes, and should therefore seldom be employed ; 
 never, indeed, unless the inflammation is combined with some 
 other form of ophthalmia ; even in these cases warm applica- 
 tions will be more suitable, and will commonly give most relief. 
 It is generally sufficient, so far as local treatment is concerned, 
 
SCROFULOUS CONJUNCTIVITIS. 1 43 
 
 to bathe the eyes frequently with tepid water, and to shade 
 them with a stiff crescent-shaped screen, which is preferable to 
 a bandage, as it neither overheats the eyes, nor deprives them 
 of the beneficial effects of fresh air. 
 
 The principal remedies for scrofulous ophthalmia are the 
 following : 
 
 Acidum Nitricum is especially adapted to protracted cases, 
 particularly when the cornea has become nebulous, or clouded 
 with dark spots. 
 
 Apis mellifica. — This remedy, though it appears to be indi- 
 cated in many cases, is generally of doubtful value. We have 
 commonly found it to prove most useful in the first stage of 
 purely scrofulous cases, attended with burning and stinging 
 pains, redness of the conjunctiva, extreme photophobia and 
 lachrymation, a nebulous state of the cornea, and an eczematous 
 eruption on the lids and face. 
 
 Arsenicum* — This remedy is particularly adapted to pro- 
 tracted cases, especially such as are subject to frequent relapses, 
 characterized by photophobia, keratitis, redness of the lids and 
 burning, itching and excoriation of the surrounding integuments. 
 
 Bellado7i7ia.-\ — This medicine is indicated in cases compli- 
 cated with catarrhal or rheumatic ophthalmia, especially if the 
 pains are accompanied with acute febrile symptoms. 
 
 Calcarea Carb.% — One of the best antipsoric remedies, 
 especially adapted to purely scrofulous cases of a protracted 
 character, and subject to frequent relapses. 
 
 Cannabis sat. is indicated in chronic cases attended with 
 corneal opacity. 
 
 Conium mac. — Chronic cases, attended with photophobia, 
 
 * See Am. Horn. Obs.^ vol. vil, pp. 120, 121. (3d and 30th.) 
 
 t Ibid. (3d). 
 
 % See Am. Horn. Obs., vol. vii. p. 120. {30th and 200th») 
 
144 PRACTICE OF MEDICINE. 
 
 spasms of the orbicularis, redness, burning and itching of the 
 eyes and lids, and an eczematous or impetiginous eruption, 
 with soreness and excoriation of the neighboring parts. 
 
 Graphites. — This remedy is adapted to both acute and 
 chronic cases, especially if accompanied with eruptions in the 
 face and behind the ears. 
 
 Hepar sulph* — This is one of the best anti-scrofulous rem- 
 edies, particularly adapted to protracted and relapsing cases, 
 especially if attended with ulceration of the cornea. 
 
 Mercurius. — This medicine is well adapted to both acute 
 and chronic cases, being equally applicable to the inflammatory, 
 exudative and ulcerative stages of the complaint. It is one of 
 our most valuable remedies for scrofulous ophthalmia, and 
 should therefore, in most cases, be used early, and not too 
 hastily discontinued. 
 
 Pulsatilla. — This medicine being well adapted to lym- 
 phatic constitutions, is especially suited to those cases depend- 
 ing on stomachic and uterine derangements, whether acute or 
 chronic. 
 
 Rhus tox/* — This remedy, notwithstanding its somewhat 
 doubtful indications, has done good service in scrofulous oph- 
 thalmia, especially when attended with photophobia, lachryma- 
 tion, spasms of the lids, and exanthematous or herpetic erup- 
 tions. 
 
 Silicea. — This remedy is well adapted to chronic cases, at- 
 tended with ulceration and opacity of the cornea, swelling of 
 the cervical glands, and cutaneous eruptions on the lips and 
 face. 
 
 Staphysagria. — This medicine has been found useful in 
 scrofulo-rheumatic ophthalmia, accompanied by spasmodic 
 closure of the lids, glandular swellings, and cutaneous eruptions. 
 
 Sulphur* — This powerful antipsoric remedy is indicated 
 
 * See Am. Horn. Obs., vol. vii., pp. 120. 121. {3d and 30th.) 
 
PHLYCTENULAR CONJUNCTIVITIS. 145 
 
 in all chronic and relapsing cases, especially when the cornea 
 is deeply involved, as in pannus, ulceration, interstitial deposi- 
 tion and onyx. 
 
 The remedies above mentioned are those of chief import- 
 ance in the treatment of the ordinary forms of scrofulous oph- 
 thalmia ; but inasmuch as the disease is frequently complicated 
 with other forms of ophthalmic inflammation, the prescriber is 
 referred for additional remedies* and details to Tables XIV. 
 and X V. ; and also to the Theraptutic Indications given at the 
 end of the Section on Ophthalmic Diseases. 
 
 DIET AND REGIMEN. — The diet should be of the most 
 nourishing and digestible character, consisting, for the most 
 part, of good home-made wheat bread, graham bread, oat-meal 
 pudding, fresh butter, tender and juicy beef, good ripe fruit, 
 dried fruit, etc. ; while all such articles as pork, sausage, bacon, 
 veal, coffee, pickles, pastry, etc., should be rigidly excluded. 
 
 Suitable and adequate clothing, with proper attention to 
 light, air and exercise, will do much to ward off the disease from 
 those that are predisposed to the affection, and to mitigate it 
 when established. 
 
 5-PHLYOTENULAR CONJUNCTIVITIS. 
 
 APTHOUS, HERPETIC OR PHLYCTENULAR OPHTHALMIA. 
 
 Fig. 7 
 
 Phlyctenular Conjunctivitis, 
 or, as it is sometimes impro- 
 perly called, pustular ophthalmia, 
 is a mild form of conjunctivitis, 
 characterized by an eruption of 
 phlyctenular conjunctivitis. vesicles, called phylyctcence ox phly- 
 ctenules, on or near the margin of the cornea. The eiuption 
 first makes it appearance in the form of small red, slightly 
 elevated points upon the inflamed conjunctiva oculi ; these 
 points as they enlarge develope into vesicles ; and finally, if the 
 
 * See Am. Horn. O&s., vol. vi, p. 559. 
 *9 
 
146 PRACTICE OF MEDICINE. 
 
 inflammation goes on unchecked, the vesicles burst and form 
 ulcers, which in mild cases gradually disappear, but in others 
 manifest a disposition to spread. Numerous vessels, or bundles 
 of vessels, {vascular fasciculi,) run toward the cornea, but never 
 pass beyond the borders of the vesicles or ulcers, in which they 
 always terminate. {See Fi%. 7.) The phlyctaenae vary in size 
 as well as in number, solitary ones being sometimes nearly as 
 large as a split pea ; generally, however, they are much smaller, 
 their relative dimensions being usually in an inverse ratio to 
 their number. Phlyctaenae are not peculiar to this form of 
 ophthalmia, being, as we have already seen, sometimes observed 
 in other forms of conjunctivitis, especially the catarrhal and 
 scrofulous ; indeed, some opthalmologists regard the phlyctenu- 
 lar as a modification of strumous conjunctivitis, intermediate in 
 character between the catarrhal and scrofulous. Like the latter, 
 it is almost entirely confined to children, but unlike it is seldom 
 attended with ciliary irritation and photophobia, though gene- 
 rally occurring in scrofulous subjects. It is only when the 
 vesicles are numerous, and are situated wholly or partly on the 
 cornea, that there is much intolerance of light, lachrymation, or 
 ciliary irritation. 
 
 Treatment. — Many cases are so mild as to require little 
 more, in the way of treatment, than rest and protection of the 
 organ. When arising from fatigue, the irritation of dust, or 
 other similar causes, hygienic measures alone will generally 
 suffice. This is especially true if the vesicles are solitary, or but 
 one or two in number, and are situated over the sclerotica. 
 Severe cases are benefited by warm fomentations, and by the 
 particular treatment recommended for scrofulous conjunctivitis, 
 (which see.) The most efficient remedy for ulceration is Mer- 
 curius, which may be prescribed with as much confidence in 
 this affection as in aphthous stomatitis. Other remedies which 
 have been found most useful for particular conditions, are the 
 following : 
 
 Ciliary Neuralgia : Atrop., Bell., Cham., Spigel. 
 
ERYSIPELATOUS CONJUNCTIVITIS. 147 
 
 Photophobia : Ant. tart., Ars., Bell, Con., Hepar, Merc, 
 Spigel. 
 
 Ulceration, with or without ciliary irritation and photopho- 
 bia : Ars., Merc. 
 
 Obstinate, the disease appearing to be seated in the sub-con- 
 junctival tissue : Ars., Cham., Merc. 
 
 6-ERYSIPELATOUS CONJUNCTIVITIS. 
 
 This form of ophthalmic inflammation is seated in the orbi- 
 tal conjunctiva, and in the subjacent cellular tissue. The 
 injection of the conjunctival vessels becomes rapidly confluent, 
 the membrane swells, assumes a uniform pale red color, be- 
 comes relaxed and wrinkled, except at the lower part of the 
 globe, where it remains tumefied and presents a more or less 
 oedematous appearance. As there is neither epiphora nor 
 photophobia, it is reasonable to infer that the deeper structures 
 are not involved. This description, however, applies only to 
 idiopathic cases ; when secondary to facial erysipelas, the 
 inflammation is generally of much greater severity. In these 
 cases the episcleral and neighboring tissues sometimes 
 participate, and then there is a deeper redness, with more or 
 less intolerance of light and ciliary irritation. As an idiopathic 
 affection, it is mostly confined to persons who have reached the 
 period of middle life, or beyond, and whose constitutions are 
 generally more or less debilitated. The chief exciting cause is 
 cold, though the disease is sometimes of epidemic origin. 
 
 TREATMENT. — Aconite and Belladonna, with warm fomenta- 
 tions, generally constitute all the treatment required. When 
 secondary to facial erysipelas, remedies should be selected 
 with special reference to the primary disease. See Erysipelas 
 of the Head and Face. 
 
 7-EXANTHEMATOUS CONJUNCTIVITIS. 
 The contagious exanthemata are accompanied by inflam- 
 mations of the conjunctiva corresponding in intensity to the 
 
I48 PRACTICE OF MEDICINE. 
 
 eruptive inflammations of the skin with which they are asso- 
 ciated. As they seldom demand special treatment, and are, for 
 the most part, neither sufficiently important nor peculiar to 
 require minute description, we shall give them but brief con- 
 sideration. 
 
 A— Scarlatinous and Rubeolous Conjunctivitis. 
 
 OPHTHALMIA SCARLATINOSA AND MORBILLOSA. 
 
 In scarlatina and measles, we have more or less redness and 
 inflammation of the external membranes of the eye, with mode- 
 rate pain or uneasiness, lachrymation, and sensibility to light. 
 Sometimes, though rarely, phlyctaenae and ulcers also appear 
 upon the cornea, and occasionally interstitial depositions take 
 place between its laminae. The ophthalmic disorder generally 
 keeps pace with the cutaneous affection. It is less frequently 
 associated with scarlatina than with measles, of which it is a 
 common attendant. 
 
 Treatment. — When the conjunctiva alone is affected, the 
 treatment is the same as required for catarrhal ophthalmia, 
 (which see.) Cool and tepid washes are generally agreeable, 
 and with protection from light, and the occasional administra- 
 tion of Aconite, the inflammation usually runs a satisfactory 
 course. When the exanthemata are succeeded by severe con- 
 junctivitis extending to the submucous tissues, and especially 
 when attended with ulceration of the cornea, the treatment 
 should be much more active, in order to prevent opacity and 
 loss of vision. In these cases, Aconite and Mercurius, with the 
 diligent use of the cold compress, will be required. 
 
 B— Variolous Conjunctivitis. 
 
 OPHTHALMIA VARIOLOSA. 
 
 This form of ophthalmia is seated in both the orbital and 
 palpebral conjunctiva, and in the cutaneous covering of the lids. 
 It occurs conjointly with, and subsequently to the variolous 
 disease ; and not unfrequently it assumes a chronic form. 
 
VARIOLOUS CONJUNCTIVITIS. 149 
 
 Most commonly it is confined to the lids, the external surface 
 of which, with their ciliary margins, are covered with a greater 
 or less number of variolous pustules, which produce extensive 
 swelling, and close the eyes. As the eruption declines, the 
 swelling abates, and the globe of the eye is found uninjured. 
 
 In a small proportion of cases, however, (stated by some 
 authorities at about four per cent, of the whole number,) the 
 inflammation likewise involves the conjunctiva and cornea. 
 This is what constitutes the true variolous ophthalmia, and is 
 always a dangerous disease. The inflammation is so violent, 
 and proceeds with such rapidity, as to cause suppuration and 
 more or less sloughing. The results are in proportion to the 
 extent and violence of the inflammation. Staphyloma, prolap- 
 sion of the iris, synechia anterior, obliteration of the pupil, 
 opacity of the cornea, collapse of the globe, and partial or com- 
 plete blindness, are not uncommon terminations. 
 
 Treatment. — The suppurative form of variolous ophthal- 
 mia, which does not generally set in until after the decline of 
 the cutaneous affection, requires the same treatment as purulent 
 conjunctivitis, (which see.) Treatment for the palpebral in- 
 flammation will be given in the next article (which see.) 
 
 ART. II. — BLEPHARITIS. 
 
 The term blepharitis, signifying inflammation of the eyelids, 
 is a general one, and may therefore be properly used to denote 
 any variety of inflammation to which the lids are subject ; but 
 inasmuch as these inflammations are mostly of a subacute or 
 chronic character, as they occur for the most part in scrofulous 
 subjects, and as they are chiefly limited to the tarsal borders ; 
 in other words, as they possess many features in common, we 
 shall include under it the several conditions known as Ophthal- 
 mia Tarsi, Psorophthalmia, Blepharitis Ciliaris, Eczema Pal- 
 pebrarum, etc., reserving the more acute, but less common forms 
 of palpebral inflammation for separate consideration. 
 
150 PRACTICE OF MEDICINE. 
 
 I-BLEPHAEITIS OILIAEIS. 
 
 FOLLICULAR INFLAMMATION GF THE LIDS. 
 
 Blepharitis ciliaris is an ulcerative inflammation of the edges 
 of the eyelids, depending on a psoric or scrofulous condition 
 of the system, or occurring as a sequence of measles and other 
 exanthemata, styes, etc. 
 
 Symptoms. — The disease commences as an eczematous 
 inflammation of the cuticle of the edge of the lid, the epidermis 
 of which either desquamates or suffers ulceration. The inflam- 
 mation and ulceration produce suppuration, and the purulent 
 matter collecting at the roots of the cilia forms scabs, beneath 
 which the ulcerative process continues. As the ciliary follicles 
 become inflamed, the cilia loosen and drop out. The inflam- 
 mation also invades the meibomian glands, or follicles, which 
 with the ciliary apertures may become permanently occluded. 
 In this manner the disease may continue until the whole ciliary 
 border becomes ulcerated, the outer surface of the lids, as well 
 as the conjunctival lining, inflamed, the cilia destroyed, the 
 tarsal edges thickened and indurated, and the puncta lachry- 
 malia everted, so that the tears overflow the lids ; ultimately, 
 the skin contracts so as to cause more or less ectropium. This 
 is the state called lippitudo or blear eye. Sometimes, in chronic 
 cases, the edges of the lids turn inwards instead of outwards, 
 producing trichiasis and entropium. The cilia by constant 
 contact with the globe may inflame the cornea, causing a super- 
 ficial vascular keratitis which may result in pannus. 
 
 Results. — These are: loss of cilia, epiphora, lippitudo, 
 ectropium, entropium, trichiasis, diatrichiasis, opacity of the 
 cornea, pannus, and more or less impairment of vision. 
 
 ETIOLOGY. — In addition to the causes already enumerated, 
 namely, scrofula, small pox, measles, erysipelas, etc., may be 
 mentioned such causes as cold and damp air, smoke, dust, and 
 other irritants, especially when acting on a psoric or strumous 
 constitution. 
 
Blepharitis ciliaris. 151 
 
 PROGNOSIS. — This disease is always protracted, and subject 
 to frequent relapses. In its earlier stages, before ulceration has 
 involved the entire margin of the lids, destroyed the cilia, and 
 produced hypertrophy of the palpebral tissues, the disease may 
 be cured ; but after these changes have occurred, it only admits 
 of palliation. 
 
 TREATMENT. — The edges of the lids should be kept free from 
 scabs and purulent accumulations by cleansing them as often 
 as may be necessary with tepid water, after which they should 
 be bathed with some mild astringent lotion, such as a weak 
 solution of alumen or muriate of hydrastia. At night, they 
 should be anointed with simple cerate or spermaceti, in order, 
 to prevent as far as possible, their becoming glued together 
 with the discharges ; and in the morning the agglutinating mat- 
 ter should be softened with tepid milk and water, or, what is 
 better, with warm cream, until the lids can be separated with- 
 out the use of force, the employment of which will surely aggra- 
 vate the disease. If trichiasis exists, the inverted hairs should 
 be carefully removed, as they are not only a great annoyance 
 to the patient, but they keep up such a constant irritation as 
 greatly to aggravate the inflammation, and ultimately produce 
 opacity of the cornea. Stimulating ointments without number 
 have been recommended, but the most popular, and, in most 
 cases effective, is the red precipitate, of the strength of 
 about fifteen grains tb the ounce of simple cerate, which should 
 be carefully applied to the tarsal edges at night. 
 
 The internal treatment should be similar to that recom- 
 mended for scrofulous ophthalmia, (which see.) Consult also, 
 the article Scrofula ; likewise, Tables XIV. and XV. and the 
 Therapeutic Indications at the end of the section on Oph- 
 thalmic Diseases. 
 
 Diet and Regimen. — The diet should be carefully re- 
 gulated ; and should consist of nutritive and easily digestible 
 food, such as milk, soft boiled eggs, and wholesome meats, 
 stale bread with fresh butter, and a due admixture of fresh 
 
152 PRACTICE OF MEDICINE. 
 
 vegetables and fruit. The clothing, also, should be carefully 
 attended to, so as to protect the patient against the effects of 
 sudden atmospheric changes. Special caution should be ob- 
 served against reading at night, or exposing the eyes to dust 
 and smoke, or to the glare of the sun, gas and other bright 
 lights. Frequent ablutions, exercise and fresh air, are import- 
 ant adjuvants in the treatment and should not be overlooked. 
 
 2-INFLAMMATIO PALPEBRARUM. 
 
 SIMPLE INFLAMMATION OF THE LIDS. 
 
 Simple inflammation of the eyelids is characterized by red- 
 ness, swelling and soreness of the tarsal border, whence it 
 spreads over the entire lid. It is generally of catarrhal origin, 
 and is almost always associated with more or less conjunctivitis. 
 When severe, the cellular tissue is apt to become involved, 
 giving rise to oedema and in some cases to abscess. 
 
 CBd^ma. — Effusion of serum into the cellular texture of the 
 eyelid, is a frequent result of ophthalmic inflammation, whether 
 simple or specific. When severe, as in the various forms of 
 purulent ophthalmia, the tumefaction of the lids becomes very 
 great, the upper projecting over the lower, and presenting a 
 smooth convex surface of a bright red color. In other cases, 
 the vascular congestion is such as to cause considerable swelling 
 with little or no external redness. In inflammation of the 
 lachrymal sac, the lids are often greatly distended, subsiding 
 only when the cause is removed. CEdema of the lids also 
 occurs in cases of hordeolum, or stye, from the bites and stings 
 of insects, from erysipelas and anasarca of the face, and from 
 other causes. 
 
 Abscess, though necessarily dependent upon inflammation, 
 is frequently the result of injury. It may form on either side 
 of the palpebral cartilage, or it may exist in both situations at 
 the same time; consequently, the matter may approach the 
 surface in either direction. Neglected cases sometimes result 
 
KERATITIS. 153 
 
 in very great deformity, giving rise to ectropium or lagophthal- 
 mus, and sometimes to both. 
 
 TREATMENT. — For simple uncomplicated inflammation of 
 the lids, Aconite, or Aconite and Belladonna in alternation, with 
 the early use of the cold compress, is generally sufficient to effect 
 a cure. CEdema usually requires Apis, Arsenicum or Rims tox. 
 Abscess calls for such additional remedies as Hepar, Silicia 
 and Calcarea. In order to prevent deformity, the lancet should 
 be used as soon as fluctuation can be detected, being careful to 
 make the incision in a horizontal direction, so that the cicatrix 
 remaining may be concealed by the natural folds of the in- 
 tegument. 
 
 ART. III. — KERATITIS. 
 
 Inflammation of the cornea is not only frequently associated, 
 as we have seen, with several forms of ophthalmia, but also 
 occurs as a primary or idiopathic affection. It is only when 
 the inflammation begins in the cornea, however, that the disease 
 is to be classed as keratitis. The affection assumes a great 
 variety of forms, according as it is simple or complicated, vas- 
 cular or non-vascular, inflammatory or non-inflammatory, partial 
 or total, acute or chronic, active or indolent, fascicular, phlyc- 
 tenular, diffuse, suppurative, neuro-paralytic, etc. These and 
 various other distinctions we shall find it convenient to con- 
 sider under the following four heads, namely: (1) diffuse kera- 
 titis ; (2) suppurative keratitis ; (3) vascular keratitis, and (4) 
 phlyctenular keratitis. Keratitis punctata being a secondary 
 form will be described under iritis. (See Serous Iritis) 
 
 1-DIFFUSE KERATITIS. 
 
 PARENCHYMATOUS, OR INTERSTITIAL CORNEITIS. 
 
 SYMPTOMS. — Diffuse inflammation of the cornea, when 
 fully formed, is characterized by more or less impairment ot 
 vision from interstitial deposition. At first the cornea has a 
 somewhat hazy, cloudy, or smoky appearance, which partially 
 impedes the transmission of light. This condition is called 
 
154 PRACTICE OF MEDICINE. 
 
 nebula, and constitutes the slightest form of corneal opacity. 
 As the disease progresses, the opacity increases, and vision 
 becomes less and less distinct ; but owing to inequalities in its 
 developement, the sight is less troubled than it would otherwise 
 be. This arises from the fact that clearer, or less affected por- 
 tions of the cornea remain scattered among the more opaque, 
 as if the infiltration had occurred only in detached points, 
 though as a general rule the opacity first begins at the limbus, 
 where its density is greatest, and spreads gradually more and 
 more towards the centre, until finally it involves the whole cor- 
 nea. Sometimes, however, the reverse of this occurs ; the infil- 
 tration beginning at or near the centre, and gradually extend- 
 ing towards the circumference. The more opaque parts are 
 sometimes of a yellowish hue, as though suppuration had oc- 
 curred there, but this is seldom the case in the form of keratitis 
 we are now considering. In addition to these changes, the 
 Fi s- 8 surface of the cornea loses its usual 
 
 polish and becomes unequal, as if sand- 
 ed or dotted over with fine points. {See 
 Fig. 8) It is this fine stippled ap- 
 pearance ol the surface which causes 
 nebulous vision, and gives to the eye 
 its peculiar dull expression at the be- 
 ginning of the complaint. 
 
 KERATITIS. 
 
 The degree of inflammation and vascular injection, varies 
 greatly in different cases. Sometimes the injection is incon- 
 siderable, and then the disease is called non- vascular. In other 
 cases, with a varying amount of conjunctival injection, the 
 disease is marked by a zone of deep parallel vessels running 
 towards the cornea — the distended trunks of which lie beneath 
 the conjunctiva, in the sub-conjunctival or episcleral tissue, and 
 known as the episcleral or circumcorneal zone — whose minute 
 branches or extremities passing the border of the cornea, form 
 upon the limbus a small circle, or oftener a segment of a circle, 
 
DIFFUSE KERATITIS. 155 
 
 of a dark red tint, which presents a marked contrast with the 
 opaque centre of the cornea and the pink-colored zone of the 
 border. {See Fig. 8,) Vascular diffuse keratitis is also charac- 
 terized by the presence of delicate vessels in the deeper layers 
 of the cornea, extending from the corneal zone to the several 
 centres of exudation. 
 
 In addition to the above symptoms, diffuse keratitis also 
 gives rise to more or less ciliary irritation, photophobia and 
 lachrymation, especially on exposure to light. Occasionally 
 these symptoms are so slight as scarcely to attract attention ; 
 but in the majority of cases they are quite marked, especially 
 at the beginning of the disease, and before exudation has taken 
 place. Afterwards, as the process of infiltration goes on, they 
 generally become less prominent and sometimes disappear alto- 
 gether; in some cases, however, they remain unchanged or 
 with varying degrees of intensity throughout the progress of the 
 disease. Having reached its height, the affection frequently 
 continues for weeks and months apparently stationary before 
 beginning to decline. The retrograde metamorphosis takes 
 place with great slowness, and several months often elapse 
 before the cornea fully recovers its transparency. Vascular 
 diffuse keratitis generally runs its course more rapidly than the 
 non-vascular which is extremely indolent. 
 
 The disease is seldom confined to one eye ; the second eye 
 is generally attacked soon after the first. This is very dis- 
 couraging to the patient, and it is generally difficult to make 
 him believe that he is not going blind. The affection is fre- 
 quently complicated with iritis, irido-choroiditis, cyclitis, or 
 with some other form of keratitis. As the iris is hid from view 
 during the progress of the case, the practitioner should be par- 
 ticularly on his guard, lest when the cornea becomes clear he 
 find his patient affected with posterior synechia. 
 
 ETIOLOGY. — Diffuse keratitis has been called syphilitic, 
 under the mistaken notion that it owes its origin to hereditary 
 
156 PRACTICE OF MEDICINE. 
 
 syphilis. There is probably no good foundation for this belief, 
 any more than there is for referring it to scrofula or tubercu- 
 losis. It is true it is frequently met with in persons affected 
 with hereditary or constitutional syphilis, but it is also true 
 that it occurs just as often in those in whom not a trace of 
 syphilitic taint can be discovered. The disease occurs at all 
 times and under all conditions of life ; but chiefly in children 
 between the ages of ten and fifteen years, especially those of a 
 delicate constitution, many of whom are more or less weakly, 
 anaemic and scrofulous. It is highly probable, therefore, that 
 delicacy of constitution, defective nutrition, or a broken-down 
 state of the system — in short, deficient vital action — contribute 
 more to its production than syphilis, either hereditary or 
 acquired. 
 
 PROGNOSIS. — This is generally favorable ; for notwithstand- 
 ing its chronicity and tendency to relapse, the disease is seldom 
 attended with ulceration, and, if properly treated, the cornea 
 finally clears up, leaving little if any trace of its previous dis- 
 eased condition. Some slight inequality in its curvature may 
 remain, however, especially if there has been much bulging 
 from intra- ocular pressure; but the causes which commonly 
 give rise to this condition generally prove more serious in other 
 ways. Hence the prognosis will be more or less favorable, 
 according as the inflammation affects the deeper tissues of 
 the eye. 
 
 Treatment — The employment of caustics, or even astrin- 
 gent collyria, should be carefully avoided, as such applications 
 not only do no good, but often do much harm. This caution 
 is all the more necessary, as the temptation to use them is 
 often stimulated by the importunities of the patient, under the 
 idea that the long duration of the disease may in this way be 
 abridged. The danger lies in their tendency to cause serious 
 complications, such as iritis, cyclitis, ulceration of the cornea, 
 etc. Atropine should be instilled as soon as it can be well 
 
DIFFUSE KERATITIS. 157 
 
 borne, for although it will not be absorbed to any great extent 
 until the cornea begins to clear, it is important to obtain its 
 early action in dilating the pupil, ' and thereby prevent the 
 formation of posterior synechias, (See Iritis}) Paracentesis 
 and iridectomy prove useful in accelerating the cure, and some- 
 times succeed in arresting the disease at an early stage. They 
 are especially indicated if symptoms of cyclitis supervene, or if 
 there is continued increase of intra-ocular pressure. (See 
 Iritis and Cyclitis) In very chronic cases, especially those of 
 the non-vascular variety, Von Graefe recommends the employ- 
 ment of warm compresses. If used with sufficient care in this 
 class of cases, and discontinued immediately they have fulfilled 
 their mission, namely, to stimulate the action of the bloodves- 
 sels of the cornea, they will doubtless do much good in pro- 
 moting absorption of the exudations ; but it is evident that 
 such applications cannot be safely left to the judgment of 
 inexperienced attendants. The same end may be accomplished 
 by applying mild irritants, such as Mercurius dulcis, to the dis- 
 eased membrane. This may be employed once a day by 
 insufflation with great advantage, being careful to see that the 
 calomel is pure and free from lumps. Wells recommends a 
 collyrium of Kali hydriod, (gr. ij. @ ?j) for the same purpose. 
 
 THERAPEUTIC INDICATIONS. 
 
 Aconite. — This remedy is useful whenever the vascular re- 
 action is in excess. 
 
 Arsenicum. — This is one of the best internal remedies for 
 ulceration of the cornea, and is also frequently serviceable in a 
 weak and impoverished state of the general system. 
 
 Belladonna is indicated whenever there is much conjunctival 
 injection and ciliary neuralgia. 
 
 Cactus frequently relieves nervous and vascular irritation in 
 the ciliary region, and also the accompanying asthenopia. 
 
 Cimicifuga. — This remedy is often useful when there is much 
 neuralgia and ciliary irritation. 
 
158 PRACTICE OF MEDICINE. 
 
 Conium is often a valuable remedy in allaying photophobia, 
 especially when accompanied with much ciliary irritation. 
 
 Gelseminum is indicated in cases attended with asthenopic 
 symptoms and photophobia, especially when associated with 
 marked hyperemia and hyperesthesia of the retina and ciliary 
 nerves. 
 
 Hepar sulph. — This remedy is useful in promoting absorp- 
 tion of the exudation and clearing the cornea, more particularly 
 in indolent and chronic cases. 
 
 Kali hydriodicum is an important constitutional remedy, 
 especially in syphilitic cases. 
 
 Mercurius is very servicable in cases attended with ulcera- 
 tion, either with or without photophobia, but is more particu- 
 larly useful in promoting interstitial absorption. It may often 
 be advantageously alternated with Hepar sulphuris. 
 
 Nitric acid is especially indicated when, in addition to 
 photophobia, lachrymation and nervous irritation, the patient is 
 laboring under syphilitic dyscrasia, or a weak and impoverished 
 state of the constitution. 
 
 Spigelia. — This is one of our best remedies for ciliary irrita- 
 tion and neuralgia, especially when there is much hyperemia 
 of the ciliary vessels, and photophobia. 
 
 For additional remedies, see Tables XIV and XV., and con- 
 sult the Therapeutic Indications at the end of the section on 
 Ophthalmic Diseases. 
 
 Diet and Regimen. — The diet will in most cases require 
 to be of the most liberal and nutritious character, consisting 
 chiefly of such articles as roast beef, eggs, milk and other kinds 
 of nitrogenous food, together with a due proportion of vegeta- 
 bles and ripe fruit. In some cases benefit will be derived from 
 partaking freely of malt liquors, wine, kumiss, and other like 
 stimulants. 
 
 Care should be taken, by shading the eyes or otherwise, not 
 to expose them while under treatment to any irritating or in- 
 
SUPPURATIVE KERATITIS. 1 59 
 
 jurious influences, such as wind, dust, smoke, heat, bright light, 
 etc., and at the same time to guard against the debilitating 
 effects of confinement and vitiated air, by regular out-door 
 exercise, ventilation and the observance of such other hygienic 
 regulations as the habits and surroundings of the patient may 
 demand. 
 
 2.-SUPPURATIVE KERATITIS. 
 
 SYMPTOMS. — Suppurative Keratitis is characterized by the 
 development of purulent collections in the substance of the 
 cornea, and by ulceration and disintegration of its tissues. 
 These changes are generally preceded and accompanied by 
 symptoms denoting high inflammatory action ; while on the 
 other hand we sometimes meet with cases in which the symp- 
 toms of inflammation and ciliary irritation are almost entirely 
 absent. 
 
 In the inflammatory form, as it is called, the conjunctival 
 and episcleral injections are strongly marked, the corneal zone 
 being of a bright rose color ; generally, also, there is severe cil- 
 iary neuralgia, with photophobia and lachrymation. The pupil 
 is frequently much contracted, and there is also, in most cases, 
 more or less chemosis. We first notice a small grayish opacity, 
 generally near the center of the cornea, which afterwards 
 becomes cream-colored or yellow, the infiltrated tissue breaking 
 down into an abcess, which may find its way to the surface, 
 forming an ulcer of corresponding depth. Or several small 
 abcesses may coalesce and form a corneal abscess of large 
 dimensions. Sometimes the pus sinks down between the 
 lamellae of the cornea, separating them, and leaving a condi- 
 tion called onyx, from its resemblance to the lunula of the 
 nail. This may be so small as to be difficult of detection, 
 appearing only as a narrow yellow line near the limbus of the 
 cornea, or so large as to cover more or less of the pupil, when 
 it may be mistaken for an hypopyon. The latter is generally 
 due to the bursting of a corneal abcess, and the precipitation 
 
160 PRACTICE OF MEDICINE. 
 
 of its contents at the bottom of the anterior chamber. It may 
 also arise from inflammation of the iris, as will be explained 
 under iritis. 
 
 The non-inflammatory form of suppurative keratitis is 
 distinguished by the absence, more or less complete, of all the 
 usual symptoms of the inflammatory form. Thus, there is 
 little or no ciliary neuralgia, photophobia or lachrymation ; the 
 sensibility of the eye is also greatly diminished, responding 
 imperfectly, and as it were with difficulty, to external irritation. 
 Sometimes the disease sets in with the usual symptoms of 
 inflammatory irritation and severe ciliary neuralgia, and then 
 these symptoms suddenly disappear, the cornea rapidly break- 
 ing down, and forming abcesses of a deeper and more uniform 
 yellow color than those of the inflammatory variety. The 
 tendency in this form of keratitis, is to rapid suppuration and 
 sloughing of the corneal tissue, the suppurative process extend- 
 ing in circumference rather than in depth, contrary to what 
 usually occurs in the other form. The inflammation frequently 
 extends to the iris, and then we are apt to have large hypop- 
 yon. (See Iritis.) 
 
 ETIOLOGY. — Suppurative keratitis sometimes results from 
 paralysis of the fifth pair of nerves, and is then called neuropara- 
 lytic keratitis. If the paralysis is incomplete, the cornea frequent- 
 ly escapes, or is but partially and lightly affected ; but when com- 
 plete, the entire cornea is generally involved, becoming opaque, 
 swollen and discolored from purulent infiltration ; ulceration 
 ensues, and more or less of the corneal texture is destroyed. 
 Neuro-paralytic keratitis is supposed to be due, not to mal-nu- 
 trition of the cornea, but simply to the irritation excited by 
 external irritants, such as air and dust, the action of which is 
 allowed to continue in consequence of the insensibility of the 
 eye. Meissner and others, however, have shown that this form 
 of keratitis is not entirely due to insensibility of the organ, 
 deeming it probable that the integrity of the nerve renders the 
 eye mor: able to resist the noxious effects of external irritants. 
 
SUPPURATIVE KERATITIS. l6l 
 
 Suppurative keratitis, both inflammatory and non-inflam- 
 matory, is frequently of traumatic origin. This is most 
 frequently the case in the aged and infirm, especially after 
 operations upon the cornea, such as cataract ; also after 
 mechanical or chemical injuries arising from blows, or from the 
 lodgment of foreign bodies, such as bits of steel, in the sub- 
 stance of the cornea. The inflammatory form is met with in 
 severe cases of purulent and diphtheritic conjunctivitis ; and 
 the non-inflammatory, after certain very debilitating diseases, 
 such as cholera, diabetes, typhus fever, etc. 
 
 PROGNOSIS. — From what has been said, it follows that in 
 most cases the cornea suffers irreparable injury, especially in 
 the non-inflammatory form. Perforation of the cornea fre- 
 quently occurs, followed by extensive ulceration and sloughing, 
 the formation of anterior senechia and staphyloma, and, when 
 the deeper tissues of the eye are involved, the disease may end 
 in panophthalmitis and atrophy of the globe. On the other 
 hand, ulcers may heal without permanent opacity, onyces and 
 hypopya may be rapidly absorbed, anterior senechiae may be 
 broken through, and in a large proportion of cases, under pro- 
 per treatment, the cornea may preserve its continuity, and 
 regain to a great extent its transparency and usefulness. 
 
 Treatment. — In the inflammatory form of suppurative 
 keratitis, attended with high vascular and nervous excitement, 
 chemosis, etc., frequent instillations of a neutral* solution of 
 the sulphate of atropine, together with the diligent use of cold 
 compresses, will be required. If the abscess is so situated that 
 perforation would endanger prolapsion of the iris by dilatation, 
 that is, towards the circumference of the cornea, the atropine 
 should be omitted, and, if necessary, calabar bean substituted 
 in its stead. 
 
 In the non-inflammatory form, the protective bandage will 
 be the best local application, unless there should be very severe 
 
 * Some chemists are accustomed to add a few drops of sulphuric acid to the solution 
 which appears to render it highly irritating to some eyes.— Wells, 
 
l62 PRACTICE OF MEDICINE. 
 
 ciliary neuralgia, when it should be combined with the diligent 
 use of atropine. If this fails to relieve, warm water compres- 
 ses, of a temperature slightly above that of the blood, may be 
 used in connection or in alternation with the bandage until the 
 pain is moderated, when the compresses should be omitted, as 
 their continued use would aggravate both the conjunctival and 
 corneal inflammation, and also tend to increase the suppurative 
 process. 
 
 If the case should become indolent, either warm or hot 
 fomentations will be required, according to the degree of pas- 
 sive congestion or vascular stasis then existing, the object 
 being to excite just sufficient inflammatory reaction to promote 
 resolution, but no more. This, it is evident, will call for the 
 exercise of sound judgment, as well as the greatest care, on 
 the part of all to whom their application is intrusted. If too 
 long continued, or if the temperature is too high, the inflam- 
 matory symptoms will be apt to pass the bounds of healthy 
 reaction, in which case they will require to be subdued by cold. 
 
 Ulceration is generally best treated by pressure, after the 
 inflammatory process has been regulated by the local measures 
 already recommended. The bandage should be elastic, like 
 flannel, and long enough to pass twice round the head, so as 
 to exercise the requisite pressure on the cornea. The pressure 
 bandage is also frequently useful in limiting the extent of sup- 
 puration, but, according to Graefe, is not applicable to those 
 cases of rapid suppurative necrosis which sometimes succeed 
 the sudden disappearance of acute symptoms. 
 
 If, in spite of the foregoing treatment, suppuration still 
 continues, especially if it threatens perforation, benefit will be 
 derived from puncturing the cornea, (paracentesis,) not so much 
 by the simple removal of the purulent infiltration, as this is 
 rarely so fluid as to escape freely from so small an opening 
 but rather, by diminishing intra-ocular tension, to promote 
 absorption of the infiltration, and hasten the restoration and 
 cicatrization of the corneal tissue. If the ulcer is compara- 
 
SUPPURATIVE KERATITIS. 163 
 
 tively small, the operation may be performed with a small 
 needle, such as is represented in Plate I, Fig. 10; but if 
 the ulcer is a large one, or if it has opened into the anterior 
 chamber and formed an extensive hypopyon, the incision 
 should be made with a broader instrument, such as the ordinary 
 lance-shaped knife, of what is better, Desmarre's stop knife, 
 represented in Plate I, Fig. 15. {See Paracentesis Cornea). In 
 order to empty the abscess entirely, it will generally be found 
 necessary to carry the instrument into or through the bottom 
 of the ulcer, and also to repeat the operation several times, at 
 short intervals, as the opening made by the incision is usually 
 soon obliterated. 
 
 But paracentesis, as usually performed, is generally less 
 effective than iridectomy, especially if the iris is involved, or if 
 the ulcer or hypopyon is of considerable size. This operation 
 not only acts beneficially upon the inflamed iris, but lessens 
 more completely, and for a longer period, the intra-ocular pres- 
 sure, and thereby exerts a greater influence in diminishing the 
 corneal suppuration, in promoting absorption of the infiltration, 
 and in facilitating the regeneration of the corneal tissue. (See 
 Iridectomy). 
 
 Another operation, called Saemisches, has more recently 
 been introduced, which consists in a free transverse section of 
 the cornea, after the manner of operating in cataract. This 
 operation is especially suited to the non-inflammatory form, in 
 which the necrosis takes place superficially, or towards the cir- 
 cumference, and which may or may not be complicated with 
 iritis or hypopyon. The operation consists in laying open the 
 base of the ulcer with a Graefe's cataract knife, (PI. II. Fig. 34), 
 the eyelids being separated with the stop speculum, (Fig. 33). 
 The point of the knife is entered on the temporal side, about 
 one millemetre from the margin of the ulcer, and having 
 penetrated the anterior chamber the blade, with its edge turned 
 towards the bottom of the ulcer, is carried through the chamber 
 
164 PRACTICE OF MEDICINE. 
 
 behind the ulcer, the counter-puncture being made at a cor- 
 responding point on the opposite side of the cornea, and just 
 beyond the margin of the ulcer. The fixing forceps, (PL II., 
 Fig. 36), with which the globe has been steadied, are now laid 
 aside, and the knife is made to cut its way out through the bot- 
 tom of the ulcer, being so managed as to allow the aqueous 
 humor to escape gently beside the blade, and with it any coex- 
 isting hypopyon. The eye is then covered with a light com- 
 press, and afterwards treated with Atropine. The success of the 
 operation, according to Saemisch, has been of the most gratify- 
 ing character, the progress of the disease having been imme- 
 diately arrested in almost every instance. 
 
 With respect to the general treatment of corneal ulcers, we 
 should be guided to a considerable extent by general principles. 
 Thus, if the degree of local inflammation is excessive, we should 
 aim to subdue it without going to the other extreme, which 
 would favor the disintegrating process, and at the same time 
 hinder the filling up of the ulcer. The remedies best adapted 
 to fulfill these opposite conditions, can be best selected accord- 
 ing to the law of similia, choosing such as correspond both to 
 the general constitutional condition and to the pathological 
 state of the cornea. The inflammatory process is so intimately 
 related to the suppurative, that, so far as medicines are con- 
 cerned, the chief aim should be to regulate it, neither attempt- 
 ing to subdue it altogether, nor on the other hand, allowing it, if 
 excessive, to go on uncontrolled. It follows, therefore, that such 
 remedies as Aconite, Belladonna, Cactus, Digitalis, Gelsemi- 
 num, Mercurius, Tartar-emetic, Veratrum, etc., will be of frequent 
 benefit, and may be prescribed agreeably to the indications al- 
 ready pointed out. The same may be said of the ciliary irri- 
 tation and neuralgia, which may be combatted with such reme- 
 dies as Atropine, (used topically), Belladonna, Cimicifuga, 
 Conium, Spigelia, etc., while the suppuration may be meas- 
 urably controlled by Arsenicum, Hepar Sulphuris, Kali hydri- 
 
Vascular Keratitis. 165 
 
 odicum, Lycopodium, Mercurius, Sulphur, etc. See Therapeutic 
 Indications on page 621, Dec, 1876 ; and consult Tables XIV. 
 XV. at the end of the Section on Ophthalmic Diseases. 
 
 Diet and Regimen. — The fact that most cases of suppu- 
 rative keratitis occur at the two extremes of life, and in delicate 
 and weakly constitutions, will suggest the importance of mak- 
 ing use, especially in non-inflammatory cases, of a liberal and 
 nourishing diet, coupled if necessary with the milder stimulants 
 such as wine, ale, porter, etc. Too much emphasis can not be 
 laid upon the importance of pure air, cleanliness, and attention 
 to the general health. The digestive and assimilative organs 
 should be kept in the best possible condition, the secretions, 
 particularly those of the bowels and skin, should be carefully 
 regulated, and in fine every suitable means should be taken to 
 cleanse, invigorate and build up the system. 
 
 3.-VASCULAR KERATITIS. 
 
 KERATITIS PANNOSA. 
 
 SYMPTOMS. — Vascular keratitis is chiefly characterized 
 by a development of vessels on the surface of the cornea. 
 The membrane first becomes more or less opaque, loses its 
 brilliancy and polish, and not unfrequently appears sandy, as if 
 dotted over with a multitude of extremely fine points. (See 
 Fig. 8) Vessels afterwards begin to show themselves upon 
 the surface, advancing towards the centre, and becoming more 
 and more numerous as the opacity increases, until finally the 
 cornea is over run with a fine vascular net work called pannas, 
 (Keratitis pannosa). Occasionally the vascular turgescence is 
 so great as to cause a rupture of some of the vessels, giving 
 rise here and there to extravasations of blood, which appear as 
 small ecchymosed spots in the interstices. The deeper por- 
 tions of the cornea generally remain unaffected. 
 
 Vascular keratitis, like other forms of corned inflamma- 
 
[66 PRACTICE OF MEDICINE. 
 
 tion, generally begins with more or less ciliary irritation, which 
 proceeds, sometimes for days, the opacity of the cornea. This 
 is accompanied with conjunctival and episcleral injection, the 
 corneal and circum-corneal zones being generally well-marked. 
 (See Fig. 8.) When the inflammation is severe, the surround- 
 ing parts participate more or less in the inflammatory process, 
 the conjunctivae and lids becoming red and swollen,and are accom- 
 panied in some cases with a marked elevation of temperature. 
 
 The pain is frequently extreme, especially when the nerve 
 fibres are exposed by the shedding of epithelium, or by excoria- 
 tion. In these cases there is generally severe photophobia, 
 with lachrymation and spasm of the lids ; sometimes, however, 
 there is little or no pain accompanying the photophobia, and 
 vice versa, even when associated with spasmodic contraction of 
 the pupil. 
 
 The duration of the disease varies considerably, according 
 as the cause is temporary or lasting. In the one case it may 
 run its course in a few days, while in the other, even under the 
 best treatment, it may continue for many weeks. 
 
 Etiology. — The chie/ causes are such as produce mechani- 
 cal irritation of the corneal surface, especially trachoma, invert- 
 ed cilia, dust, cinders and other foreign bodies. Besides these, 
 other deleterious external influences, such as heat, smoke, steam, 
 irritating collyria, salves, caustic fluids, sudden changes of tem- 
 perature, and even long exposure to air 1 itself, as in ectropion, 
 sometimes induce it. The vascularity may also result from the 
 excitement of active inflammation in neighboring parts, as in 
 the different forms of conjunctivitis. It is also an accompani- 
 ment of other forms of keratitis, especially the phlyctenular. 
 Finally, it may owe its origin in some cases to internal causes, 
 either pathological or functional, especially such as give rise to 
 protrusion of the globe, or to spasmodic pressure of the lids. 
 
 PROGNOSIS. — This is generally favorable, as the causes 
 producing it are such as may be usually, and in many cases, 
 
VASCULAR KERATITIS. 1 67 
 
 speedily overcome. When the cause is not removable, of course 
 the prognosis is bad, as then the pannus and opacity are likely to 
 continue in spite of the very best treatment. On the other 
 hand, many cases amenable to treatment are rendered tedious 
 and difficult of cure, by reason of the long existence of the in- 
 flammation, and the extent and character of the resulting 
 opacity. Relapses are also common, and the utmost care is 
 required on the part of both the surgeon and the patient to 
 prevent them. 
 
 TREATMENT. — The first, and in many cases the only treat- 
 ment required, will be the removal, whenever possible, of the 
 cause. Hence, misdirected cilia, or any foreign substance which 
 may have found a lodgment in the conjunctival sac, should be 
 carefully sought for and extracted. For the same reason, 
 trachomatous elevations should be destroyed by caustics, the 
 removal of which generally leads to speedy improvement. 
 
 After remedying as far as possible the action of external 
 causes, if the inflammation continues unchecked, and especially 
 if there is much heat of the neighboring tissues, cold compresses 
 should be applied until the vascular action is sufficiently reduc- 
 ed, when additional benefit will be derived from the instillation 
 of Atropine, and the application of a protective bandage. If 
 these measures, aided by suitable internal treatment, fail to 
 relieve the excessive ciliary neuralgia, photophobia and spasm 
 of the lids, and especially if, as is generally the case, the patient 
 h delicate or debilitated, such hygienic, dietetic and constitu- 
 tional treatment should be adopted as will be best calculated to 
 invigorate the general system. 
 
 After the inflammatory and nervous symptoms subside, if 
 the cornea still remains cloudy, or if the disease threatens to 
 become chronic, the vascular stasis may be overcome by dust- 
 ing the corneal surface once or twice a day with Mercurius 
 dulcis. The calomel, which of course should be entirely free 
 from all impurities or lumps, may be applied by insufflation, or 
 
l68 PRACTICE OF, MEDICINE. 
 
 which is better, by means of a short camel's hair pencil, by tap- 
 ping the brush, not too heavily loaded, immediately in front of 
 the cornea. The remedy is generally well borne, but if not, it 
 should be used less frequently, or else entirely omitted. 
 
 Vascular keratitis, whether arising from trachomatous irri- 
 tation, herpes corneae, or pannus, is often greatly benefitted by 
 the operation called canthoplasty. This operation consists in 
 dividing the outer canthus with a bistoury or pair of strong scis- 
 sors. If the former is employed, the instrument (PL I, Fig. 30) 
 is introduced upon a director, behind the external canthus, and 
 is made to emerge near the orbital border. The commissure is 
 then divided horizontally, that is, in the direction of the palpe- 
 bral fissure. If the scissors are used, one blade should be pass- 
 ed behind, and the other in front of the outer canthus, and the 
 commissure divided as before. An assistant now causes the in- 
 cision to gape by holding the lids widely apart, and the raw 
 edge of the conjunctiva is united to that of the skin by means 
 of two or three fine sutures, one of which should be at the upper 
 and another at the lower angle of the wound. The operation 
 as described is a perfectly safe one, and highly serviceable in 
 allaying irritation of the cornea, by diminishing the friction be- 
 tween it and the palpebral surfaces. 
 
 The internal remedies best adapted to this affection, to- 
 gether with their therapeutic indications, will be found on pages 
 577 and 578 of this journal for 1876. 
 
 Consult, also, Tables XIV and XV, and the TJierapeutic 
 Indications at the end of the Section on Ophthalmic Diseases. 
 
PRACTICE OF MEDICINE. 1 69 
 
 ^.-PHLYCTENULAR KERATITIS. 
 
 HERPES CORNER. 
 
 SYMPTOMS. — Phlyctenular keratitis is principally charac- 
 terized by the development of herpetic vesicles, or phlyctenulae, 
 on the surface or in the substance of the cornea. The disease 
 is frequently associated with phlyctenular ophthalmia, and is of 
 the same nature, differing only in its seat and the consequent 
 severity of the subjective symptoms. (See Phlyctenular Con- 
 junctivitis}) 
 
 The vesicles vary considerably in number, size and arrange- 
 ment. Sometimes they are solitary, or nearly so ; at other times 
 they are numerous, and scattered irregularly over the surface ; 
 or they may be arranged in groups at or near the margin of the 
 cornea, where they frequently form an arc of considerable ex- 
 tent. Occasionally they are very superficial, appearing like 
 beads of sweat just under the epithelium. Most commonly, 
 however, they are larger and more deeply seated, having at first 
 the appearance of little rounded tubercles, of a grayish or pearly 
 color, imbedded in the superficial layer of the cornea, with their 
 apices slightly raised above its surface. The portion of cornea 
 immediately surrounding the tubercle is generally somewhat 
 swollen, the puffed appearance being. due to a cloudy border of 
 infiltration, which is most marked in places where the 
 phlyctenulae are most closely aggregated. Sometimes a trans- 
 parent vesicle forms on the summit of a tubercle, the bursting 
 of which gives rise to a small ulcer, with a grayish, or grayish- 
 yellow, base and well-defined edges. Occasionally the ulcer ex- 
 tends at its circumference, at the expense of the cloudy border 
 surrounding it, constituting what is called the resorption ulcer. 
 Sometimes no vesicle forms, and then the tubercle becomes 
 denuded of its epithelium, and melts away, as it were, into an 
 ulcer of corresponding dimensions. The phlyctenulae, and their 
 associated tubercles and ulcers, do not all appear at once, but in 
 
I70 PRACTICE OF MEDICINE. 
 
 successive crops, so that they may be seen in various stages of 
 development at the same time. The ulcers when properly pro- 
 tected generally heal readily, gradually filling up and becoming 
 covered with epithelium.without, as a general rule, permanently 
 impairing the transparency of the cornea. 
 
 When the Phlyctenular are numerous and scattered, the 
 conjunctival and episcleral injections are generally strongly 
 marked, especially the rose-colored zone around the cornea ; 
 but when confined to one side of the cornea, the hyperaemia is 
 usually limited to the corresponding portion of the ciliary 
 region. In this case the phlycten forms the apex of an irregu- 
 lar vascular triangle, whose base is turned towards the circum- 
 ference of the globe. As the eruption is situated exactly at the 
 apex, and the vascular net-work extends at first only to the 
 border of the cornea, if the vesicle happens to be seated at a 
 distance from the corneal border, the vascular triangle will be 
 incomplete, a clear or non-vascular portion of the cornea inter- 
 vening between the eruption and the marginal cut-off. This 
 appearance, however, is sometimes only temporary ; after a 
 while the irritation developes vascular keratitis, and the vacant 
 portion of the triangle becomes bridged over with a net-work of 
 vessels, constituting what is sometimes called the herpetic bridge. 
 When the vesicles are much scattered, each group or phlycten 
 may be connected with a separate bundle of vessels, and these 
 may so inter. ningle and overlap each other, as to destroy in a 
 great measure their individuality. 
 
 The disease is preceded and accompanied with more or less 
 pain, heat, photophobia, spasm of the lids, and lachrymation. 
 These symptoms vary greatly in different cases, and in different 
 stages of the same case, being sometimes so intense as to be al- 
 most intolerable, and at others so light as scarcely to attract at- 
 tention. As a general thing, however, they are much more 
 prominent and persistent then when the disease is confined to 
 the conjunctiva. 
 
PHLYCTENULAR KERATITIS. 171 
 
 ETIOLOGY. — The causes of phlyctenular keratis are as 
 varied as they are numerous. Not only is it capable of being 
 excited by external irritants, such as usually give rise to other 
 forms of keratitis, but it is so frequently associated with a simi- 
 lar eruption occuring in the course of the distribution of the 
 trifacial nerve that many observers refer its origin in such cases 
 to irritation of the ophthalmic branch of that nerve, or to ac- 
 companying branches of the sympathetic. Another supposed 
 cause is the scrofulous diathesis, the disease appearing most fre- 
 quently in scrofulous children, and in persons of a feeble, irrita- 
 ble and cachetic habit, (See Scrofulous Conjunctivitis) 
 
 PROGNOSIS. — Notwithstanding the great tendency to re- 
 lapses in this disease, and its consequent liability to become 
 chronic, it frequently terminates in perfect recovery. When the 
 phlyctenular are few and superficial, excoriations or ulcusles 
 formed from them soon fill up, and under favorable circum- 
 stances leave no trace of their previous existence. But the 
 more deeply-seated tubercles rarely disappear altogether, but 
 leave opacities of greater or less size, the effects of ulcers 
 that may have existed for weeks or even months. Occasion- 
 ally the history of the herpetic tubercle is still less favorable, 
 the resulting ulcer extending deeper and deeper, and finally 
 ending in perforation. Or it may undergo cartilaginous or 
 calcareous degeneration, forming opacities of a dense and per- 
 manent nature. Finally, the disease sometimes becomes com- 
 plicated with iritis, trachomatous conjunctivitis and pannus 
 with their attendant consequences. 
 
 Treatment. — The treatment of phlyctenular keratitis is 
 similar to that recommended for phlyctenular conjunctivitis and 
 vascular keratitis, (which see p 610, 1876). The most important 
 points are, the instillation of Atropine and the application of 
 a protective bandage. The Atropine acts beneficially by 
 diminishing ciliary irritation, and also by lessening intra-ocular 
 pressure. The latter is of special consequence in the case of 
 
172 PRACTICE OF MEDICINE. 
 
 deep ulcers, the floor of which may be so thin and weak as 
 to render it unable to sustain the normal amount of pressure 
 In case the Atropine is found to disagree, Belladonna collyrium 
 should be substituted. In a few rare instances, owing to some 
 peculiar idiosyncrasy of the patient, neither of these prepara- 
 tions will be well borne, in which case their use will have to 
 be abandoned. The protective bandage, however, is of uni- 
 versal application. It effectually protects the ulcerated sur- 
 face from contact with the air, which is always highly irritat- 
 ing, not only to corneal ulcers, but to ulceration in every part 
 and tissue of the body. It is likewise equally serviceable in 
 allaying the ciliary irritation, pain, photophobia, and other 
 sympathetic symptoms. The bandage may be made of flannel, 
 and of sufficient length to extend twice around the head. The 
 best way of applying it is to place a piece of fine muslin over 
 the closed eye, and then to fill the orbital depression with fine 
 charpie, so that the bandage may exert a uniform pressure 
 upon the diseased organ. 
 
 Other local measures, as well as the most appropriate 
 hygienic and constitutional treatment, will be found under the 
 two heads above referred to, and therefore need not be repeat- 
 ed. (See Phlyctenular Conjunctivitis a?id Vascular Keratitis) 
 
 ART. IV. — SCLERITIS. 
 
 Although inflammation of the sclera is a very frequent 
 accompaniment of conjunctivitis and keratitis, it is doubtful 
 whether it ever occurs as a primary or idiopathic affection. As 
 a secondary disease it is quite common, but its symptoms are 
 so often masked by those with which they are associated, that 
 they frequently escape observation. The inflammation is gen- 
 erally partial, affecting only the anterior and superficial portions 
 of the membrane ; but it is sometimes general and deep-seated, 
 in which case -it is nearly always associated, perhaps always, 
 
EPISCLERITIS. 173 
 
 with general choroiditis. It seldom leads to suppuration ; but 
 sometimes portions of it undergo fatty degeneration, breaking 
 down into fatty and purulent products, and nearly destroying 
 the tissue. As commonly met with the disease occurs in two 
 distinct forms, both of which are usually described under the 
 head of 
 
 EPISCLERITIS. 
 
 SYMPTOMS. — Episcleritis, properly so called, is a partial or 
 circumscribed inflammation of the anterior portion of the 
 episcleral tissue. It is characterized by the appearance near 
 the cornea of one or more small dusky-red spots, which as the 
 disease progresses generally become more or less elevated and 
 nodular, and of a deeper or somewhat purplish hue. These 
 elevations are commonly situated near the insertion of the recti 
 muscles ; most frequently near that of the external rectus. The 
 conjunctival and episcleral injection, which usually precedes and 
 accompanies the formation of the little tumors, is generally 
 limited to their immediate vicinity, at which points the episcleral 
 tissue is more or less infiltrated and swollen, the vessels distend- 
 ed and vein-like, and the affected portion of the membrane of a 
 dark, bluish or purplish color. 
 
 The subjective symptoms are not generally very strongly 
 marked, unless the cornea is implicated. As a general rule 
 there is little or no pain, perhaps only a sense of uneasiness, 
 though sometimes there is a dull, heavy, aching feeling in the 
 eye, which renders the patient quite uncomfortable. Photopho- 
 bia and lachrymation are more constant symptoms ; but, 
 although sometimes considerable, they are often insignificant. 
 
 At first the disease is liable to be mistaken for phlyctenular 
 conjunctivitis, but the little tumor or nodule continues to in- 
 crease in size, especially at the base, until it sometimes threatens 
 to develope into what is called anterior sclerotic staphyloma ; but 
 after existing for weeks, and perhaps months, it generally 
 begins to diminish in size, and at last gradually dies away and 
 
174 PRACTICE OF MEDICINE. 
 
 disappears. Or, it may recede only to return in the same or 
 some other spot, and in this way the disease is sometimes pro- 
 longed for an indefinite period. 
 
 ETIOLOGY. — Very little is definitely known concerning the 
 origin of this affection. Its frequent occurrence in young 
 women has led some to infer that it is in some way connected 
 with the menstrual function, but this is mere conjecture. It is 
 perhaps most frequently met with in persons of a rheumatic or 
 gouty habit. Its extreme obstinacy in subjects affected with 
 syphilis, except when treated with anti-syphilitic remedies, 
 renders it probable that it may sometimes owe its origin to that 
 disease, especially when we consider how often syphilis affects 
 other similar tissues. When occurring independently of other 
 constitutional causes, it is probably due, in most cases, to over- 
 work, debility, or some other depressing influence. 
 
 PROGNOSIS. — This is almost always favorable. If, how- 
 ever, the disease goes on uncontrolled, or if resolution fails to 
 occur, the tumors may suppurate, giving rise to small abscesses 
 in the sub-conjunctival tissue ; or they may degenerate, becom- 
 ing cartilaginous or calcareous ; or, finally, deep-seated ulcera- 
 tion may occur, resulting in anterior sclerotic staphyloma, or 
 prolapse of the uvea. 
 
 TREATMENT. — Little treatment is generally necessary, 
 provided the patient will abstain from using the eyes, and will 
 protect them from bright light by wearing a shade. The instil- 
 lation of Atropine at night, and the use of warm fomentations 
 when necessary, will generally relieve the ciliary neuralgia, 
 which is not often very severe. Caustic collyria not only do no 
 good, but frequently do harm by increasing the ciliary irritation. 
 Wells, however, strongly recommends a weak collyrium of 
 chloride of zinc, beginning with one-half grain to the ounce of 
 water, and if well borne, increasing the strength to one or two 
 grains to the ounce. When syphilis is at the bottom of the 
 trouble, Kali hydriodicum is by far the best constitutional 
 
IRITIS. 175 
 
 remedy, though good results have been obtained in these cases 
 from Mercurius protoiodatus. Colchicum is generally the best 
 remedy for rheumatic and gouty subjects, Bryonia being most 
 serviceable for aggravations resulting from fatigue. Sepia is 
 particularly useful when the catamenia are deranged. Nux 
 vomica is a good remedy when the disease is induced or aggra- 
 vated by over-taxing the eyes, especially when there is debility 
 of the digestive organs or constipation. 
 
 Diet and Regimen. — Whatever benefits the general 
 health is likely to have a salutary influence on the disease. The 
 diet should therefore be liberal, nutritious and easily digestible. 
 The several animal functions, especially those of digestion and 
 secretion, should be carefully regulated ; and the patient should 
 take regular but moderate exercise in the open air. 
 
 • • ART. V. — IRITIS. 
 
 Ophthalmic writers have divided iritis into numerous forms 
 or varieties, distinguishable for the most part by the special 
 causes which are supposed to give rise to them. Thus, we have 
 the simple or rheumatic, the arthritic, the gonorrhoeal, the 
 syphilitic, the serous or cedematous, the suppurative or 
 parenchymatous, the idiopathic, the sympathetic, the traumatic, 
 etc. We may, however, reduce them all to the following four 
 groups: (1), simple iritis ; (2), serous iritis ; (3), suppurative 
 iritis ; and (4), syphilitic iritis. 
 
 l.-SIMPLE ACUTE IRITIS. 
 
 SYMPTOMS. — The principal symptoms of simple acute iritis 
 are : Episcleral redness, pain, Iachrymation, photophobia, 
 chemosis, structural changes lin the iris, sluggishness or immo- 
 bility of the pupil, and more or less febrile disturbance of the 
 system. 
 
 The characteristic redness is due to sub-conjunctival or 
 episcleral injection, in the form of a narrow band or zone, 
 
176 PRACTICE OF MEDICINE. 
 
 immediately around the cornea. This zone, commonly called 
 the corneal zone or circle, is composed chiefly of deep-seated 
 arterial twigs, of a rose-red, or violaceous hue, straight and 
 arranged parallel to each other, commencing at the junction of 
 the sclerotica with the cornea, becoming finer and finer as they 
 radiate from the latter, and terminating about a line from the 
 corneal border. The vascularity of the conjunctiva is in some 
 cases confined to the palpebral portion of the membrane ; in 
 others the ocular conjunctiva is involved, the distended vessels 
 proceeding from the circumference of the globe, following an 
 irregular but nearly parallel course towards the cornea, and 
 dividing into numerous branches, are at length lost in the nar- 
 row, but deeper-seated, more constant and characteristic circle 
 of vessels situated immediately around the cornea. The con- 
 junctival vessels are readily distinguishable from those compos- 
 ing the corneal zone, by being of a deeper red color and of 
 larger calibre, by being displaced by the movement of the con- 
 junctiva, by their more or less irregular distribution, and by 
 their connection with other similar vessels coming from the 
 palpebral surface. The episcleral redness is much more evenly 
 diffused than the conjunctival, owing to the fineness, closeness 
 and parallelism of the vascular injection. It is generally limit- 
 ed, at first, to the corneal border ; but as the disease progress- 
 es, the injection frequently becomes deeper and more general, 
 until, in some cases, the entire surface of the subjacent sclera 
 presents a reddish or rose-carmine appearance. Occasionally, 
 however, we meet with severe cases in which the subconjunc- 
 tival injection is but feebly developed, as in pyaemia, typhus, 
 puerperal, and other low forms of fever. 
 
 Some degree of chemosis of the ocular conjunctiva is gen- 
 erally present, and this may be so great as to cause considerable 
 bulging of the conjunctiva around the cornea. The eyelids also 
 participate in the affection, especially the upper lid, which fre- 
 quently becomes more or less inflamed and cedematous, when- 
 
SIMPLE ACUTE IRITIS. 1 77 
 
 ever the attack is severe. These complications, however, are 
 frequently absent. 
 
 The pain, also, which is occasionally throbbing, and ac- 
 companied with a feeling of distension or pressure, is sometimes 
 almost entirely wanting ; but in most cases it is severe, often 
 extremely so, and of a lancinating, burning or aching character. 
 When confined to the eye it is generally superficial, but as the 
 inflammation spreads the pain augments, and extends to the 
 orbit, temple and side of the head. It undergoes frequent exa- 
 cerbations and remissions, chiefly of a periodical character, and 
 is always most severe during the night. So long as the inflam- 
 mation is confined to the iris, the globe is not particularly pain- 
 ful to the touch ; but when it extends to the ciliary body, con- 
 stituting cyclitis, there is more or less tenderness and pain in 
 the ciliary region. 
 
 At first the eye is preternaturally dry, but soon the lachry- 
 mal secretion is re-established, and becoming excessive, consti- 
 tutes the condition called epiphora. This hyper-secretion,which 
 is due to the sympathetic influence of the inflammation on the 
 lachrymal gland, sometimes becomes so great as to overflow 
 the lids. The tears are frequently hot and burning, particularly 
 if there is much co-existing inflammation of the neighboring 
 parts, and so irritating as sometimes to inflame the skin over 
 which they flow. 
 
 Photophobia is another prominent symptom of acute iritis, 
 especially if the cornea is implicated, and is generally in propor- 
 tion to the violence of the inflammation. The eye is unable-to 
 bear the full light of day, and suffers more or less when expos- 
 ed to a diffused light ; hence the patient generally keeps the 
 eyes closed or deeply shaded. 
 
 The constitutional disturbance, though modified to some 
 extent by the age and health of the patient, commonly varies 
 in proportion to the amount of local disorder. When severe 
 there is generally considerable febrile excitement, which is 
 
 23 
 
178 PRACTICE OF MEDICINE. 
 
 sometimes accompanied by more or less derangement of the 
 digestive organs. 
 
 Vision is always more or less impaired, and in mild cases 
 this is sometimes the only symptom that attracts attention. 
 Many causes contribute to this result. Sometimes it is chiefly 
 due to haziness or opacity of the cornea, the membrane appear- 
 ing as if dotted over with fine points of opaque matter, as rep- 
 resented in Fig. 8. In most cases of simple iritis, however, 
 the cornea remains unaffected, or at most is rendered only 
 slightly hazy. Vision may also be affected by cloudiness of 
 the aqueous humor, or by diffuse opacity of the vitreous, due 
 to co-existent inflammation of the ciliary body, in which case 
 the power of accommodation is also impaired. But the chief, 
 or rather the most constant causes of impaired vision in iritis, 
 are such as result from paralysis of the muscles caused by 
 proliferation of tissue, from immobility of the iris, or from a 
 greater or less amount of occlusion or obstruction of the 
 pupil by inflammatory products. 
 
 In all cases the pupil is rendered more or less sluggish. 
 This is owing partly to hyperaemia of the vessels, but chiefly 
 to plastic or serous exudations into, or upon the surface of 
 the iris, whereby its motions are mechanically hindered. 
 
 Contraction and irregularity of the pupil are characteris- 
 tic symptoms, dependent upon exudations between the iris and 
 capsule of the lens, giving rise to a greater or less amount of 
 adhesion between them. These exudations may be so situated, 
 or so minute, as to escape detection until the pupil is arti- 
 ficially dilated, or is examined by lateral illumination, when 
 we may discover the beads of lymph which tie it to the anter- 
 ior capsule. The exudations coalesce as they increase in size, 
 until in some cases the entire pupillary margin becomes 
 adherent, constituting what is called annular synechia. This 
 condition does not materially interfere with vision, as the 
 centre of the pupil still remains clear ; but when the exuda- 
 
SIMPLE ACUTE IRITIS. 179 
 
 tions invade the pupillary opening, a greater or less portion of 
 its area is covered with lymph, and then, of course, vision is 
 proportionally obstructed. 
 
 The contraction and immobility of the pupil are always 
 associated with more or less dullness and discoloration of the 
 iris. These symptoms are all due to the same causes, namely, 
 to hyperaemia and effusion, and are among the earliest signs 
 of the disease. The iris in its natural state has a more or 
 less bright, glistening appearance, which is changed by inflam- 
 mation to a dull, lustreless aspect, as though the membrane had 
 lost its vitality. In addition to this the color itself changes. Blue 
 and gray irides become slate-colored or greenish, while brown 
 and black irides change to a reddish-brown or cinnamon color. 
 As such changes are sometimes only apparent, the affected 
 iris should always be carefully compared with that of the sound 
 eye, remembering at the same time that dullness and discolora- 
 tion of the iris may be caused by cloudiness of the cornea and 
 of the aqueous humor. 
 
 ETIOLOGY. — The chief predisposing cause of simple iritis 
 is the rheumatic or gouty diathesis. But the same form of 
 iritis may occur independently of rheumatism in other parts of 
 the body, and unassociated with the gouty or rheumatic consti- 
 tution. In such cases, however, the same exciting causes gener- 
 ally give rise to it, namely, exposure to sudden atmospheric 
 changes, dampness, wind, cold draughts of air, etc., and hence, 
 as there are no characteristic symptoms by which to distinguish 
 one form from the other, it has been customary to call them both 
 rheumatic. Simple acute iritis, though frequently of traumatic 
 origin, is most generally 'secondary, inflammation originating in 
 other parts being transmitted to it in consequence of the close 
 anatomical or functional relation they sustain to each other. 
 Hence we have found it to be frequently associated with various 
 forms of ophthalmia, especially the purulent. On the other 
 hand, also, as we have seen, acute iritis is frequently complicated 
 
180 PRACTICE OF MEDICINE. 
 
 with inflammation of the neighboring parts, constituting what is 
 frequently called rheumatic ophthalmia. 
 
 Prognosis. — The prognosis in the great majority of cases 
 is favorable. The disorder is often obstinate, owing to its fre- 
 quent complication with other forms of ophthalmic inflamma- 
 tion, the diathesis of the patient, atmospheric influences, etc. ; 
 but sooner or later the inflammation undergoes resolution, and, 
 unless complicated with more serious affections, such as unyield- 
 ing posterior synechiae, the organ fully recovers. Of course, in 
 traumatic iritis the prognosis will have to depend, in a great 
 measure, upon the nature, extent and precise seat of the injury, 
 and should therefore always be particularly guarded. 
 
 DIAGNOSIS. — The diagnosis has already been given with 
 sufficient accuracy. Iritis is distinguished from simple inflam- 
 mation of the conjunctiva, with which it is sometimes 
 confounded, by the injection being originally confined 
 to the episcleral tissue ; by its pinkish or violaceous hue ; 
 by its forming a narrow zone about the cornea 
 composed of straight, deep-seated, parallel vessels, disconnected 
 with those of the conjunctiva; by the epiphora, photophobia, 
 and orbital and circumorbital pain ; by the dullness and dis- 
 coloration of the iris by exudations of plastic lymph upon its 
 surface or margin ; and by the contracted, irregular and slug- 
 gish state of the pupil. Not unfrequently the points of some 
 of the vessels constituting the corneal zone encroach upon the 
 edge of the cornea, forming upon its border a small vascular 
 circle, or segment, varying in breadth from one-eighth to three- 
 eighths of a line ; this is supposed to constitute one of the 
 differential signs of rheumatic iritis. 
 
 RESULTS. — The chief results attending this form of iritis 
 are : exudations upon the surface of the iris, or upon its margin, 
 and in the pupillary aperture ; adhesions to the anterior capsule ; 
 {posterior synechia) ; occlusion of the pupil ; and, when compli- 
 cated with keratitis, the development of phlyctaena on the cor- 
 
SEROUS IRITIS. l8l 
 
 nea : superficial ulceration resulting from their rupture ; 
 and more or less opacity of the cornea arising from depositions 
 upon the inner surface or between its laminae. (See Fig. 8.) 
 Treatment. — The medical and surgical treatment of iritis 
 is so varied, and at the same time is of such great importance, 
 that we deem it best to defer its consideration until after the 
 other forms of iritis have been described. 
 
 2 -SEROUS IRITIS. 
 
 DESCEMETITIS. KERATITIS PUNCTATA. 
 
 SYMPTOMS. — This form of iritis is chiefly characterized by 
 an increase of the aqueous humor, and by the absence of plastic 
 exudations. Instead of the usually contracted state of the 
 pupil, this aperture is generally more or less dilated, in conse- 
 quence of the increased intra-ocular pressure. Discoloration of 
 the iris is not very perceptible, nor are the other symptoms of 
 acute iritis sufficiently marked to attract attention. Pain and 
 photophobia are generally absent, and the injection is usually 
 limited to the vessels composing the narrow circum-corneal 
 zone of the episcleral tissue. The aqueous humor is more or 
 less turbid, the cloudiness arising from minute particles of float- 
 ing lymph in the anterior chamber. Similar particles are de- 
 posited in the form of points upon the posterior surface of 
 the cornea, from which they occasionally project, giving to that 
 membrane a punctated appearance, (keratitis punctata). Inter- 
 stitial opacities also occur in the different layers of the cornea, 
 especially of the posterior laminae, similar in appearance to 
 those observed on the posterior wall of Descemet's membrane. 
 These, however, are supposed to be caused by inflammatory 
 changes, and not by deposits from the aqueous humor. Vision 
 is always more or less impaired, owing partly to cloudiness of 
 the cornea and aqueous humor, partly to intra-ocular tension 
 caused by hypersecretion of the aqueous, and sometimes of the 
 
1 82 PRACTICE OF MEDICINE. 
 
 vitreous humor, and partly to deeper seated inflammation, es 
 pecially cyclitis and choroiditis, with which it is frequently as- 
 sociated. 
 
 ETIOLOGY. — Anaemia, chlorosis, scrofula, and especially 
 syphilis, both constitutional and hereditary, have all been re- 
 garded as predisposing causes. It is often observed in children 
 affected with the peculiar notching of the central incisors, of the 
 second dentition, which indicates congenital syphilis. It also 
 constitutes one of the forms of sympathetic ophthalmia. 
 
 PROGNOSIS. — Serous iritis is usually very chronic, but is 
 generally less serious than either the suppurative or the syphili- 
 tic. When timely recognized, if the affection which causes it 
 can be overcome, the disease will generally soon disappear. On 
 the contrary, if the deep structures of the eye have become im- 
 plicated, and especially if there is at the same time a syphilitic 
 dyscrasia to contend with, the prognosis is particularly bad. 
 
 Treatment. — This we shall defer until we come to con- 
 sider the treatment of the other forms of iritis. 
 
 3-SUPPURATIVE IRITIS. 
 
 SYMPTOMS. — Suppurative or parenchymatous iritis is 
 characterized by the presence of pus-cells in the stroma or 
 tissue of the membrane. In some cases their situation corres- 
 ponds to the course of the vessels ; in others they coalesce and 
 form small collections, constituting true abscesses. These find 
 their way to the surface, either by ulceration or rupture, and 
 sinking to the bottom of the anterior chamber, form an hypopyon. 
 Generally, however, the exudation takes place on the surface of 
 the iris, either in the form of a thin gray secretion, covering the 
 iris like a veil, or else thick and puriform, interpersed here and 
 there with minute patches of extravasated blood. The tissues 
 of the iris swell and impede the circulation, and soon large 
 varicose veins become visible on its surface. 
 
 Neoplastic exudations also take place along the edge and 
 
SUPPURATIVE IRITIS. 1 83 
 
 into the area of the pupil, as well as upon the posterior surface 
 of the iris, giving rise to extensive adhesions between it and the 
 anterior capsule. Frequently the deposits assume the form of 
 irregular masses, or nodules, especially around the pupillary 
 opening, where they sometimes give rise to annular synechias, 
 or by extending into the area, fill up and completely occlude 
 the pupil. Occasionally some of these nodular masses become 
 detached, and melting down become mixed with the aqueous 
 humor, and render it more or less turbid. The particles of 
 disintegrated lymph and the pus globules, thus liberated, 
 gradually settle to the bottom of the anterior chamber. The 
 hypopyon thus formed is sometimes so small as to be seen 
 with difficulty, appearing only as a narrow, yellow line along 
 the floor of the anterior chamber ; in other cases it reaches 
 the level of the pupil; and in some rare instances it fills the 
 whole chamber of the aqueous humor. 
 
 According to Von Graefe and other authorities, these col- 
 lections of puriform matter are not always entirely due to in- 
 flammation of the iris, some portions of them being derived 
 from the membrane of Descemet, and some from the ciliary 
 muscle, which is occasionally affected with the same form of 
 inflammation. Suppurative iritis may also be complicated with 
 choroiditis, constituting irido-choroiditis, one of the forms of 
 sympathetic ophthalmia, (which see). 
 
 ETIOLOGY. — As suppurative iritis is generally the result of 
 a higher grade of inflammation than the simple, it follows that 
 the same causes in some instances give rise to it. It is rarely 
 the case, however, that catarrhal and traumatic iritis take on the 
 suppurative form ; and when they do, it is generally by the ex- 
 tension of the disease from other parts. On the other hand, it 
 is not unfrequentlythe result of the continuation of the suppura- 
 tive process from parts which are in anatomical or functional 
 relation with it, as in keratitis and choroiditis. In other cases, 
 again, it seems to depend upon certain constitutional affections, 
 
1 84 PRACTICE OF MEDICINE. 
 
 especially syphilis. According to some authorities, it is occa- 
 sionally due to a neurotic condition caused by malaria, in which 
 case it assumes the intermittent form. That it may be caused 
 by an irritative condition transmitted through the nervous 
 system, has been established by the testimony of many recent 
 observers. In this case it generally assumes the form of an 
 irido-choroiditis. (See Sympathetic Ophthalmia}) 
 
 PROGNOSIS. — Suppurative iritis is generally a much more 
 serious affection than either simple or serous iritis, in conse- 
 quence of the greater amount of neoplastic formations associat- 
 ed with it, and which frequently give rise to extensive posterior 
 synechias that effectually resist the action of Atropine. More- 
 over, the disease is much more apt to be complicated with de- 
 structive changes in the cornea, and also in the deeper-seated 
 tissues of the eye. In these cases, of course, it is the complica- 
 tions and sequelae, rather than the iritis, which often renders the 
 prognosis doubtful, as the tissue of the iris may recover its 
 normal condition, and yet its function, as well as that of the 
 eye itself, may remain greatly impaired, or even be entirely de- 
 stroyed. 
 
 Treatment. — This will be given in connection with that 
 of syphilitic iritis, (which see). 
 
 4.-SYPHILITI0 IRITIS. 
 
 SYMPTOMS: — Syphilitic iritis is characterized by the pro- 
 duction of true gummy tubercles {gummata syphilitica), originat- 
 ing in the stroma of the iris, and projecting above its surface in the 
 form of condylomata or warts. They are often solitary, or nearly 
 so; but occasionally they are more numerous, and either scat- 
 tered about over the surface of the iris, or collected into a ring 
 upon its pupillary or ciliary border. The tubercles vary in size 
 from that of a millet seed to a split pea, their apices sometimes 
 extending to the posterior surface of the cornea. They are 
 
SYPHILITIC IRITIS. 1 85 
 
 mostly of a reddish or copper-colored tint, suggestive if not 
 characteristic of their syphilitic origin. In this respect, how- 
 ever, they vary considerably, according to the natural hue of 
 the iris. Thus, in light irides, they are generally of a yellowish- 
 red or cinnamon color, while in dark irides they are commonly 
 of a dull reddish or muddy brown. They also become darker by 
 age. 
 
 The subsequent condition of the tumors varies according 
 to circumstances. Sometimes they are rapidly absorbed ; at 
 other times they undergo fatty degeneration and purulent solu- 
 tion, the detritus mixing with the aqueous humor. Occasion- 
 ally, on the other hand, after passing through certain 
 metamorphic processes, they assume a more or less permanent 
 form, as we shall see hereafter. 
 
 The inflammatory changes in the iris are most marked in 
 the vicinity of the tuberculous nodules, and as these are often 
 confined to a particular portion of the membrane, the thicken- 
 ing and vascularity of the iris are greatest at that point. This 
 feature of the disease, like that of the gummy tumors on which 
 it depends, is a peculiarity of syphilitic iritis. 
 
 Although the appearance of gummy tubercles in the iris is 
 an almost certain indication of their syphilitic origin, yet it 
 is generally conceded that their presence is not necessarily 
 connected with secondary syphilis ; nor, on the other hand, 
 does their absence establish the non-syphilitic character of the 
 affection. It is well to remember, therefore, that while the 
 existence of gummy tubercles may be regarded as satisfactory 
 evidence of the syphilitic nature of the inflammation, the dis- 
 ease may have an undoubted syphilitic basis, and yet appear 
 in the simple idiopathic or suppurative form. 
 
 Diagnosis. — As there are no local symptoms sufficiently 
 characteristic to establish beyond a doubt the syphilitic nature 
 of the affection, it follows that it can only be positively de- 
 termined by the existence of constitutional syphilis. Thus, 
 
1 86 PRACTICE OF MEDICINE. 
 
 the specific character of the disease may reveal itself by a 
 co-existent papalar eruption, by the presence of syphilitic 
 ulcers in the pharynx, by enlargement of the lymphatic 
 glands, or by the cicatrix of a chancre. In the absence of any 
 of the peculiar evidences of constitutional syphilis, the history 
 of the case, though it may not supply positive proof, may serve 
 to elucidate the nature of the disease, or at least furnish prob- 
 able grounds for suspicion. 
 
 PROGNOSIS. — The prognosis in many cases of syphilitic 
 iritis is most grave. Although the gummy tubercles are often 
 quickly absorbed, they sometimes undergo permanent degener- 
 ation, shrinking into hard nodules, or changing into tough, 
 tendon-like masses, which either lie upon the surface or are 
 buried in the stroma of the iris. In other cases, as we have 
 seen, the suppurative process gives rise to formidable hypopya, 
 many of which never entirely disappear, but leave behind per- 
 manent products, which in some cases undergo fatty and cal- 
 careous degeneration. In other cases, again, the deeper 
 structures of the eye become involved, the disease finally ter- 
 minating, it may be, either in atrophy of the globe or in 
 panophthalmitis. 
 
 TREATMENT OF IRITIS. 
 
 The leading indications in the treatment of iritis are, first, 
 to prevent, and afterwards, if necessary, to destroy or break up 
 any adhesions of the iris to the anterior capsule ; (posterior 
 synechia) ; to relieve ciliary irritation and neuralgia ; to lessen 
 intra-ocular tension ; and to quiet the muscular action of the 
 inflamed tissue. These indications are best met by the instil- 
 lation of a strong neutral solution of Atropine (grs. ij — v. ad 
 water gj), the free application of which produces complete 
 dilatation of the pupil, sets the muscular fibres of the iris at 
 rest by paralyzing the constrictor pupillae, and relieves the 
 interior circulation of the eye, thereby diminishing congestion 
 
SYPHILITIC IRITIS. 1 87 
 
 of both the ciliary body and iris. These results, however, can 
 only be accomplished by the free and judicious use of the 
 Atropine, as the inflamed, swollen and infiltrated state of the 
 iris prevents, to* a great degree, its absorption, and also dimin- 
 ishes its mydriatic effect, by producing stiffness and want of 
 freedom of the muscular fibres of the membrane. It is there- 
 fore advisable, and in most cases necessary, to apply the 
 Atropine fifteen or twenty times during the day,or which is bet- 
 ter, at intervals of only a few minutes, until it affects the pupil, 
 so as to produce at once, if possible, sufficient dilatation to pre- 
 vent adhesions and to set the membrane at rest. And should 
 adhesions have already formed, the synechias if recent, narrow, 
 or easily ruptured, may also by this means be broken through, 
 and their reunion prevented, by keeping the pupil completely 
 dilated. But this is not all ; the ciliary irritation and pain are 
 generally greatly lessened, and in many cases entirely overcome, 
 by the instillations, in which case nothing remains to hinder 
 speedy recovery. 
 
 But sometimes, owing to the peculiar state of the eye or 
 the idiosyncrasy of the patient, the Atropine does not agree ; 
 instead of lessening the ciliary irritation it seems to increase it. 
 This result is most apt to occur when its influence upon the iris 
 is resisted, the remedy not appearing to be absorbed sufficiently 
 to produce its mydriatic affect, but, spending its action chiefly 
 upon the ciliary region, greatly increases the hypersemia and 
 irritability of the eye. In such cases the difficulty may often be 
 overcome, and the best results obtained, by simply applying 
 warm fomentations, the effect of which seems to be to relax 
 the affected tissues and thereby favor the absorption of the 
 remedy. In some of these cases the irritability may be allayed 
 by substituting a collyrium of Belladonna in place of Atropine. 
 at the same time rubbing in Belladonna ointment around the 
 eye. 
 
 Should the foregoing treatment fail in producing sufficient 
 
1 88 PRACTICE OF MEDICINE. 
 
 dilatation of the pupil, a precious resource remains to us in 
 paracentesis cornea. This operation not only favors absorption 
 of the Atropine,but also lessens irritability of the eye, by dimin- 
 ishing intra-ocular tension and relieving the internal circulation. 
 The mydriatics will now be almost certain to act f ivorably, 
 even in cases in which they had previously seemed to have lost 
 their power. 
 
 When extensive adhesions exist, it is well to bear in mind 
 that if the Atropine does not quickly succeed in breaking them 
 up, it is better to use them simply with the viewof allaying irri- 
 tation and lessening intra-ocular tension, as a too energetic use 
 of them under such circumstances serves only to fret the im- 
 prisoned iris, and consequently to augment the inflammation. 
 Should any doubt exist as to the inability of the iris to over- 
 come the synechia, Calabar bean, which sometimes proves 
 effective after Atropine has failed, may be tried. 
 
 We have already suggested the use of warm fomentations, 
 in case the Atropine fails to act on the pupil. Similar applica- 
 tions, used as hot as they can be borne, and frequently changed, 
 are equally beneficial in promoting absorption of recently 
 effused lymph, and also of hypopyon. This remedy, simple as 
 it appears, is invaluable in the treatment of both suppurative 
 and syphilitic iritis. To be effective, however, the applications 
 will require to be faithfully followed up. If for any reason this 
 is found to be impracticable, heat and moisture may be applied, 
 and the same end attained, by the use of hot emollient poultices, 
 which should be changed every half hour or so, according to the 
 severity of the case. These measures will not, of course, be 
 required after the acute symptoms have subsided ; but the use 
 of Atropine should be continued for several weeks, the object 
 being to keep the pupil dilated and at rest. Unabsorbed 
 hypopya will require to be removed by paracentesis. (See 
 Paracentesis Cornea.) Other operative procedures will be con- 
 sidered after we have given the 
 
SYPHILITIC IRITIS. 1 89 
 
 THERAPEUTIC INDICATIONS. 
 
 Aconite. — In the first stage of iritis, especially when the 
 pupil is greatly contracted. Its usefulness is generally measur- 
 ed by the acuteness of the symptoms and the earliness at which 
 it is given. 
 
 Arnica is most serviceable for nervous and plethoric 
 patients, and when the iritis is of traumatic origin. • 
 
 Arsenicum is one of our best remedies in serous iritis, 
 especially in scrofulous subjects. It may sometimes be advan- 
 tageously alternated with Kali hydriodicum. 
 
 Belladonna is best adapted to cases attended with much 
 conjunctival injection and swelling, especially when there is 
 considerable ciliary neuralgia and photophobia. It is often 
 alternated with Aconite, particularly at the commencement of 
 the disease. 
 
 Bryonia is especially suited to rheumatic cases, or when the 
 eyeballs are sensitive to the touch or. on motion. It may be 
 given in alternation with Aconite or Mercurius whenever these 
 remedies are indicated. 
 
 Chamomilla is useful in the iritis of scrofulous children, 
 especially when characterized by severe ciliary neuralgia. 
 
 Cimicifnga** is indicated when there is much pain and in- 
 traocular tension. It is especially adapted to rheumatic cases. 
 
 Colchicum is also indicated in rheumatic cases, especially 
 when there is very great soreness of the eyeballs. 
 
 Digitalis is another useful remedy in rheumatic iritis, es- 
 pecially in the early stages, when there is contraction of the 
 pupil and great tenderness of the globe, with more or less ach- 
 ing in and around the eye. 
 
 Kali hydriod. — This remedy is adapted to nearly every 
 form of iritis, especially the serous and syphilitic. 
 
 Mercurius. — This is, without exception, the most reliable 
 general remedy for iritis, especially after exudation has taken 
 
 * See Am. Horn. Obs., vol. 4, p. 229. 
 
190 PRACTICE OF MEDICINE. 
 
 place. It is adapted to acute, sub-acute and relapsing cases ; 
 also to those which become complicated with inflammation of 
 other parts of the eye, particularly the cornea, ciliary body and 
 choroid. 
 
 Spigelia. — This is generally the best internal remedy with 
 which to relieve ciliary neuralgia and photophobia. It is par- 
 ticularly adapted to children, especially those of scrofulous con- 
 stitutions. See " Additio7ial Therapeutic Indications" at the end 
 of section on Ophthalmic Diseases. 
 
 Diet and Regimen. — The diet should be simple and 
 unstimulating. If the disease is chronic, or subject to frequent 
 relapses, the patient will need to be particularly on his guard 
 against everything calculated to favor hyperaemia and conges- 
 tion, such as exposure of the eyes to bright light, wind, draughts 
 of air, etc., or to straining them with reading, sewing, or any 
 fine work. If necessary he should wear blue or smoke-colored 
 glasses. (See NOTE, on page 129. 
 
 OPERATIONS FOR ARTIFICIAL PUPIL. 
 
 We have already passed in review the following circum- 
 stances and conditions in which the operation for the formation 
 of an artificial pupil is recommended : (1), permanent opacity 
 of the cornea interfering with normal vision ; (2), permanent 
 closure of the pupil, {atresia pupillce), either by contraction, 
 occlusion, or complete posterior synechias of the pupillary mar- 
 gin ; (3), suppurative keratitis, threatening extensive perfora- 
 tion of the cornea ; (4), corneal perforation, and prolapse of the 
 iris ; (5), to diminish intra-ocular tension ; and (6), to lessen in- 
 flammatory symptoms. We shall also have occasion to recom- 
 mend it in (7), glaucoma ; (8), staphylomata ; (9), cataract ; and 
 (10), to facilitate the removal of foreign bodies from the 
 aqueous chamber or iris. 
 
 {a.) Iridectomy. — Of the numerous operations daily per- 
 formed on the eye, this is both the most frequent and the most 
 important. Being the safest and most successful operation for 
 
ARTIFICIAL PUPIL. I9I 
 
 the formation of an artificial pupil, it has almost entirely super- 
 ceded every other method. It consists in excising a small por- 
 tion of the iris, after it has been drawn through an opening in 
 the cornea made for that purpose. The instrument generally 
 made use of for dividing the cornea is called a keratome. The 
 blade is of a triangular or lance shape, and when the iridectomy 
 is made on the temporal side, is set straight with the shaft ; 
 (See PL I., Fig. 24) ; but when it is required to be made in- 
 wards or upwards, the blade is bent to suit the plane of the 
 nose and orbit. (Fig. 26). The forceps should for the same 
 reason be straight, as in PL II., Fig. 36, or bent at an acute 
 angle, as shown in Fig. 37. They should be so constructed that 
 when closed the extremity will be perfectly smooth, so that 
 they may be passed through the lips of the incision without 
 lacerating them, or doing any injury to the iris. 
 
 The operation is most conveniently performed as follows : — 
 The patient having been placed upon a couch or bed, in a 
 good light, with his head slightly raised, and chloroform ad- 
 ministered to him by an experienced assistant, the operator 
 places himself either behind or in Iront of the patient, as may 
 be found most convenient, and having separated the lids to 
 the desired extent by means of the stop speculum, (PL II., 
 Fig"- 33)> an< 3 having fixed the globe by seizing the ocular 
 conjunctiva with the fixing forceps, (Fig. 36), at a point exactly 
 opposite where the incision is to be made, he takes either the 
 straight or angular keratome, (PL I., Figs. 24, 26), as the case 
 may require, and forces it in at the desired point, parallel 
 with, and generally near to, the sclero-corneal junction, being 
 careful to lay the handle of the instrument well back, so as to 
 guide the point of the keratome into the anterior chamber in 
 such a manner as to permit of its being safely pushed forward 
 between the iris and cornea until the incision is of the requisite 
 length. 
 
 When the iridectomy is performed with the view of lessen- 
 
192 PRACTICE OF MEDICINE. 
 
 ing intra-ocular tension, or for the purpose of relieving the in- 
 terior circulation, as in iritis or glaucoma, or when there is but 
 a limited space for the pupil on the margin of the cornea, the 
 incision should be made in the sclerotica, about half a line from 
 the corneal border, so as to penetrate the chamber exactly at 
 the ciliary edge of the iris. But when it is intended for optical 
 purposes only, the incision should be made through the cornea ; 
 the preferable point being a little to the inner side of the centre, 
 that being the direction of the visual ray. Other things being 
 equal, however, the corneal opening should if possible be made 
 near the superior border of the cornea, so that the upper lid will 
 conceal to some extent the obliquity of the pupil, and at the 
 same time reduce the amount of irregular refraction resulting 
 from it: 
 
 In withdrawing the keratome, care should be taken not to 
 allow the aqueous humor to flow off too rapidly, otherwise the 
 sudden reduction of the intra-ocular tension will cause conges- 
 tion of the interior vessels, which may result in a greater or less 
 amount of hemorrhage from rupture of the choroidal and 
 retinal capillaries. In ^ase the incision made by the keratome 
 is not sufficiently broad, or if, for any reason, it becomes neces- 
 sary to widen it, it may readily be enlarged in either direction 
 by an instrument designed for that purpose, represented in PL 
 I., Fig. 20. 
 
 On completing the section of the cornea as above describ- 
 ed, if the iris does not protrude into the wound, the surgeon 
 should pass the iris forceps, closed, through the lips of the 
 incision, and having seized a fold of the iris, should draw it 
 gently through the opening; and when a sufficient portion of it 
 protrudes, the prolapsed part should be divided, either with a 
 scalpel or bistoury, (PI. I., Fig. 22), or what is better a pair of 
 iris scissors, (Fig's. 1, 18, 19). If on withdrawing the keratome 
 the iris prolapses, there will of course be no necessity of enter- 
 ing the anterior chamber with the forceps, but the protruding 
 
SYPHILITIC IRITIS. 1 93 
 
 portion should be immediately seized, drawn out to the required 
 extent, and then excised. 
 
 (b.) Iriodesis. — This operation, consisting of an artificial 
 prolapse of a portion of the pupillary margin of the iris, is 
 often substituted for iridectomy in cases requiring simple dis- 
 placement of the pupil. The general management of the 
 patient, and the method of making the corneal incision, are 
 the same as in iridectomy, except that the incision is always 
 made near the border of the cornea. Sometimes the stop 
 needle (PI. I., Fig. 15.) is used in making the corneal incision 
 instead ot the keratome, in order to prevent the too sudden 
 evacuation of the aqueous humor. After withdrawing the 
 needle, a small loop of fine silk thread is placed directly over 
 the opening in the cornea, and then a small blunt iris hook, 
 bent at the proper angle, (PL I., Fig. 35, b.), is introduced 
 through the loop into the anterior chamber, pushed forward 
 until it catches in the proximal side of the pupil, which is then 
 gently pulled out through the loop and tied by an assistant. 
 The ends of the loop should cut off; but if the corneal 
 incision has been made so large as to render the position of 
 the prolapsed portion of the iris insecure, they should be 
 cut long enough to be attached to the integument by means of 
 a narrow adhesive slip. The loop will fall off in two or three 
 days; if not it may be removed. If the operator chooses, he can 
 make use of the canula forceps, (PI. I., Fig. 3.) instead of 
 the hook for seizing the iris, and in many cases it is to be pre- 
 ferred, especially when the pupil is required to be only slightly 
 displaced. The operation, it is seen, is quite simple, but 
 requires care in order to avoid separating the opposite border 
 of the iris from its ciliary attachment. 
 
 (c.) Iridenkleisis . — This operation is similar to the last. 
 It consists in strangulating a portion of the pupillary margin 
 of the iris in a long narrow opening made in the corneal bor- 
 der of the sclerotica. The incision is generally made with a 
 
 25 
 
194 PRACTICE OF MEtUCINE. 
 
 keratome or lance-shaped knife (PI. I., Fig. 24.) precisely as 
 in iridectomy, except that the instrument is entered very obli- 
 quely three-fourths of a line from the corneal border, and 
 only far enough to admit of the easy entrance of the canula 
 forceps, (PL I., Fig. 3.) by means of which the iris is pulled 
 out of the opening in the sclerotica, and there left. The stran- 
 gulated portion generally drops off in a few days ; if it should 
 not it may be removed. 
 
 (d.) Iridotomy. — This operation consists in simply making 
 an opening in the iris with a knife in cases in which, the lens 
 being absent, the pupil closed, and the cornea clear, or if par- 
 tially opaque, the opacity not interfering with the formation of 
 an artificial pupil, one may be made by simply dividing the 
 membrane. The operation may be performed either with a 
 straight, spear-pointed, or lance-shaped knife, by passing the 
 instrument through the cornea perpendicular to its surface, and 
 after incising the iris to the required extent, immediately 
 withdrawing it. The edges of the incision generally retract 
 sufficiently to form a useful pupil ; but in case they do not, one 
 of them may be drawn out with a blunt iris hook (PL I., Fig, 35) 
 and excised. 
 
 (e.) I rido dialysis. — This is a convenient method of forming 
 an artificial pupil in cases where the central part of the cornea 
 is opaque, or in which the only transparent portion is a narrow 
 line at the circumference. The operation consists in entering 
 the anterior chamber with the canula forceps, (PL I., Fig. 3), 
 and separating a portion of the iris from its ciliary attachment. 
 A better pupil may generally be obtained by first incising the 
 cornea as in iridectomy, and then with the iris forceps or hook 
 gently separating a small portion of the iris from its insertion, 
 which is afterwards drawn out of the wound and cut off. 
 
 (/.) Corelysis. — The object sought to be accomplished by 
 this operation is the detachment of adhesions between the edge 
 of the pupil and the anterior capsule of the lens, (posterior 
 
CYCLITIS. 195 
 
 synechia). The latest and best method of operating is that 
 devised by Passavant. which consists in introducing a pair of 
 blunt-pointed iridectomy forceps through an incision in the 
 cornea, ( See Iridectomy), seizing the iris between the senechia 
 and the corneal opening, and gently drawing it towards the 
 latter far enough to detach the adhesion. The operation should 
 be repeated every two or three days until the entire pupillary 
 margin is relieved. 
 
 AFTER Treatment. — For several days after an operation 
 for artificial pupil, the patient should be kept in bed, or re- 
 clining quietly on a sofa, in a darkened room. All noise and 
 excitement of every kind should be suppressed, and the patient 
 kept in a state of complete mental and bodily repose. A pres- 
 sure bandage should be immediately applied to both eyes, and 
 drawn sufficientlytight to guard against intra-ocular hemorrhage. 
 In a few hours the bandage may be loosened, but it should not 
 be entirely removed for several days. After the operation of 
 corelysis a strong solution of Atropine should be immediately 
 applied, and the instillation repeated from hour to hour until 
 the pupil is well dilated, after which the protective bandage 
 should be applied, and so adjusted as to exercise just enough 
 pressure to prevent winking. The diet for the first few days 
 should be such as to require little or no mastication, consisting 
 of such articles as milk, soft-boiled eggs, soups, etc. If much 
 inflammation or ciliary irritation should set in, the treatment 
 previously recommended should be rigidly enforced. 
 
 ART. VI. — CYCLITIS. 
 
 Inflammation of the ciliary body is seldom idiopathic. It 
 is generally associated with its forerunner, iritis, constituting 
 irido-cyclitis, or with iritis and choroiditis, forming irido- 
 choroiditis. Sometimes the inflammation is transmitted to the 
 ciliary body and iris from the choroid, and then we have what 
 is called choroido-cyclitis or choroido -iritis. These combinations 
 
I96 PRACTICE OF MEDICINE. 
 
 are readily understood, when we consider the similarity of 
 structure and close anatomical relations of the parts involved, 
 the iris, corpus ciliare and choroid constituting one continuous 
 tissue, or tract, namely the uveal. Hence, inflammation 
 beginning in one of these parts, is very apt to extend to the 
 others, and vice versa. The disease presents two principal 
 forms, or varieties, namely : (1) the serous, and (2) the purulent. 
 
 1.-SEB0US CYCLITIS. 
 
 SYMPTOMS. — Serous cyclitis is chiefly characterized by 
 tenderness to the touch in the ciliary region, and by more or 
 less intra-ocular tension, and impairment of vision. It is 
 generally combined with serous iritis, the leading symptoms of 
 which are : episcleral injection, ciliary irritation and neuralgia, 
 increased tension, exudation of lymph upon the posterior 
 surface of the iris, the veins of which are dilated and tortuous, 
 enlargement of the pupil, and a greater or less degree of 
 hypersecretion and cloudiness of the aqueous humor. In 
 addition to these symptoms, irido-cyclitis is distinguished by an 
 actual shallowness of the anterior chamber, due to a bulging 
 froward of the floating portion of the iris, combined with an 
 appearance of unusual depth, arising from a retraction of its 
 ciliary margin, which is fastened by lymph to the ciliary body ; 
 and the ophthalmoscope reveals large opaque spots scattered 
 through it. Vision is always much impaired, and the field 
 limited. The power of accommodation is also more or less 
 affected. If the disease continues unchecked, it soon spreads 
 to the choroid ; the aqueous humor, which at first was in 
 excess, diminishes and becomes less than normal ; the tension 
 also diminishes, so that the globe becomes soft ; and finally a 
 condition of general atrophy ensues. 
 
 The etiology, prognosis and treatment will be given under 
 the head of 
 
PRACTICE OF MEDICINE. 1 97 
 
 2.-PUBULENT CYCLITIS. 
 
 SYMPTOMS. — The chief characteristic symptoms of purulent 
 or suppurative cyclitis are : intense episcleral injection, severe 
 ciliary neuralgia, photophobia and lachrymation, associated with 
 pain and tenderness in the ciliary region ; occasionally, also, 
 there is more or less cedema of the conjunctiva and lids. The 
 iris is generally discolored, its ciliary margin retracted, and its 
 veins dilated and varicose. Abscesses form in the ciliary body, 
 and sooner or later purulent exudations take place from them 
 into the anterior chamber, sometimes forming an hypopyon of 
 very great size. 
 
 ETIOLOGY. — The causes of cyclitis are : extension of 
 inflammation from the neighboring tissues ; traumatic injuries 
 of the ciliary body, especially those arising from operations on 
 the eye. as in cataract ; and irritation resulting from adhesions 
 of the pupillary margin to the anterior capsule. It also occurs 
 in the form of "sympathetic ophthalmia," (which see.) 
 
 PROGNOSIS. — Inflammation of the ciliary body, whether 
 acute or chronic is always a very serious affection, especially 
 the purulent form of it. Few cases, except the most recent, 
 fully recover ; the tendency being to suppuration, atrophy, or 
 chronic degeneration. 
 
 Treatment. The indications being the same, irido-cyclitis 
 calls for similar treatment to that already given under the head 
 of iritis. If used early, hot fomentations, faithfully applied, 
 will often give great relief, especially when the symptoms are 
 acute; but to be effective they must be used early and 
 assiduously, and even then they will sometimes fail in arresting 
 the disorder. As soon as the fomentations have produced 
 sufficient relaxation, atropine should be instilled, with the view 
 of producing immediate dilatation. If, however, there is closure 
 of the pupil, and especially if the deeper structures of the eye 
 have become involved, no time should be lost in making an 
 extensive iridectomy, provided there is no purulent exudation, 
 
198 PRACTICE OF MEDICINE. 
 
 but it will not do to resort to this measure if there are any 
 indications of suppuration. 
 
 So far as internal treatment is concerned, the chief reliance 
 must be on Merc, and Kali iod., with such other remedies as 
 special symptoms may from time to time indicate. See 
 Sympathetic Ophthalmia, Iritis, and Choroiditis. 
 
 ART. VII. — IRIDO-CHOROIDITIS. 
 
 The preliminary remarks made under the head of cyclitis, 
 apply with equal force to irido-choroiditis, to-wit, that inflam- 
 mation of any portion of the uveal tract ' may originate in the 
 same, or in any other portion of it, and gradually spread 
 through contiguous parts until the whole tract becomes involved. 
 The same is likewise true respecting the various forms of 
 inflammation to which each particular part is subject ; but we 
 shall confine our attention at present to the consideration of 
 the two principal varieties commonly met with in practice, 
 namely : (1) simple or serous, and (2) pseudo-membranous irido- 
 choroiditis. 
 
 l.-SIMPLE IRID0-CH0B0IDITI3. 
 
 SYMPTOMS. — This form of irido-choroiditis generally sets 
 in with the usual symptoms of simple iritis, such as ciliary 
 irritation and episcleral injection, abnormal appearance and 
 discoloration of the iris, distension and varicose condition of its 
 veins, sluggishness of the pupil, etc., to which is added, unless 
 prevented by treatment, complete adhesion of the pupillary 
 margin to the anterior capsule, {annular synechia), thus cutting 
 off all communication between the anterior and posterior 
 chambers of the aqueous humor. This closure of the posterior 
 chamber necessarily destroys the balance of intra-ocular tension 
 before and behind the iris, causing the latter to be pressed 
 forward into the anterior chamber, either in the form of a 
 circular cushion, or, as is more frequently the case, in the shape 
 
SIMPLE IRIDOCHOROIDITIS. 199 
 
 of irregular knobs or, protuberances, due to the unequal resist- 
 ance offered by different portions of its tissue. These knob- 
 like projections are sometimes so extensive as to reach the 
 posterior surface of the cornea, from which the pupillary margin 
 of the iris suddenly recedes, giving to the central portion of the 
 membrane a cup-like appearance, while the outer portion slopes 
 gradually towards the circumference. If, now, an artificial 
 communication be made between the two chambers, a yellowish 
 watery fluid will flow out from behind the iris, the pressure 
 upon the two surfaces will be equalized, the knob-like projec- 
 tions will recede, and the membrane again resume its normal 
 position. And since this will occur in whatever portion of the 
 iris the iridectomy is done, it is plain that fhe irregularities are 
 not due to plastic exudations on the posterior surface of the 
 iris, but to an unequal distension of portions of its tissue, in 
 consequence of an increase of intra-ocular pressure behind it 
 arising from exclusion of the pupil. This exclusion, it will be 
 remembered, may exist either with or without an open pupil, 
 the only essential condition necessary to constitute it being an 
 adhesion of the entire circumference of the pupil to the posterior 
 capsule, so as to shut off all communication between the two 
 chambers. (See Iritis) 
 
 The tension of the globe varies greatly at different periods. 
 At first it is generally normal, or nearly so ; then it is more or 
 less increased ; afterwards, as the disease progresses and the 
 inner structures become atrophied, the tension diminishes, until 
 finally the globe becomes quite soft. 
 
 If the pupil is in a condition to admit of an ophthalmoscopic 
 view of the interior of the eye, the vitreous humor will generally 
 be found to exhibit more or less cloudiness, mostly of a diffuse 
 character, but here and there interspersed with flocculent tufts, 
 and delicate leaf-like or moss-like opacities. Sometimes the 
 cloudiness is most marked in the vicinity of the ciliary body, 
 especially when there is extreme tenderness in the ciliary region ; 
 
200 PRACTICE OF MEDICINE. 
 
 but usually the opacity is general, showing that the inflamma- 
 tion has extended to both the ciliary body and choroid. 
 
 The vision always becomes greatly impaired, even when 
 the pupil remains unobstructed. At first there is a mere hazi- 
 ness, which gradually deepens until the patient appears to be 
 looking through a dense cloud. As the disease progresses, 
 objects are seen with more and more difficulty, until finally the 
 patient may be wholly unable to recognize them. 
 
 The etiology, prognosis and treatment will be considered 
 in connection with 
 
 2.-PSEUD0-MEMBKAN0US IRIDO-OHOROIDITIS. 
 
 SYMPTOMS. — This form of irido-choroiditis is characterized 
 by the development of thick, tough masses of false membrane 
 and plastic lymph upon the posterior wall of the iris and the 
 anterior capsule, to the latter of which they adhere. The com- 
 munication between the two chambers being thus cut off, the 
 iris, and with it the lens to which it is attached, yielding to the 
 intra-ocular pressure, is pushed forward into the anterior 
 chamber, rendering it more and more shallow, until the pupil, 
 which in these cases is not retracted, appears just behind the 
 cornea. The iris is generally very much discolored, its fibrillar 
 obscured, its tissue stretched, and its surface covered with large 
 tortuous vessels, due to venous engorgement, the latter arising 
 from obstruction of the circulation caused by inflammation of 
 the ciliary body and choroid. 
 
 The course of the disease varies according as the inflamma- 
 tion begins in the iris or choroid. In the former case, the 
 symptoms of iritis predominate. The episcleral injection of the 
 corneal zone is generally well developed, and there is also more 
 or less ciliary irritation and pain. The ocular conjunctiva 
 frequently participates in the congestion, which is mostly of a 
 venous character ; and, as in other cases of acute iritis, the 
 palpebral conjunctiva and lids are apt to be more or less 
 
PRACTICE OF MEDICINE. 201 
 
 swollen and inflamed. The iris is generally somewhat dis- 
 colored, the pupil sluggish or immovable, and the aqueous 
 humor sometimes cloudy or turbid. At a later period, the 
 ciliary region becomes sensitive, and the vitreous humor more 
 or less opaque, showing that the inflammation has reached 
 the ciliary body. On the other hand, when the inflammation 
 begins in the choroid, the first and most marked symptom is, a 
 sudden and often very great loss of the power of vision, arising 
 chiefly from diffuse opacity of the vitreous humor. Pain if 
 present is not usually very great, nor is there generally much 
 photophobia. The vascular injection of the superficial tissues 
 is also very slight, and occasionally it is entirely absent. The 
 retina generally becomes detached, in consequence of which the 
 field of vision is more or less contracted. As the disease pro- 
 gresses, the posterior portion of the lens frequently loses its 
 transparency, and the ciliary region becomes sensitive and 
 painful. Subsequently, as a general rule, the iris becomes 
 discolored, and its veins tortuous and enlarged ; the pupil con- 
 tracted, adherent, and more or less obstructed ; the aqueous 
 humor cloudy and perhaps flocculent ; the anterior chamber 
 greatly diminished by the bulging forward of the iris ; and the 
 ciliary injection and neuralgia frequently augmented. The 
 tension of the globe, which at first was somewhat increased, 
 now begins to diminish, and unless the disease is speedily 
 arrested, symptoms of atrophy and degeneration set in, the 
 globe ultimately becoming soft, and vision extinct. These 
 changes, though progressive, are often interrupted and irregular, 
 being sometimes acute and rapid, at others slow, insidious and 
 variable. 
 
 ETIOLOGY. — The causes of irido-choroiditis are in many 
 cases the same as those of iritis, the extension of the inflamma- 
 tion to the ciliary body and choroid depending, in most 
 instances, upon the location, extent, severity and duration of 
 the irritation or injury ; and especially upon the presence of 
 extensive posterior synechias, which, when complete or nearly 
 
 86 
 
202 PRACTICE OF MEDICINE. 
 
 so, lead to the frequent renewal of iritis, and to a gradual ex- 
 tension of the inflammation to the other portion of the uveal 
 tract. Sympathetic irritation may also give rise to it, as we 
 shall find when we come to treat of " sympathetic ophthalmia." 
 
 PROGNOSIS. — The prognosis differs very much, according 
 to the character and extent of the pathological changes. It is 
 only in recent and uncomplicated cases that we may reasonably 
 expect to effect a satisfactory cure, or even to restore the vision 
 to anything like a normal standard. On the other hand, if the 
 disease is already of some standing, if there is complete 
 adhesion of the pupillary margin to the anterior capsule, if 
 large masses of false membrane exist between the iris and lens, 
 and especially if extensive lesions of the choroid, opacity of the 
 lens, or detachment of the retina has occurred, the prospect of 
 cure is so slight as to render the prognosis very unfavorable. 
 Some of these conditions, however, may be relieved ; and so 
 long as the field of vision is good, and the sight but little 
 impaired, the case cannot be considered altogether hopeless, 
 even though a certain amount of atrophy has already taken 
 place. 
 
 Treatment. — Recent cases require no other treatment 
 than that given under the heads of iritis, cyclitis and choroiditis, 
 (which see). Those of longer standing will require that the 
 operation of iridectomy shall be performed, perhaps repeatedly, 
 both for the purpose of relieving intra-ocular tension, and of 
 breaking up adhesions between the iris and anterior capsule. 
 In pseudo-membranous irido-choroiditis this is extremely 
 difficult to accomplish, partly in consequence of the shallow- 
 ness of the anterior chamber and the rotten condition of the 
 iris, but chiefly on account of the extent and firmness of the 
 adhesions, which generally require the sacrifice of the lens. 
 This, however, is of but little consequence in these cases, as 
 both the lens and capsule are generally opaque. Von Graefe, in 
 order to facilitate the operation, recommends the previous 
 
POST-FEBRILE OPHTHALMIA. 203 
 
 extraction of the lens ; while Bowman performs what he calls 
 "excision of the pupil," by cutting out with scissors a square 
 portion of the iris, including the pupil, and afterwards removing 
 it, along with the attached membrane, with forceps. If the lens 
 is opaque, or if it is dislocated or wounded in the operation, it 
 should be removed at the same time. These operations are 
 very apt to excite fresh attacks of inflammation ; but neverthe- 
 less it is necessary, in order to relieve the undue tension and 
 prevent subsequent attacks of recurrent iritis, to re-establish 
 communication between the two chambers at the earliest 
 practicable moment. When this is satisfactorily accomplished, 
 the vision often clears up in a remarkable manner, and even 
 atropic symptoms, when not too far confirmed, are sometimes 
 arrested ; the eye frequently regaining to some extent its normal 
 condition and fullness. 
 
 ART. VIII. — OPHTHALMIA POST-FEBRILIS. 
 
 A peculiar form of irido-choroiditis, occurring in connec- 
 tion with the so-called recurrent typhoid fever, and which has 
 been referred to mal-nutrition and starvation, has been describ- 
 ed by Mackenzie and other writers. We shall notice it briefly 
 under the head of 
 
 POST-FEBEILE OPHTHALMIA. 
 
 SYMPTOMS. — This form of ophthalmia, which is generally 
 confined to one eye, is characterized by inflammation of the 
 iris and opacities of the vitreous humor. The disease does not 
 usually manifest itself until several weeks after the last attack 
 of fever has been subdued. The iritis is not generally very 
 severe, seldom resulting in entire closure of the pupil, though 
 frequently giving rise to scattered posterior synechias, and 
 sometimes to hypopium. The adhesions are limited to the 
 pupillary margin, and are generally easily overcome by the 
 
204 PRACTICE OF MEDICINE. 
 
 energetic use of Atropine ; but the disturbances of vision, which 
 in the latter stages arc chiefly due to purulent and flocculent 
 opacities of the vitreous, frequently remain long after the more 
 acute symptoms have been subdued. The disease, however, 
 generally pursues a comparatively mild course; and, after lasting 
 ten or twelve weeks, usually ends in entire recovery. It seldom 
 attacks children under ten years of age ; but when it does, it is 
 said to run a shorter, and in most cases a milder course, than 
 when the patient is more mature. 
 
 ETIOLOGY. — The chief cause is supposed to be an impov- 
 erished state of the blood, resulting from mal-nutrition ; but the 
 true nature of its connection with recurrent fever is not known. 
 Some authorities attribute it to leucocythaemia, or an excess of 
 white cells in the blood ; but, as Stellwag observes, this assump- 
 tion is rendered very doubtful by the fact that the ophthalmia 
 usually makes its appearance long after the last febrile attack, 
 and, therefore, after the quality of the blood has become 
 essentially improved. 
 
 PROGNOSIS. — As already stated, the disease is seldom fol- 
 lowed by any very serious consequences to vision, as the 
 opacities are generally soon absorbed, and the synechiae can 
 commonly be broken up. Cases complicated with hypopium 
 are, however, more serious, and sometimes terminate in atrophy 
 of the globe. 
 
 Treatment. — We have already treated so fully of the 
 remedial measures required in this disease, that to give them 
 here would only be to repeat what we have said as to the 
 therapeutic indications and local treatment of iritis, (which see). 
 
 ART. IX. — OPHTHALMIA SYMPATHETICA. 
 
 It has long been known that when one eye has become 
 diseased, or has been severely injured, the other eye is liable to 
 become sympathetically affected, especially if the causes or cir- 
 cumstances which first give rise to the disorder are continued ; 
 
SYMPATHETIC OPHTHALMIA. 205 
 
 but it has only been within a few years that sympathetic 
 inflammation of the eye has attracted the attention which its 
 importance demands. This form of inflammation is peculiar, 
 since it does not follow operations for cataract or iridectomy, 
 nor the loss of an eye from suppurative inflammation. The 
 liability to the sympathetic affection appears to be greatest in 
 cases in which the injured eye remains irritable and sensitive 
 after recovery from the immediate effects of the accident ; as 
 when a foreign body penetrates the eye, and, by remaining 
 within it, keeps up a constant irritation, and finally excites 
 sympathetic inflammation in the other eye. The affection thus 
 excited is denominated 
 
 SYMPATHETIC OPHTHALMIA. 
 
 By " sympathetic ophthalmia " is understood a peculiar 
 form of inflammation set up in a previously sound eye by an 
 injury inflicted upon the other eye. It generally assumes the 
 character of an insidious but malignant irido-cyclitis. In some 
 cases the symptoms supervene within a short time of the inflic- 
 tion of the injury; but in others the wounded eye appears to 
 recover from the inflammation caused by the accident, and may 
 continue in this condition for months without exciting any 
 apprehensions of approaching danger, when fresh symptoms 
 unexpectedly arise, the injured eye again becomes injected and 
 painful, and soon the sound eye becomes sympathetically 
 affected. This is especially apt to occur where the injury is 
 caused by a bit of steel, or other metal, which, by remaining 
 in the eye, afterwards sets up the usual suppurative process of 
 elimination about the offending substance. In other instances, 
 again, the wounded eye, especially if the injury happens to be 
 in the ciliary region, instead of becoming quiescent, never fully 
 recovers, but remains in a state of low inflammation, which 
 greatly impairs the safety of the other eye. 
 
 SYMPTOMS. — The symptoms vary considerably in different 
 
206 PRACTICE OF MEDICINE. 
 
 cases. The most constant are : temporary disturbances of 
 vision, accompanied with a gradual diminution of sight in the 
 sound eye ; discoloration of the iris ; effusion of lymph upon 
 its posterior surface and in the pupillary area ; adhesion of the 
 iris to the anterior capsule ; exclusion of the pupil ; increased 
 intra-ocular tension ; and, if not arrested, partial atrophy fol- 
 lowed by softening of the globe. These symptoms are generally 
 accompanied by more or less ciliary neuralgia, photophobia and 
 lachrymation ; but in some cases there is neither orbital nor 
 circum-orbital pain sufficient to attract attention, though the 
 ciliary region is almost always sensitive to pressure. 
 Occasionally, the disease manifests itself chiefly by amblyopic 
 symptoms, either with or without photophobia ; and Von 
 Graefe describes a rare form of the affection in which the retina 
 is implicated. In these cases there is little or no pain ; the 
 vision is greatly impaired, and the power of accommodation is 
 almost wholly lost. The ophthalmoscope reveals congestion of 
 the optic nerve ; the retinal veins are sometimes found to be 
 dilated and tortuous ; and, in cases connected with increased 
 hardness of the globe, especially such as occur in advanced life, 
 there is frequently exhibited a glaucomatous excavation of the 
 optic disc. 
 
 ETIOLOGY. — The most frequent causes of sympathetic 
 ophthalmia are : penetrating wounds in the ciliary region, 
 especially such as are accompanied with loss of vitreous or 
 wounding of the lens ; severe laceration or bruising of the eye, 
 followed by ciliary irritation and unattended with general 
 suppuration ; foreign bodies, such as chips of metal, glass, stone, 
 etc., lodged within the eye ; intra-ocular hemorrhages ; con- 
 traction, degeneration, or calcification of extensive fibrous 
 deposits within the eye, especially when implicating the ciliary 
 body ; and, when the stump remains irritable, the wearing of 
 artificial eyes. In short, any injury which is capable of excit- 
 ing prolonged irritation of the ciliary nerves, may give rise to 
 
SYMPATHETIC OPHTHALMIA. 20*J 
 
 sympathetic irritation or inflammation of the other eye ; and, 
 as stated by Wells, this is frequently found to occur at a spot 
 of the ciliary region which corresponds symmetrically to that 
 at which the injured eye was hurt, or at which the ciliary 
 region still retains its sensibility to the touch. 
 
 PROGNOSIS. — This is so unfavorable as to afford very 
 little ground for hope after the disease has become fully estab- 
 lished. It therefore becomes the imperative duty of the sur- 
 geon to warn the patient in time of the very serious nature of 
 his complaint, impressing upon him the fact that, notwith- 
 standing the long period which may have elapsed since the 
 original injury was received, and the apparently trivial character 
 of his present symptoms, their presence constitutes an insidious 
 source of mischief to the other eye, and that unless he speedily 
 avails himself of the only effective treatment known to the 
 profession, even that will prove unavailing, and vision will be 
 surely and irretrievably lost. 
 
 Treatment. — The most efficient, and, in the vast majority 
 of cases, the only efficient treatment, either preventive or 
 curative, consists in the early removal of the injured eye. Not 
 that every considerable injury, even when involving the ciliary 
 region, requires the loss of the injured eye in order to insure 
 the safety of its fellow, for the observance of such a rule 
 would cause many an eye to be needlessly sacrificed. But 
 since no case of sympathetic ophthalmia is known to have 
 originated after the injured eye has been removed, and since 
 its removal generally arrests the disease in the other eye, when 
 the operation is performed immediately after the latter becomes 
 affected, it follows that if the power of vision is lost in the 
 injured eye, and there is no prospect of its restoration, there 
 can be no question as to the propriety of immediately enucleat- 
 ing it. But the case is different if the sight continues tolerably 
 good in the injured eye, or even if only a limited degree of it 
 remains, especially if the sympathetic disease has already 
 
208 PRACTICE OF MEDICINE. 
 
 made considerable progress, since the chances are that in these 
 cases the injured eye will finally prove more serviceable to the 
 patient than the other. Again, it may be regarded as an 
 established fact, that the performance of any operation upon 
 the affected eye during the height of the sympathetic disease 
 not only fails in arresting its progress, but actually tends to 
 increase it. No benefit, therefore, can be expected from 
 iridectomy, unless it be performed at the very outset of the 
 disease, before active inflammatory symptoms have set in, or is 
 postponed until by treatment or otherwise they shall have 
 measurably subsided. In the latter case, the operative 
 measures indicated will consist in the performance of an 
 extensive iridectomy, together with the removal of the lens, 
 capsule, and adherent masses of exudation. Such an extensive 
 operation will necessarily be attended with considerable 
 danger, not only by directly increasing the inflammatory 
 process, but by giving rise, in many cases, to profuse intra- 
 ocular hemorrhage. " The weight of authority, therefore, 
 especially in this country, is in favor of immediate enucleation, 
 in preference to iridectomy or any other operative procedure, 
 in all cases in which there is any doubt of a favorable 
 termination. 
 
 ENUCLEATION OF THE EYE-BALL. 
 
 The removal of the eye-ball, which before the introduction 
 of anaesthetics was regarded, even by the profession, as an 
 operation of the most formidable character, has since been 
 divested of all its terrors, and, under the improved method of 
 doing it, will hereafter be considered as one of the most simple 
 and trivial nature. 
 
 The patient having been fully anaesthetized, the eyelids 
 widely separated by the stop-speculum, (PL II. Fig. 33), and the 
 globe steadied with a pair of fixing forceps, (Figs. 36, 37), the 
 surgeon divides the conjunctival and sub-conjunctival tissues 
 close to the edge of the cornea. He then introduces a stra- 
 
GLAUCOMATOUS IRIDO-CHOROIDITIS. 200, 
 
 bismus hook (PI. I. Fig. 17) beneath the recti-muscles, one 
 after the other, and divides them close to their insertion ; after 
 which he carries a pair of curved scissors behind the globe and 
 severs the optic nerve as far back as possible. The eye now 
 springs forward from beneath the lids, and may be easily 
 seized with the fingers and lifted from the socket, when the 
 remaining muscles and conjunctival attachments are to be cut 
 away, and the operation is finished. 
 
 The hemorrhage, which ensues when the optic nerve and 
 ophthalmic artery are divided, is generally soon arrested by 
 injections of cold water ; if not, it may be readily controlled 
 by placing a piece of sponge in the orbital cavity and apply- 
 ing a compress and bandage. In the course of twenty-four 
 hours, or sooner if the dressings are very painful, the sponge 
 should be removed, and the orbit cleansed with a little tepid 
 water, after which cold wet compresses should be applied for a 
 few days, or until the discharges cease. The extremities of 
 the severed muscles and optic nerve soon become covered over 
 with a cicatrix composed of the contracted edges of the con- 
 junctiva, and the stump thus formed is found to be well adapted 
 for the adjustment of an artificial eye, the insertion of which 
 need not generally be delayed more than two or three weeks 
 after the performance of the operation. 
 
 ART. X. — GLAUCOMATOUS IRIDO-CHOROIDITIS. 
 
 The terms glaucoma and glaucomatous, signifying of a sea- 
 green color, have been in use ever since the days of Hippocra- 
 tes, by whom they were used to designate every form of deep- 
 seated opacity. Afterwards they were limited to vitreous 
 opacities and cataracts, which, occurring for the most part in 
 advanced life, present a greyish or greenish appearance. Still 
 later, the terms were applied to a particular form of oph- 
 thalmia, which, as it occurs chiefly in gouty subjects, is some- 
 times denominated arthritic. But since the invention of the 
 ophthalmoscope, in 185 1, our knowledge of the internal 
 diseases of the eye has been greatly advanced, the various 
 pathological changes occuring in the choroid, vitreous, retina 
 and optic nerve disc have been carefully studied and described, 
 and as a consequence, the above terms are now used with much 
 greater precision than ever before. By glaucoma, therefore, 
 we no longer mean simply that condition of the globe which 
 is marked by stony hardness with its associated symptoms, 
 
2IO PRACTICE OF MEDICINE. 
 
 but also the previous abnormal conditions or diseases which 
 give rise to it. We shall here treat only of the primary forms ; 
 the secondary will be considered in connection with the 
 diseases with which they are associated. 
 
 1 -ACUTE INFLAMMATORY GLAUCOMA, 
 
 ARTHRITIC OR VENOUS OPHTHALMIA. 
 
 SYMPTOMS. — Premonitory Stage. — In by far the larger 
 number of cases, the disease is preceded by certain premon- 
 itory symptoms, such as repeated attacks of cephalalgia; 
 neuralgia pains in the forehead and temples ; more or less 
 venous congestion, which, however, is always slight during the 
 premonitory stage ; indistinctness of vision, arising chiefly 
 from disturbances in the circulation, and coming on periodi- 
 cally ; the appearance of a colored halo, like a rainbow, around 
 a flame, due probably to congestion ; dilatation and sluggish- 
 ness of the pupil ; more or less cloudiness of the aqueous and 
 vitreous humors ; and, occasionally, a slight variation in the 
 field of vision. But the chief characteristic symptom, and 
 that on which most of the above-mentioned signs depend, is a 
 gradual increase in the tension of the globe, which, however, 
 never becomes very considerable during this stage, and is some- 
 times said to be entirely wanting. But this symptom is of 
 such high importance, that whenever observed it should always 
 excite our suspicions, especially if any of the before-mentioned 
 signs co-exist. At the same time we should be on our guard 
 against mistaking the subjective sense of tension or fullness 
 within the eye for the objective sense of hardness, which may 
 and often does exist without any real increase of tension. 
 
 At first, and during the premonitory stage, these symptoms 
 are more or less periodic, that is, they occur at intervals of 
 longer or shorter duration, with a period of complete intermis- 
 sion between them ; but sooner or later the intermissions cease, 
 or are superceded by remissions only, certain symptoms belong- 
 
ACUTE INFLAMMATORY GLAUCOMA. 211 
 
 ing to the disease remaining permanently, and constituting 
 what is called 
 
 Confirmed Glaucoma. — Glaucoma Evolutum or Con- 
 firmatum. — After a longer or shorter duration of the 
 premonitory stage — which in some cases lasts for years, 
 although it generally extends over only a few months, 
 and may even be limited to the first two or three attacks 
 — the glaucoma breaks out suddenly, with symptoms of 
 high inflammation ; the patient is seized with an intense head- 
 ache and excruciating ciliary neuralgia, the pain shooting 
 from the orbital and sub-orbital regions to the forehead, temple, 
 face and occiput. The pain is always more or less remittent 
 in its character, becoming greatly intensified on the approach 
 of night, and is frequently accompanied with photopsy, or 
 flashes of light. It is also frequently associated with cold or 
 icy sensations, attended with a feeling of numbness, or anaes- 
 thesia, in and around the affected eye, and in the corresponding 
 side of the head. At the same time there is generally more or 
 less febrile excitement, accompanied in some cases with nausea 
 and vomiting. The eyelids are often red and swollen, the 
 superficial tissues infiltrated and injected, and the veins greatly 
 engorged. The vascularity bears a general resemblance to 
 that of simple irido-choroiditis, but differs from it in the fol- 
 lowing particulars. The corneal zone, while it has a similar 
 disposition about the cornea, is composed of vessels exhibit- 
 ing more numerous anastomoses, a deeper and more livid hue, 
 and a sort of varicose enlargement ; but that which chiefly 
 distinguishes the episcleral injection is a whitish or bluish-white 
 ring, frequently more or less incomplete, and about the fourth 
 of a line in breadth, which separates the vascular zone from 
 the edge of the cornea, and called the venous circle. Some- 
 times the chemosis is so great as to completely hide the 
 episcleral vascularity quite up to the circumference of the 
 cornea. The conjunctival injection consists of large vessels, 
 
212 
 
 PRACTICE OF MEDICINE. 
 
 ACUTE GLAUCOMA. 
 
 tortuous and more or less vari 
 cose, their trunks turned to- 
 wards the great fold of the 
 palpebral conjunctiva, and their 
 K& branches ramifying by bifurca- 
 tion ; those on the border of the 
 cornea anastomosing here and 
 there with branches from the 
 other vascular trunks. (See 
 Fig. p). There is generally con- 
 siderable photophobia and lachrymation, but not much mucus 
 discharge. The latter presents some peculiar features. In 
 consequence of the frequent motion of the lids, the mucus 
 collects on their edges, or in the angles and folds of the con- 
 junctiva, in the form of white froth or foam ; this is the 
 "arthritic foam" of the old authors. 
 
 To complete the picture, the cornea becomes nebulous on 
 its posterior surface ; the anterior chamber shallow, so that 
 the iris is nearly or quite in contact with the membrane of 
 Descemet ; the aqueous humor cloudy ; the iris more or less 
 discolored ; the pupil dilated, irregular and sluggish ; the 
 vitreous humor hazy and opaque ; and the globe abnormally 
 hard. Vision is either entirely lost or greatly impaired ; in 
 the latter case the field is generally contracted. As the 
 inflammatory symptoms subside the blindness may continue, 
 but this is not the general rule ; the sight may be fully restored. 
 This, however, is only temporary. The acute inflammatory 
 attacks continue to recur, the visual field becomes more and 
 more contracted, and finally the sight is entirely lost. At the 
 same time the globe becomes more and more tense, until 
 finally it reaches a state of stony hardness. In other cases 
 the inflammatory symptoms subside permanently, but still the 
 eye does not recover its normal condition. The inflammation 
 continues in a low form and becomes chronic ; the glaucomatous 
 
ACUTE INFLAMMATORY GLAUCOMA. 21 3 
 
 degeneration increases more and more ; and finally all percep- 
 tion of light, even quantitative, is lost. This state, called by 
 way of distinction glaucoma absolutum or consummatum, is 
 sometimes, but very rarely, reached within a few hours, and 
 sometimes even within a few minutes, of the setting in of the 
 attack. This last variety, known as fulminating glaucoma, is 
 distinguished from the ordinary acute form by the rapid devel- 
 opment of glaucomatous symptoms, especially by the sudden 
 and complete destruction of vision, followed by atrophy and 
 degeneration of the deep-seated tissues of the globe. 
 
 The ophthalmoscopic symptoms, as well as the etiology, 
 prognosis and treatment, will be given after the other forms 
 of glaucoma have been described. 
 
 2.-CHE0NI0 INFLAMMATORY GLAUCOMA. 
 
 In our description of acute glaucoma we alluded to the 
 fact, that after the subsidence of the acute attack, the disease 
 frequently passed over into the chronic form. It may, how- 
 ever, be developed insidiously from the prodromal or premon- 
 itory stage. 
 
 SYMPTOMS. — Chronic inflammatory glaucoma, when develo- 
 ped from the acute, generally assumes at first a sub-acute form, 
 at which degree it continues, with more or less decided exacer- 
 bations and remissions, for a few weeks, after which the 
 inflammatory symptoms become less and less conspicuous, 
 while the glaucomatous process itself continues slowly to 
 advance. Thus, the globe gradually becomes harder and 
 harder, until at last it reaches the highest point of tension. 
 (Tn. 3). The cornea becomes hazy, less convex, and more and 
 more anaesthetic, until finally, in some cases, it loses all sensibil- 
 ity. The sclera becomes atrophied and more or less translucent, 
 assuming at last a peculiar waxy or porcelain tint. The 
 episcleral veins are engorged and tortuous, the anterior cham- 
 ber is narrowed by the pushing forward of the iris until the 
 
214 PRACTICE OF MEDICINE. 
 
 latter almost rests upon the cornea, the aqueous humor is 
 rendered cloudy or turbid, the pupil is dilated and either 
 sluggish or immovable, and the iris loses its brilliancy, becom- 
 ing more or less maculated and discolored. The diminution 
 of sight generally keeps pace with these changes, and at the 
 same time the field of vision becomes more and more contrac- 
 ted. At last the sight is entirely destroyed, not even a trace 
 of sensitiveness to light remaining. This state is generally 
 characterized by a pale-greenish opacity of the lens, constitu- 
 ting the so-called glaucomatous cataract. This symptom is 
 not due, as is generally supposed, to degeneration of the lens, 
 but to the combined effect of the mixing of the yellow color 
 of the lens, peculiar to elderly people, with the bluish-grey 
 color of the aqueous humor, which the latter assumes after it 
 has become cloudy and turbid. The effect of this green reflex 
 is somewhat heightened by the greyish opacity of the vitreous 
 and the dilated state of the pupil. While glaucomatous 
 cataract is generally due to changes developed in the course 
 of the disease, it is not, as was formerly considered, an essen- 
 tial, and consequently not a pathognomonic, symptom of 
 glaucoma. 
 
 Although absolute glaucoma may exist for a long period 
 without any very striking changes in the symptoms, the above 
 result is not generally reached without the recurrence, at longer 
 or shorter intervals, of inflammatory attacks and exacerbations ; 
 but these are usually of a low and insidious character, and 
 are seldom attended, as in the acute form, with any very great 
 amount of pain or suffering. Occasionally, however, acute 
 inflammatory exacerbations occur, attended with headache, 
 ciliary neuralgia, photopsy, etc.; and these may recur from 
 time to time, either spontaneously, or as the result of external 
 causes. At a later period the stage of atropic degeneration 
 sets in ; the iris becomes greatly narrowed, and is reduced to a 
 mere streak, the cornea is softened and rendered opaque, 
 
CHRONIC NON-INFLAMMATORY GLAUCOMA. 21 5 
 
 hemorrhagic effusions take place in various portions of the 
 globe, the choroid and retina degenerate, sclerotic staphy- 
 loma are produced, followed, it may be, by suppurative 
 inflammation and general atrophy. 
 
 3.-CHR0NIC NON-INFLAMMATORY GLAUCOMA. 
 
 GLAUCOMA SIMPLEX, OF DONDERS. 
 
 Symptoms. — This form of glaucoma is chiefly character- 
 ized by the absence during the earlier stages, and sometimes 
 during nearly its entire course, of any appearance of inflam- 
 matory symptoms. The only symptom that at first is apt to 
 attract attention, is a gradually increasing weakness of vision ; 
 and this, in the absence of other symptoms, is generally 
 attributed to the approach of old age. The defect is most 
 apparent for near vision, as in reading, writing, etc., though in 
 many cases it is also well marked for distance. Owing to the 
 absence of premonitory symptoms, the approach of the disease 
 is generally very insidious ; and so quietly does it advance, 
 that the patient is often unaware of his danger until after it 
 has made considerable progress. Careful examination, how- 
 ever, will generally detect an increase of tension in the weaker 
 eye, accompanied with rapidly increasing presbyopia and more 
 or less hypermetropia. As the disease advances the tension of 
 the globe increases, the cornea loses its sensibility, the ciliary 
 veins become congested, the pupil is sluggish and more or less 
 dilated, the anterior chamber becomes shallower, the field of 
 vision is progressively narrowed, and the sight more and more 
 diminished, until finally all perception of light is extinguished. 
 The disease seldom runs its course, however, without the acces- 
 sion of inflammatory symptoms, which may be more or less 
 violent according to the type of the inflammation. When 
 acute, the symptoms of acute glaucoma will be superadded to 
 those above-mentioned ; and in all cases there will be more or 
 less ciliary neuralgia, cloudiness of the aqueous and vitreous 
 
2l6 
 
 PRACTICE OF MEDICINE. 
 
 humors, increase of intra-ocular tension, etc. These symptoms, 
 however, may be so slight and transitory as scarcely to attract 
 attention, and in some cases will be likely to escape detection 
 unless particular attention be paid to the objective symptoms, 
 such, for example, as a slight discoloration of the iris, or some 
 cloudiness of the aqueous humor. 
 
 Ophthalmoscopic Symptoms. — These are : (i) a char- 
 acteristic "cupping" of the optic nerve disc ; and (2) pulsation 
 of the retinal arteries. The glaucomatous, or "pressure" 
 excavation, as the cupping of the optic papilla is sometimes 
 called, is easily distinguished from the other two forms ; 
 namely, from what is known as the congenital or physiological 
 excavation, and also from that which characterizes simple 
 atrophy of the optic nerve, by not being partial or limited to 
 the central portion of the optic disc, as in the former, nor by a 
 gradual sloping from its edges, towards the centre, as in the 
 latter ; but the cup extends quite up to the edge of the disc, 
 from which the lamina cribrosa suddenly retreats, as if pushed 
 directly backward by the increased intra-ocular pressure- 
 Indeed, so abrupt and precipitous are its edges, that the latter 
 may even over-hang the cup, as though the margin were un- 
 dermined. The cupping of the papilla is made apparent by 
 the course of the retinal vessels as they pass over the edge of 
 FIG - IO - the excavation. Instead of 
 
 passing straight over the mar- 
 gin of the disc, as in the nor- 
 mal eye, (Fig. 10), we find 
 that as they descend into the 
 excavation they make a more 
 or less abrupt curve ; and if 
 the edges of the excavation 
 are undermined, the veins, as 
 they curl over them, appear to 
 be so much displaced, that 
 when they reappear on the 
 optic papilla, N orma L .* optic disc they no longer 
 
 *After Zander. 
 
CHRONIC NON-INFLAMMATORY GLAUCOMA. 21/ 
 
 seem to be the same vessels. This is especially the case if the 
 excavation is deep, the displacement sometimes equalling, or 
 even exceeding, the diameter of the vessel. 
 
 Spontaneous pulsation of the retinal veins is a common 
 occurrence in healthy eyes ; but spontaneous arterial pulsation 
 is known to occur only in cases where there is insufficiency of 
 the aortic valves, or where the intra-ocular tension is consid- 
 erably increased. The pulsation is generally limited to the 
 optic disc, and is of a rapid and somewhat jerky character. 
 
 ETIOLOGY. — Many theories have been advanced to 
 account for the glaucomatous process ; of these not more than 
 three appear to be of sufficient importance to claim our atten- 
 tion. The first attributes the increased eye tension, and excav- 
 ation of the optic disc, to hypersecretion of the fluids of the 
 eye, the result of some abnormal irritation of the secretory 
 nerves, which irritation is regarded as a reflex from the sym- 
 pathetic. The second attributes the glaucomatous symptoms, 
 primarily, to inflammation of the uveal tract ; the other struc- 
 tures of the eye becoming secondarily involved. According to 
 this theory, the irido-choroiditis first gives rise to hypersecre- 
 tion of the vitreous humor, and this causes an increase of the 
 intra-ocular tension, which latter, by its interference with the 
 circulation, occasions the glaucomatous symptoms. The 
 third and last theory which we shall notice, attributes the 
 disease to a want of elasticity in the sclerotica. The fact that 
 glaucoma is pre-eminently a disease of advanced life, and 
 generally attacks only those whose age exceeds forty or fifty 
 years, in whom the sclerotica appears comparatively rigid and 
 unyielding, is regarded by the advocates of this theory as 
 furnishing conclusive evidence that the disease is due to con- 
 gestion in the internal circulation caused by a rigid and un- 
 yielding capsule. We have not room to examine these theories 
 in detail, but are inclined to regard the inflammatory theory 
 as the most tenable, notwithstanding the fact that some cases 
 
 28 
 
218 PRACTICE OF MEDICINE. 
 
 of glaucoma simplex seem to run their course without any, or 
 at least with but very little, appearance of inflammatory 
 symptoms. It should be remembered, however, (i), that the 
 absence of any external, or of any subjective signs of external 
 inflammation, is no proof of its non-existence, the contrary 
 having been frequently established by ophthalmoscopic evi- 
 dence ; and (2) that, in the vast majority of cases, inflamma- 
 tory symptoms of greater or less severity do show themselves 
 at some period of the disease. On the other hand, there can be 
 but little doubt that rigidity of the sclerotica has more or less 
 to do with the origin and progress of glaucoma. For, as Wells 
 very appropriately observes, we find that in youthful indivi- 
 duals, in whom the sclerotica is more elastic and yielding, an 
 increase of the intra-ocular tension, dependent upon some 
 inflammation of the uveal tract, may exist for some time 
 without exerting any deleterious effect upon the optic nerve or 
 retina. 
 
 PROGNOSIS. — Previous to the year 1856, when Von Graefe 
 discovered the value of iridectomy in this disease, glaucoma 
 was justly regarded as incurable ; for the disease is of such a 
 progressive and destructive character, that if left to itself, or 
 if treated exclusively by other remedies, it leads, sooner or 
 later, to atrophy and permanent blindness. On the other hand, 
 so effective has the operation of iridectomy proven in relieving 
 intra-ocular tension, and in arresting the progress of the 
 disease, that in those cases in which irreparable damage to the 
 structures of the eye has not yet taken place, the glaucoma- 
 tous symptoms have been greatly benefited, and in most cases 
 have entirely disappeared. Much, however, depends upon the 
 kind as well as the stage of the disease. Glaucoma fulminans, 
 from the rapidity with which it runs its course, is extremely 
 dangerous. Secondary glaucoma, especially that which super- 
 venes upon hemorrhagic effusions, is equally dangerous, the 
 operation either proving inefficient, or else complicating the 
 
CHRONIC NON-INFLAMMATORY GLAUCOMA. 219 
 
 disease by increasing the hemorrhagic effusion. The prognosis 
 in the latter stages of acute glaucoma, as well as in the chronic 
 inflammatory form, must be guarded ; since in the first case 
 there may already be such a deterioration of the retina and 
 cupping of the optic nerve, as to render any improvement from 
 the operation temporary and imperfect ; and in the latter, the 
 progress of the disease is so insidious, that serious structural 
 changes of the retina and optic nerve, and especially atrophy 
 of the latter, may occur before treatment is instituted. 
 
 Treatment. — As already indicated, operative measures 
 stand at the head of remedial agencies in this affection ; and 
 of these iridectomy is incomparably the most efficient. When 
 we take into consideration the fact that in the early stages of 
 glaucoma, iridectomy is almost a certain cure for it, it is evi- 
 dent that to postpone the operation a single day after the 
 disease fully declares itself, is to incur a great and unnecessary 
 risk. It is true the operation sometimes cures even in the 
 later stages, and in nearly all cases it proves palliative, but in 
 order to insure the greatest benefit from it, the sooner it is 
 performed the better. The operation is similar to that already 
 described, {see Iritis), except that the incision is made in the 
 sclerotica, near its junction with the cornea, instead of being 
 made in the cornea itself, in order that by extending the incis- 
 ion quite up to the ciliary border, a larger section of the iris 
 may be secured ; for the same reason, also, the opening is 
 made as large as the keratome will allow.. In no other way 
 can the intra-ocular tension be so effectually and permanently 
 relieved. Neither myotomy, or division of the ciliary muscle, 
 nor paracentesis, nor the more recent operation of sclerotomy, 
 can compare in effectiveness with a large iridectomy. Even a 
 smaller iridectomy, such as is made through the cornea for 
 artificial pupil, is not likely to be followed by permanent and 
 satisfactory results. 
 
 But while there can be no question as to the propriety of 
 
220 PRACTICE OF MEDICINE. 
 
 operating as soon as possible after the disease has fully 
 declared itself, or after the congestive and inflammatory 
 symptoms have ceased to intermit and have become remittent, 
 the case is different during the purely premonitory stage- 
 During this period we may reasonably expect to benefit the 
 patient by the careful administration of well-selected constitu- 
 tional remedies. This will be obvious when we take into 
 consideration the fact that, in the great majority of instances, 
 there co-exist various constitutional disturbances, such as 
 rheumatism, gout, derangements of the menstrual function, 
 hemorrhoids, etc., all of which are amenable to treatment, and 
 which exercise more or less influence upon the disease. But 
 in order to prove curative they must be administered during 
 the period of intermission : if used later than this they must 
 possess the quality of reducing intra-ocular tension, otherwise 
 they will prove to be of little or no benefit. We have has yet 
 discovered no remedy which will surely and permanently 
 produce this effect, although there are several medicines that 
 are capable of causing the subjective symptom of tension 
 within the eye. As before observed, we should be careful not 
 to confound this symptom with the objective sense of hard- 
 ness ; but as the latter is probably due, at least secondarily, to 
 hypersecretion of the ocular fluids, it is not at all unlikely 
 that we may yet find remedies which are capable of reducing 
 or limiting it, by causing, perhaps, a retrograde metamorphosis 
 to take place within the affected tissues. However this may be, 
 we should endeavor, with the light we now have, to equalize 
 the circulation and remedy constitutional derangements, 
 especially during the premonitory period. 
 
 THERAPEUTIC INDICATIONS. 
 
 Arsenicum. — Deep-seated throbbing pain in the eyeball, 
 especially at night ; photopsy ; obscuration of sight, amount- 
 ing at times to almost complete blindness ; periodic burning 
 
CHRONIC NON-INFLAMMATORY GLAUCOMA. 221 
 
 pains in and around the eye, worse at night or after midnight. 
 Especially indicated in cases where there is an increase of the 
 aqueous humor. 
 
 Belladonna. — Obscuration of sight, with dilatation of 
 the pupils ; rapidly increasing presbyopia ; hypermetropia ; 
 rainbow colors around flames, especially when the red pre- 
 dominates ; aching pressure within the eye ; also burning pains 
 in and around the eye, especially when accompanied with con- 
 gestion to the head and face. The best results are obtained 
 by using the remedy tolerably high, say the 200th, never less 
 than the 30th. 
 
 Bryonia. — This remedy is indicated when there is sore- 
 ness to the touch in the ciliary region, accompanied with sharp 
 shooting pains in the eyes, extending to the head and face; 
 also when there is a sense of fullness and pressure, as though 
 the eyes were being forced out of the sockets ; aggravation of 
 the pains by moving the eyes, or by any exertion of them in 
 reading or writing, especially at night. 
 
 Cedron. — Severe ciliary neuralgia, especially when the 
 pains are distinctly periodical ; dilatation of the pupils, with 
 dimness of vision ; eyes injected and sore to the touch. This 
 remedy is most useful in relieving ciliary irritation and neural- 
 gia, especially when the pains appear to follow the course of 
 the supra-orbital nerve. 
 
 Cimicifuga. — This is one of our most reliable remedies 
 for ciliary neurosis, especially when there is a sense of enlarge- 
 ment of the globes, the eyes feeling as though they would 
 be pressed out of the sockets ; also when there are amblyopic 
 symptoms, with dilated pupils ; or congestive headache, with 
 aching in the eyes and lachrymation. 
 
 Conium. — Dilatation of the pupils, with dimness of 
 sight, especially when accompanied with protrusion ; feeling of 
 pressure in the eyes, especially when reading, writing, or doing 
 any fine work ; also for photophobia and photopsy, particularly 
 in scrofulous subjects. 
 
222 PRACTICE OF MEDICINE. 
 
 Gelseminum. — Amaurotic symptoms, with dilatation of 
 the pupils ; disturbances of the power of accomodation; pain 
 in the eyes, either with or without lachrymation. Especially 
 indicated in choroidal and venous congestions, either with or 
 without serous effusion. 
 
 Hamamelis. — This remedy is indicated in all venous 
 congestions of the eye associated with hemorrhoids, especially 
 if there is much conjunctival vascularity, ciliary neuralgia, 
 photophobia and lachrymation. 
 
 Kali tod. — Amaurotic symptoms, with dilatation of the 
 pupils; burning in the eyes; lachrymation, and a dull, discolored 
 state of the iris. This remedy, which is of undoubted value 
 in every form of choroidal congestion and inflammation, has 
 appeared to give relief in many cases of incipient glaucoma, 
 especially when occurring in syphilitic constitutions. 
 
 Phosphorus. — This remedy has been found useful in glau- 
 coma, especially when accompanied with determination of 
 blood to the eyes, photopsy, photophobia, cromopsia, or play 
 of colors around flames, and lachrymation ; also when atten- 
 ded with a sensation of pressure in the eyes, dimness of vision, 
 and dull orbital and circum-orbital pains. 
 
 Phytolacca. — Dimness of vision, with hypermetropia or 
 rapidly increasing presbyopia ; dull, aching pain in the eye- 
 balls, worse from motion, light, or exercise. Especially suited 
 to rheumatic and syphilitic cases. 
 
 Rhododendron. — Incipient glaucoma, accompanied with 
 violent attacks of pain in the orbit and head, always worse on 
 the approach of rough weather, or of a thunder storm, and 
 ameliorated when the storm sets in. The pains are of a 
 burning, shooting character, and distinctly periodical. The 
 remedy is best adapted to rheumatic subjects. 
 
 Spigelia. — Sharp stabbing pains through the eye and cor- 
 responding side of the head, worse at night and on motion. 
 The remedy is particularly indicated if, along with dimness of 
 vision, there is presbyopia, strabismus, or photopsy. 
 
PRACTICE OF MEDICINE. 223 
 
 Sulphur. — This medicine is generally most useful as an 
 intercurrent remedy, especially in scrofulous cases. The 
 special indications are ; gradual diminution of the power of 
 vision ; illusions of sight, photopsy and photophobia ; sharp, 
 sticking or stabbing pains in the eyes, worse on motion and at 
 night. 
 
 In addition to the above remedies, the following have also 
 been recommended : Arm, Cham., Cocc, Colch., Collin., Col- 
 ocynth, Crot. tig., Hepar, Merc, Nuxv., Prunus spin., Val. Zc. 
 
 Diet and Regimen. — The diet should be liberal, nutri- 
 tious, and easily digestible, especially for scrofulous constitu- 
 tions and elderly patients. Stimulants should be avoided by all 
 except those addicted to their use, and then used only in a feeble 
 state of the system, the object being in all cases to keep the 
 health in the best possible condition. Bright light should 
 always be avoided, or the eyes protected by amber or smoke- 
 colored glasses. The eyes should enjoy perfect rest during the 
 attacks, or when the latter follow each other in quick succes- 
 sion ; and in no case should they be used for near objects, or 
 when exercise causes pain or provokes an attack. 
 
 ART. XI. — CHOROIDITIS. 
 
 We have already considered anterior, or partial choroiditis, 
 under the head of irido-choroiditis ; and one of the most 
 important and complicated forms of general choroiditis has 
 been described under the head of glaucoma. It remains to 
 consider (i) simple serous choroiditis; (2) disseminated or 
 exudative choroiditis ; (3) suppurative choroiditis ; and (4) 
 sclerotico choroiditis posterior, or posterior staphyloma. 
 
224 PRACTICE OF MEDICINE. 
 
 l.-SIMPLE SEROUS CHOROIDITIS. 
 
 Symptoms. — This form of choroiditis is chiefly character- 
 ized by diffuse cloudiness of the vitreous humor and consequent 
 diminution of vision. The disease is frequently complicated, 
 sooner or later, with serous iritis, the iris becoming more or less 
 discolored, the pupil dilated or adherent to the anterior cap- 
 sule, the aqueous humor hazy and more or less turbid from 
 particles of floating lymph, and the posterior surface of the 
 cornea clouded with similar deposits, {Keratitis punctata). The 
 diffuse turbidness of the vitreous is rendered more opaque by 
 fixed or floating opacities, of a filiform and membranous 
 character, which, according to Graefe, affect the structure of 
 the vitreous humor, leading to the destruction of its septa, and 
 even to the dissolution of the zonule of Zinn. The relaxation 
 and softening thereby produced frequently give rise to dis- 
 placement of the lens. In other cases the intra-ocular tension 
 increases, the aqueous humor is secreted in greater quantity, 
 the vision becomes more and more impaired, and finallysymp- 
 toms of glaucoma appear. These complications, however, 
 rarely take place in simple serous choroiditis, the opacities of 
 the aqueous and vitreous humors generally disappearing 
 altogether, or leaving only a slight amount of cloudiness in the 
 ciliary region. 
 
 Treatment. — Little more is generally required in the 
 way of treatment, than to keep the eyes in a state of perfect rest, 
 to protect them against bright lights, cold, dampness, etc., to 
 keep the pupil dilated with Atropine, and to hasten the absorp- 
 tion of the vitreous opacities by the internal administration of 
 Kali iod. In those cases in which the intra-ocular tension is 
 increased, the operation of paracentesis may be tried ; but if 
 this fails to relieve, and secondary glaucoma sets in, it will 
 probably be necessary to perform the operation of iridectomy, 
 (which see). Aurum, Bryonia, Colocynth, Gelseminum, 
 Ipecacuanha, Phosphorus, Psorinum, and Sulphur, have been 
 employed in these cases with favorable results. (See Glaucoma). 
 
PRACTICE OF MEDICINE. 225 
 
 2.-DISSEMINATED CH0H0IDITIS. 
 
 SYPHILITIC OR EXUDATIVE CHOROIDITIS. 
 
 SYMPTOMS. — The subjective symptoms of this affection 
 are often so light during the early stages, that its existence is 
 frequently not suspected until after the disease has made con- 
 siderable progress. There is generally little or no pain, 
 photophobia, lachrymation, or vascular injection ; the iris is 
 but slightly implicated ; and the only symptom of which the 
 patient is apt to complain, is a peculiar impairment of sight, 
 in which the vision is more or less obstructed and distorted by 
 dark, fixed, cloud-like opacities appearing before it. These 
 scotomata, as they are called, are supposed to be due to the 
 dissemination or exudation of matter from the choroid upon 
 the under surface of the retina, the pressure of which upon 
 the latter impairs its function by injuring or destroying some 
 of its elements. The injury to vision is, of course, greatest 
 when the exudations are situated in the region of the yellow 
 spot, and least when confined to the anterior portion of the 
 fundus. The vitreous humor sooner or later becomes diffusely 
 clouded, and frequently exhibits fixed or floating opacities, of 
 a filimentous or membranous appearance. These vitreous 
 opacities sometimes make their appearance previous to that 
 of the choroidal exudations before mentioned. The latter, 
 which are far the most important, vary in size from a millet 
 seed to large circular patches. They occur both in the stroma 
 and upon the retinal surface of the choroid. At first they are 
 of a dull, yellowish color ; but at a later period the exudative 
 masses are absorbed, leaving the corresponding parts of the 
 choroid so much thinned as to be more or less transparent, so 
 that the subjacent sclera shines through the patches, giving 
 them a somewhat pearly, glistening appearance. The patches 
 are more or less irregular in shape, and are rendered very con- 
 spicuous by proliferation of epithelium pigment cells upon 
 29 
 
2 26 PRACTICE OF MEDICINE. 
 
 their borders, the blackness of which contrasts strongly with 
 the whiteness of the more central portions. 
 
 The exudation may commence either at the periphery or 
 at the posterior pole of the eye, from which parts it becomes 
 gradually disseminated over the fundus. In the latter case, 
 the patches sometimes exhibit pale-red areolae round them, 
 which are thought by some to indicate a syphilitic origin. 
 Notwithstanding, however, this is probably the most common 
 form of specific disseminated choroiditis, it is far from being 
 the only one, as we find that almost every variety of the 
 disease is sometimes due to syphilis. 
 
 DIAGNOSIS. — The only certain diagnostic signs of the 
 disease are the ophthalmoscopic symptoms ; but these are so 
 peculiar as to render it almost impossible to mistake dissemin- 
 ated choroiditis for any other form of the affection, so long as 
 the vitreous remains sufficiently transparent to allow the details 
 of the fundus to be made out. As to the precise seat of the 
 exudations, we may readily satisfy ourselves that it is in the 
 choroid, by observing that the retinal vessels can be traced 
 directly over the patches, and are not obstructed in their course, 
 or rendered the least indistinct by them ; moreover, the retinal 
 veins retain their normal calibre and straightness, and the 
 retina its usual appearance and transparency. At a later 
 period, the retina generally becomes thinned and atrophied by 
 the pressure of the exudations ; and not unfrequently the optic 
 nerve, also, shows signs of atrophy, the blood-vessels becoming 
 more or less indistinct, and in some cases obliterated. 
 
 Etiology. — Disseminated choroiditis is found to be most 
 frequently associated with syphilis; but the insidious form 
 complicated with serous iritis sometimes occurs in lymphatic, 
 scrofulous, and consumptive patients. 
 
 Prognosis. — The prognosis should always be guarded, 
 especially if the exudations are extensive, or are seated in the 
 region of the yellow spot. The most favorable cases, com- 
 
DISSEMINATED CHOROIDITIS. 22/ 
 
 parativcly, are those of a distinctly syphilitic origin, in which 
 the spots are surrounded by reddish areolae. In these and 
 other favorable cases, the exudations are sometimes absorbed, 
 leaving but slight traces of their former existence behind them. 
 In most instances, however, the choroid, retina and optic nerve 
 all suffer to some extent, becoming more or less atrophied and 
 disorganized. 
 
 Treatment. — Disseminated choroiditis has been treated 
 most satisfactorily, in its early stages, with Merc. cor. and Kali 
 iod. These two remedies are not only indicated in all cases 
 dependent upon a syphilitic basis, but they are also serviceable 
 in every other form of choroidal inflammation, especially when 
 complicated with iritis. Nux. v. and Phos. ac. are found to 
 be the most useful remedies after the vision becomes impaired 
 in consequence of atropic changes in the retina and optic 
 nerve. Of the other remedies which have proven curative, or 
 which have been found useful in this affection, the following 
 are especially worthy of attention : Ars., Bell., Cact, Con., 
 Phos., Rut., SiL, Sol. n., Spig. and Sulph. The selection 
 should be governed, to a great extent, by the condition of the 
 digestive, assimilative, and uterine organs. 
 
 Diet and Regimen. — The diet should be plain, unstim- 
 ulating, nutritious, and easily digestible. The patient should 
 be careful to abstain from all use of the eyes in reading, 
 writing, etc., and to protect them against bright lights by 
 wearing colored glasses. Moderate exercise in the open air, 
 and whatever tends to invigorate the constitution, will be likely 
 to prove beneficial. 
 
 3.-SUPPURATIVE CHOROIDITIS. 
 
 PANOPHTHALMITIS. 
 
 SYMPTOMS. — As the name denotes, this form of choroiditis 
 is characterized by the formation of pus in the choroidal 
 tissues. It generally assumes from the first the character of a 
 
228 PRACTICE OF MEDICINE. 
 
 very acute and severe inflammation, in which sooner or later 
 the choroid, iris, conjunctiva, and all other vascular tissues of 
 the eye participate ; hence it is frequently termed /^-ophthal- 
 mitis. The eyelids also become red, hot, and tender, or swollen 
 and cedematous, especially the upper lid, which often overlaps 
 the lower in large puffy rolls. Both the palpebral and ocular 
 conjunctivae are injected and swollen, the chemosis being so 
 great as to cover the cornea, or to surround it in the form of a 
 tense, livid, circular fold or ring. In these cases the conjunc- 
 tiva appears dry, and more or less encrusted with exudative 
 matter ; but when the inflammation is milder, the secretion is 
 not arrested, but oozes out from between the lids in the form of 
 muco-pus. If the chemosis is not too great, and the cornea is 
 clear, we generally find the iris bulged forward, discolored, and 
 its stroma infiltrated with pus ; and if the pupil is dilated, it 
 also is frequently of a yellowish tint, owing to a purulent 
 infiltration of the vitreous. Sometimes, however, the pupil is 
 contracted, its area occluded with lymph, and its margin adher- 
 ent, perhaps, to the anterior capsule. The anterior chamber is 
 rendered shallow by the bulging of the iris, the aqueous humor 
 is clouded, and not unfrequently we discover below the pupil a 
 considerable hypopyon. In other cases the cornea is opaque 
 from becoming infiltrated with pus, and either breaks down 
 into a mass of purulent matter, or shrinks into a thin, yellow- 
 ish, rudimentary membrane. The eye is extremely sensitive 
 and painful, and owing to inflammatory swelling of the orbital 
 tissues, protrudes more or less from its socket; it is also greatly 
 limited in its motions, and even rendered immovable by the 
 surrounding swelling. The intra-ocular tension is increased, 
 and the globe more or less enlarged. These symptoms are 
 generally accompanied by intense pain, mostly of a paroxysmal 
 character, which radiates from the eye to the orbit, head, and 
 corresponding side of the face. The disease is also attended 
 with fever proportionate to the local disorder, which is some- 
 
SUPPURATIVE CHOROIDITIS. 229 
 
 times accompanied with considerable gastric disturbance. 
 Vision is soon lost, but the patient remains troubled by the 
 subjective symptoms of photopsia, or flashes of light, and 
 chromopsia, or the appearance of colored spectra before the eyes. 
 Sooner or later perforation occurs, either through the cornea 
 or between the recti-muscles, and then the suffering is greatly 
 mitigated. In some cases the pain and other inflammatory 
 symptoms are much less severe, while at the same time the 
 suppurative process is equally as extensive and disastrous. 
 Even the retina undergoes suppurative changes, and also 
 becomes more or less detached from the choroid, in consequence 
 of serous or hemorrhagic effusions from that membrane. 
 
 ETIOLOGY. — The most frequent causes of suppurative 
 choroiditis are traumatic injuries, both accidental and surgical, 
 especially those involving the ciliary region. Chemical injuries, 
 blows, concussions, and other like causes, may also give rise to 
 it ; but it is much more apt to follow penetrating wounds and 
 surgical operations, such as are connected with the removal of 
 the lens in cataract operations, or the lodgment of bits of metal 
 or other irritating substances within the eye ; in short, whatever 
 is capable of giving rise to sympathetic ophthalmia, or of 
 exciting suppurative inflammation in the cornea or iris, 
 is liable to be followed by panophthalmitis, especially 
 in cases complicated with typhus, cerebro-spinal menin- 
 gitis, puerperal fever, and other low states of the system. 
 
 PROGNOSIS. — This is so unfavorable, that unless the 
 disease is seen in its very incipiency, there will be very little 
 chance of arresting it before it has destroyed the vision, or 
 even before it has led to disorganization and collapse of the 
 globe. In most cases it runs a very rapid course, and termin- 
 ates in perforation and atrophy of the eyeball. The worst 
 results are generally met with in metastatic cases, such as occur 
 in cerebro-spinal meningitis or pyemia, since, both eyes being 
 involved, if the patient does not die of the primary disease, 
 
230 PRACTICE OF MEDICINE. 
 
 which is usually the case, he will most probably be left totally 
 blind. The suppurative process is, however, sometimes, though 
 very rarely, limited to a very small portion of the globe, and 
 if under these circumstances the pus escapes, either by perfor- 
 ation or otherwise, a certain and sometimes very useful degree 
 of vision may be preserved ; but in the vast majority of cases 
 perforation does not take place until the eye is irreparably 
 injured and the sight destroyed: The globe now generally 
 becomes more or less atrophied, shrivelling up into a small 
 nodular stump, not larger perhaps than a pea, or it may retain 
 for a longer or shorter period a certain degree of fullness and 
 sensibility, subject to repeated attacks of inflammatory action, 
 especially if the opening becomes temporarily closed. In these 
 cases, if there is much ciliary irritation, and especially if it is 
 kept up by the presence of a foreign body within the eye, the 
 other eye may become sympathetically involved, as stated 
 under the head of sympathetic ophthalmia. At last, however, 
 all inflammatory action subsides, and then the suppurative 
 process ceases, the perforation becomes permanently closed, 
 and the globe dwindles away until it becomes completely 
 atrophied. 
 
 Treatment. — Whenever suppurative choroiditis is threat- 
 ened, its occurrence should if possible be prevented, by 
 directing the treatment against any exciting cause that may 
 be discovered. Thus, if a bit of metal or other foreign body 
 has entered the eye, it should be carefully and speedily remov- 
 ed, especially if it has penetrated the ciliary body. If it 
 has injured the lens, or if the latter is swollen and cataractous, 
 the lens should be extracted by the flap operation, removing at 
 the same time a portion of the iris. If there is a large hypop- 
 yon, and especially if it is complicated with corneal abscess, 
 paracentesis or iridectomy should be performed. If the eye is 
 badly bruised or lacerated, and the vision hopelessly destroyed, 
 and especially if a foreign body also remains in the eye, the 
 
SUPPURATIVE CHOROIDITIS. 23 1 
 
 latter should be removed at once, in order to prevent the occur- 
 rence of both suppurative choroiditis and sympathetic ophthal- 
 mia, for it is not always safe to enucleate the eye after the 
 suppurative process begins, After suppuration once sets in, 
 there will of course be little if any chance of saving the eye, 
 but the suffering may be greatly relieved, and for this purpose 
 the remedies best calculated to allay ciliary irritation and sub- 
 due inflammation will be the most efficacious. If the inflam- 
 mation is very severe, and especially if the case is seen early, 
 ice-water compresses will be indicated ; but if the latter are 
 not well borne, or if suppuration has begun, and there is intense 
 ciliary irritation and neuralgia, warm applications will be the 
 most soothing as well as the most beneficial. If the intra- 
 ocular tension is increased and the pain is very severe, par- 
 acentesis, repeated several times if necessary, or an iridectomy, 
 will give great relief; but if the sclerotica is distended with 
 purulent matter, or we have reason to believe that there is any 
 considerable accumulation of pus in the interior of the eye, it 
 will be advisable to open the abscess at once by making a deep 
 and free incision into it. Finally, if the suppurative process is 
 so protracted as to undermine the health, and especially if its 
 continuance threatens the life of the patient, the eye should 
 be enucleated without hesitation, notwithstanding the danger 
 thereby incurred of the disease extending itself to the meninges 
 of the brain. 
 
 THERAPEUTIC INDICATIONS. 
 
 Aconite is a useful remedy whenever there is high fever, 
 especially in the first stages of the disease, or when the lids 
 are red, hot, dry and swollen. 
 
 Apis is recommended when the lids are cedematous and 
 the conjunctiva chemosed, with stinging pains through the 
 globe. 
 
 Arnica is indicated during the first stage when the disease 
 
232 PRACTICE OF MEDICINE. 
 
 is of traumatic origin, if the lids are swollen and echymosed, 
 and the globe protruded, tense and painful. 
 
 Arsenicum is sometimes useful in cases attended with rest- 
 lessness, thirst, cedematous swelling of the lids and conjunctiva, 
 and deep-seated throbbing and burning pains, especially if 
 there is much prostration of the system. 
 
 Belladonna is indicated when there is intense ciliary neu- 
 ralgia, with burning dryness in the eyes, pain in the orbits, and 
 a severe aching pressure within the globe. 
 
 Hepar sulph. is indicated after suppuration has commen- 
 ced. The eye is protruded and externally tender to the touch ; 
 the lids are highly inflamed and swollen, especially the upper ; 
 and the pains are deep, throbbing, and ameliorated by warmth. 
 
 Mercurius is useful in the first stage, when there is much 
 burning in the eyes, with ciliary injection and more or less red- 
 ness and swelling of the lids. 
 
 Rhus tox. is said to be useful in every stage of the disease, 
 especially the first. The indications are : cedematous swelling 
 of the lids ; chemosis of the ocular conjunctiva ; severe orbital 
 and circum-orbital pains, aggravated at night and during rainy 
 and rough weather. 
 
 Bryonia, Phytolacca, Silicea, Sulphur, and a few other 
 remedies have been recommended, and may occasionally be 
 found useful, not so much by virtue of any direct influence 
 they may have upon the diseased organ, as by contributing to 
 the general physical and mental well-being of the patient. 
 
 Diet and Regimen. — As in other suppurative diseases, 
 the strength will need to be sustained by a free allowance of 
 the most nourishing diet ; and in some cases it may be advis- 
 able to administer stimulants, especially if the patient is very 
 much prostrated, or is old and feeble. 
 
PRACTICE OF MEDICINE. 233 
 
 i-SCLERO-CHOROIDITIS POSTERIOR. 
 
 SCLERECTASIA POSTERIOR — STAPHYLOMA POSTICUM. 
 
 SYMPTOMS. — Sclero-choroiditis posterior is chiefly char- 
 acterized by an intra-ocular inflammation involving the fundus 
 of the globe, and accompanied with a greater or less degree of 
 myopia. The inflammation and accompanying myopia may 
 exist either with or without a posterior staphyloma of the 
 sclera ; and in like manner the bulging of the sclera may occur 
 without giving rise to any appearance of inflammation in the 
 fundus ; hence, although these conditions are often associated 
 together, there is no necessary connection between them, and 
 therefore the old notion that staphyloma posticum results 
 from inflammation is, as a rule, erroneous. Nevertheless, when 
 the staphylomatous process advances rapidly, and in nearly 
 every case in which there is a considerable degree of myopia, 
 an inflammatory condition of the fundus sooner or later super- 
 venes, and gives rise to sclero-choroiditis. 
 
 The characteristic ophthalmoscopic symptom of staphy- 
 loma posticum is a bright, yellowish or bluish-white line or 
 crescent at the edge of the optic disc. It may be limited to 
 one side, generally the outer, or it may extend quite around the 
 disc, the broadest part being in the direction of the yellow spot. 
 Although its general form is that of a single or double cres- 
 cent, its shape may be quite irregular, assuming in some cases a 
 more or less pointed, in others a zigzag, and in others, still, 
 a wavy outline, which may be sharply defined, or may 
 gradually fade away into the neighboring tissues. The crescent 
 is often spotted or marbled over with small patches of dark 
 pigment, especially on its edges, where the pigment cells of 
 the choroid are not yet entirely destroyed by the advancing 
 atrophy. It is owing to this thinning of the stroma of the 
 choroid, that the sclera, shining through the former, gives to the 
 crescent its usual glistening-white appearance. 
 
234 PRACTICE OF MEDICINE. 
 
 Amblyopic symptoms, due chiefly to disturbances in the 
 intra-ocular tension, frequently manifest themselves. As a 
 general rule, the more rapid the development of the staphy- 
 loma, the greater will be the disturbance of vision. This 
 arises partly from the hyperaemic condition of the venous sys- 
 tem of the eye, and partly from irritability of the retina. The 
 latter is generally most pronounced when, along with the 
 amblyopia and disturbance of vision, the patient is troubled 
 with photopsies, such as flashes of light, dazzling points, colored 
 corruscations, etc., or when exposure to the light causes a sense 
 of pain and tension in the eye. 
 
 As in other forms of choroiditis, the inflammation fre- 
 quently gives rise to cloudiness or opacity of the vitreous 
 humor, especially in its posterior part, which is sometimes 
 detached from the retina by a thin, serous-like transudation. 
 These opacities, which are both movable and fixed, are espec- 
 ially annoying to the patient, whose short-sightedness renders 
 them unusually distinct. The most serious form of vitreous 
 opacity is that which generally precedes detachment of the 
 retina, and is supposed to be due to a separation of the vitreous. 
 The following is Iwanoff 's explanation : — The vitreous humor 
 does not expand in proportion as the proterior chamber of the 
 eye is increased in volume by the staphyloma, but the vitreous 
 recedes from the retina, and the space thus formed between 
 them is filled with a serous exudation, which detaches the 
 vitreous more and more from the limiting membrane, and not 
 unfrequently separates the latter from the subjacent retina. 
 
 Secondary glaucoma, in the form of serous irido- 
 choroiditis, frequently supervenes in the course of sclero- 
 choroiditis posterior, accompanied with periodic cloudiness of 
 the aqueous humor, effusions into the vitreous, and glaucom- 
 atous excavation of the optic nerve.. The latter varies greatly 
 in different cases, being in some instances extremely steep and 
 abrupt ; in others it is quite shallow, or confined, apparently, 
 
SCLERO-CHOROIDITIS POSTERIOR. 235 
 
 only to the margin of the disc ; and in other cases the disc or its 
 margin is not only cupped, but the latter is surrounded by a 
 second excavation, which is situated in the sclerotic near the 
 edge of the disc. In these cases vision is relatively far less 
 affected than in similar conditions in primary glaucoma, in 
 consequence, no doubt, of the relief afforded to the intra-ocular 
 tension by the staphylomatous enlargement. Nevertheless, 
 iridectomy should be performed as early as possible in all cases 
 where the contraction of the field does not already encroach 
 closely on the centre, in which latter class of cases, according 
 to Graefe, the operation sometimes proves injurious. 
 
 ETIOLOGY. — Staphyloma posticum is generally hereditary. 
 Although denied by some, it has been satisfactorily shown by 
 Jaeger and others, that it is by far the most common in the 
 children of myopic parents. Its subsequent development is no 
 doubt chiefly due to a hyperaemic condition of the fundus, 
 caused by the severe and long continued straining of the accom- 
 modation of the eyes for near objects. The main reason that 
 the elongation of the eye takes place at the posterior pole, is 
 because the latter receives no support from either the capsule 
 or the muscles of the globe ; but the enlargement is also fav- 
 ored by the conjoint effects of the relaxation caused by the 
 intra-ocular congestion, and the extension resulting from the 
 increased pressure of the fluids. This extension gives rise to 
 atrophy of the choroid, which is still farther increased by the 
 consecutive inflammation that sooner or later supervenes. 
 
 PROGNOSIS. — The prognosis should always be guarded, 
 since, although no further development of the ectasia may take 
 place for many years, yet it is liable to occur at any time, and 
 to progress with great rapidity. This is especially to be feared 
 if there is already a co-existing choroiditis, particularly if the 
 visual field is much clouded by it, or if there exist diffuse 
 opacities of the vitreous threatening the retina. 
 
 Treatment. — The first and most important point to be 
 
236 PRACTICE OF MEDICINE. 
 
 observed in treatment is, to see that the patient gives his eyes 
 sufficient rest, and that when in use he does nothing that will 
 be likely to over tax their accommodative power. He should 
 therefore be specially warned against using his eyes for any 
 considerable length of time on near and fine objects, even with 
 suitable glasses, as these require extreme convergence of the 
 visual axes, and thus overtax the power of accommodation ; it 
 also tends to increase the hyperaemic condition of the fundus, 
 and to enlarge the posterior staphyloma, by causing undue 
 pressure of the external muscles. Care should also be taken 
 not to expose the eyes to the direct glare of the light, nor to 
 continue using them after a sense of fatigue sets in, especially 
 for near objects ; neither should they be used in a stooping 
 posture, as this favors congestion. If the light is too dazzling, 
 and especially if it causes headache and ciliary neuralgia, it 
 should be tempered by wearing blue or smoke-colored glasses, 
 which always give marked relief. If the eye is very irritable, 
 and especially if there is a hyperaemic state of the optic disc, 
 all use of the organ for such purposes as reading, writing, 
 sewing, etc., should be abandoned, and the eye should be 
 allowed perfect rest until all the symptoms of irritation and con- 
 jestion have subsided, and even for a considerable period after- 
 wards. In those cases in which the conjunctiva is more or less 
 injected, benefit will generally be derived from the employment 
 of a weak collyrium, consisting of a grain of the sulphate of 
 zinc or copper, two or three grains of the acetate of zinc, or 
 eight or ten grains of borax, each, to the ounce of distilled 
 water. 
 
 THERAPEUTIC INDICATIONS. 
 
 Aconite is generally useful in all cases in which there is 
 much heat and congestion of the external tunics. 
 
 Belladonna is indicated whenever there is much ciliary 
 irritation and neuralgia, especially if there is a hyperaemic 
 condition of the optic disc and retina. 
 
SCLERO-CHOROIDITIS POSTERIOR. 237 
 
 Congestive headache with flushed face, sensitiveness to 
 light, and photopsia, is an additional indication. 
 
 Cactus is also a good remedy in these cases, especially if 
 there is a congested state of the optic nerve and fundus. 
 
 Cimicifuga is an excellent remedy in most cases of sclero- 
 choroiditis with marked internal and external hpyeraemia, 
 especially if the eye is sore to the touch, or if there is much 
 ciliary neuralgia and irritation. 
 
 Crocus is said to be useful in cases where the pain extends 
 from the eye to the top of the head, or from the left eye to the 
 right. 
 
 Merc. cor. — This is one of our most reliable remedies in all 
 cases where the choroid exhibits marked inflammatory changes, 
 and its use in such cases should not be hastily abandoned. 
 
 Phosphorus. — Hyperaemia of the retina with congestion to 
 the head, indicated by severe headache, flashes of light, colored 
 rings betore the eyes, etc. 
 
 Spigelia. — Severe pain in and around the eyes, especially 
 on moving them ; great ciliary nervous irritation and conges- 
 tion. 
 
 Zinc. Phos. — Congestion of the fundus, with fiery balls 
 and other luminous spectra before the eyes. 
 
 The following additional remedies have also been recom- 
 mended : — Atropine, (locally), Gels., Glon., Lyco., Kali iod., 
 Nux v. Physostig., Sulph. and Zinc. 
 
 ART. XII. — HYALITIS. 
 
 Inflammation of the vitreous humor is usually associated 
 with some other disease of the fundus, such as choroiditis, 
 retinitis, etc., but it may also occur idiopathically ; at least 
 such is the opinion of most ophthalmologists, although Pagen- 
 stecher, who made numerous experiments on the eyes of rabbits, 
 came to the conclusion that the disease never occurs as a prim- 
 ary affection, but always depends on changes in the neigh- 
 
238 PRACTICE OF MEDICINE. 
 
 boring structures. Indeed, Galezowski goes so far as to assert 
 that the vitreous humor never can become inflamed, since it 
 has no organized structure, but that the inflammation is always 
 confined to the hyaloid membrane. This, however, is now 
 known not to be the case, it having been clearly proven by 
 Virchow, Weber and others, that inflammatory changes fre- 
 quently occur in the vitreous, and may assume either the 
 simple or the suppurative form. 
 
 l.-SIMPLE HYALITIS. 
 
 Simple hyalitis is sometimes, though very rarely, idiopa- 
 thic. It is generally secondary to inflammation of the ciliary 
 body, choroid or retina, and consequently the symptoms are 
 almost always combined with those of an accompanying 
 cyclitis, choroiditis or retinitis. 
 
 SYMPTOMS. — The disease is chiefly characterized by diffuse 
 opacities within the vitreous. If the inflammatory process is 
 much advanced, connective-tissue opacities, of various forms 
 and sizes, may sometimes be discerned even by the naked eye, 
 glistening indistinctly in the midst of the diffuse cloudiness ; 
 but at the commencement the opacities are generally too thin 
 and indistinct to be recognized, except by the aid of the oph- 
 thalmoscope. Viewed through this instrument, the vitreous 
 appears at first more or less clouded, and the optic nerve and 
 retinal vessels have an indistinct or blurred appearance, as 
 though seen through a mist; the observer may also discover, 
 here and there, thicker opacities in the form of dark specks, 
 delicate filaments, etc. As the inflammation increases, the 
 vitreous humor becomes less and less transparent and the 
 cloudiness more evenly diffused, so that the details of the 
 fundus are rendered either very indistinct, or become entirely 
 invisible. In addition to the fixed and floating opacites above- 
 mentioned, neoplastic formations of connective tissue appear 
 
SIMPLE HYALITIS. 239 
 
 in various portions of the vitreous, having a filamentous or 
 membraneous character, which, variously inter-twined and cross- 
 ing each other in every direction, divide it into irregular 
 sections which sometimes have the form of separate compart- 
 ments. These appearances are generally most marked in the 
 vicinity of the ciliary body, and at the posterior pole of the 
 lens, where the opacity is sometimes so great as to be termed 
 posterior polar cataract. In some cases vessels are seen in the 
 vitreous, which divide and sub-divide in the most varied 
 manner. Sometimes synchesis of the vitreous occurs, that is, 
 it becomes partly or completely fluid. This generally occurs 
 in proportion to the development of the connective-tissue 
 formation. In this state the movable opacities sometimes 
 disappear from the visual field by sinking to the bottom of the 
 fundus, but re-appear whenever the eye is subjected to any 
 rapid movement. Even when the vitreous is not fluid, the 
 denser opacities are very movable, floating about more or 
 less freely on every quick motion of the eye and head. 
 In some cases where fluidity of the vitreous occurs, owing 
 to the presence of crystals of cholesterine in the fluid, 
 the floating opacities and crystals present the appearance of 
 bright, glittering, star-like bodies, the movement of which 
 seems to the patient like a shower of stars. In other cases, 
 where the proportion of connective tissue in the vitreous 
 becomes very large, the latter detaches itself from the 
 limiting membrane and shrivels up, until in some instances 
 
 it occupies less than one-fifth of its natural space. In 
 these cases, also, the retina is often extensively detached, 
 either alone or along with the vitreous, the separation 
 finally extending from the ora serrata to the entrance of 
 the optic nerve. These changes, according to IwanofT, most 
 frequently occur when a foreign body, such as a depressed 
 cataractous lens, becomes encapsuled ; they also occur in irido- 
 choroiditis, from a gradual shrinkage of the connective-tissue 
 products developed in the vitreous as a consequence of inflam- 
 matory proliferation. 
 
24O PRACTICE OF MEDICINE. 
 
 2.-SUPPURATIVE HYALITIS. 
 
 Suppurative hyalitis generally occurs in connection with 
 suppurative iritis, cyclitis, or irido-choroiditis. It generally 
 supervenes upon injuries of the eye, cataract operations, etc., 
 and frequently leads to panophthalmitis and destruction or 
 atrophy of the globe. 
 
 Symptoms. — Suppuration may commence in any por- 
 tion of the vitreous, and may either remain confined to the 
 part in which it originates, or it may spread throughout the 
 whole # of the vitreous humor. In some cases the purulent 
 matter appears just behind the lens, {posterior hypopyon), and 
 is due to pus which has burst through the retina from the 
 ciliary body. In this case the other portions of the vitreous 
 are frequently normal. Generally, however, the entire vitreous 
 becomes involved in the suppurative process, except in the 
 case of foreign bodies, which frequently give rise to circum- 
 scribed abscesses. 
 
 Etiology. — It is generally conceded that hyalitis usually 
 depends oh inflammation of the neighboring structures. In 
 our study of cyclitis, irido chorioditis, glaucoma, etc., we have 
 seen how uniformly-cloudiness of the vitreous appears amongst 
 the symptoms; but it is especially in the more acute and 
 suppurative forms of those diseases that it is an invariable 
 attendant. It may also be excited by the presence of foreign 
 bodies, by wounds of the vitreous humor, by loss of vitreous 
 after operations for cataract, by extravasations of blood, etc. 
 
 Prognosis. — Diffuse opacities of the vitreous, when 
 dependent on inflammation of the investing vascular structures, 
 generally soon disappear in cases where the latter take a fav- 
 orable turn and undergo resolution ; but the contrary occurs if 
 the inflammation is frequently repeated, or if the neighboring 
 tissues are much altered. In short, the prognosis depends 
 chiefly upon the cause of the inflammation, and the extent to 
 which the surrounding tissues are implicated. 
 
SEROUS RETINITIS. 24I 
 
 Treatment. — As the removal of the cause constitutes 
 the first and most important point in treatment, it is evident 
 that whenever the existence of hyalitis depends upon irido- 
 cyclitis, irido-chorioditis, or any other disease of the fundus, 
 the treatment will require to be directed to the removal of the 
 primary affection. (See cyclitis, choroiditis, glaucoma, retinitis, 
 etc.) If the inflammation is due to the presence of a foreign 
 body in the vitreous, and its location can be determined, either 
 with the ophthalmoscope or otherwise, it should be immed- 
 iately cut down upon, and removed with a Daviel's spoon, 
 (PL I. Fig. 31), the canular forceps, (Fig. 3), or any other con- 
 venient instrument. If this is found to be impracticable, then 
 the best course is to enucleate the eye at once, and thus save 
 the other eye from being destroyed by sympathetic ophthalmia, 
 (which see). Fixed opacities remaining after severe inflamma- 
 tion of the vitreous, have sometimes been torn or cut through 
 with a sickle-shaped needle, (Fig. 8), introduced through the 
 sclera, and the vision thereby considerably improved. What 
 effect, if any, the long-continued administration of such, 
 remedies as Baryta, Causticum, Magnesium, Phosphorus, Sepia, 
 Silicea, etc., may have upon them has not yet been satisfactor- 
 ily determined. 
 
 ART. XIII. — RETINITIS. 
 
 We are now to consider a class of diseases of the highest 
 importance, which previous to the invention of the ophthalmo- 
 scope were very imperfectly understood — so much so, in fact, 
 as to be confounded with an affection of a totally different 
 nature, namely, hyperesthesia of the retina. The latter is 
 characterized by intense photophobia, lachrymation, ciliary 
 injection and neuralgia, while retinitis, as we shall see, is 
 distinguished by no such symptoms. 
 31 
 
242 PRACTICE OF MEDICINE. 
 
 1 -SEROUS RETINITIS. 
 
 (EDEMA OF THE RETINA. 
 
 SYMPTOMS. — Serous retinitis, or oedema of the retina, is 
 chiefly characterized by a delicate greyish opacity of the fun- 
 dus of the eye, which shows itself in the form of a bluish-grey 
 veil or mist spread over the surface of the retina, and which 
 hides to a greater or less extent the choroidal vessels. The 
 opacity, which is due to a serous infiltration of the connective 
 tissue of the retina, may be either general or partial, that is, it 
 may affect the whole or only parts of the fundus. In the latter 
 case, the ©edematous cloudiness is most marked in the region 
 of the optic nerve entrance, but becomes fainter and fainter as 
 it approaches the macula lutea, or yellow spot, in consequence 
 of the diminished thickness and greater transparency of that 
 portion of the retina. As the oedema increases, the details of 
 the choroid and optic disc are rendered less and less distinct, 
 until, in severe cases, the fundus presents nearly a uniform 
 reddish-grey or bluish-grey appearance. In these cases the 
 optic disc appears somewhat swollen and indistinct, but the 
 opacity is so diffuse and veil-like as to produce but little alter- 
 ation in the appearance of the arteries ; the retinal veins, on 
 the contrary, are dilated and more or less twisted in their 
 course, those in the vicinity of the optic nerve describing com- 
 paratively large curves, while the smaller branches are decidedly 
 tortuous. The oedematous character of the affection can 
 generally be made out by carefully observing the varying 
 depths of the vessels in different parts of their course ; as in 
 those places where they are the most superficial, they have a 
 distinctness and clearness of outline which is lost or obscured 
 in parts where they dip more deeply into the effusion. Small 
 hemorrhagic extravasations are occasionally to be seen in the 
 vicinity of the retinal veins, but they are not often met with in 
 this form of retinitis. 
 
SEROUS RETINITIS. 243 
 
 Externally, the eye appears nearly or quite normal. The 
 pupil is sometimes slightly dilated and sluggish, but this is 
 seldom very noticeable ; and as there are no symptoms of 
 irritability present, such as photophobia, lachrymation and 
 ciliary neuralgia, the disease in its first stage is apt to attract 
 but little attention. Soon, however, the visual field becomes 
 more or less darkened and contracted, and it is this which 
 generally leads the patient to apply for treatment. His com- 
 plaint is that all objects appear as if enveloped in a mist or 
 fog, or as if he was looking through a veil. If the disease is 
 partial, or if the opacity is limited to only a small portion of 
 the fundus, the corresponding part of the visual field will 
 alone be impaired. As the affection progresses, however, both 
 peripheral and central vision deteriorate, the sight grows dim- 
 mer and dimmer, and if the disease is not arrested the retina 
 finally becomes atrophied, and vision is permanently destroyed. 
 
 ETIOLOGY. — Serous retinitis is chiefly due to a hyperaemie 
 state of the optic nerve and retina, superinduced by long ex- 
 posure of the eye to bright lights, by mechanical violence, and, 
 in many cases, by certain constitutional affections, such as 
 syphilis, albuminuria, etc. As the causes are similar to those 
 of the exudative variety, the etiology will be given more at 
 length in the next section. 
 
 PROGNOSIS. — This should be particularly guarded, for the 
 reason that the affection is liable to become more or less 
 chronic, in which case vision may be lost through atrophy or 
 detachment of the retina, or it may take on the exudative 
 form, and lead perhaps to disease of the choroid and vitreous. 
 
 Treatment. — The patient should be strictly enjoined 
 not to exercise his eyes in reading, writing, etc. He should 
 also be careful to protect them from the irritating effects of 
 bright light by wearing blue or smoke-colored glasses. 
 
 The internal remedies which have proven most beneficial 
 in this form of retinitis are : — Apis, Ars., Bell., Bry., Cact, 
 
244 
 
 PRACTICE OF MLDICINE. 
 
 Digit., Gels., Merc, Phos., and Puis., the latter, more especially 
 when dependent on menstrual irregularities. The following have 
 also been recommended in complicated cases, or as intercurrent 
 remedies : Aeon., Cimicif., Collin., Con., Croc, Hepar., Nux v., 
 Kali iod., Lach., Sulph., and Zinc. For special indictions see 
 previous sections. 
 
 As illustrative of the character and treatment of a some- 
 what complicated traumatic form of this affection, we subjoin 
 an interesting and instructive case from the N. Y. Ophthalmic 
 Hospital Rec, 1876, kindly furnished us by F. H. Boynton, 
 M. D., Asst. Surg, to the Institution. 
 
 Chas. Birch, aet. 54, Leominster, Mass. Three weeks before ap- 
 plication for treatment, (March 4th, 1876), while bending suddenly 
 forward, the eye came in contact with the post of a rocking chair ; 
 the blow was received in the inner angle of the right eye ; lids soon 
 became ecchymosed, slight discoloration still remaining. V=Per- 
 ception of light. Field of vision of right eye according to diagram : 
 
 Fig. 11. 
 ■P 
 
 NO VISION. 
 
 PERCEPTION OF 
 OBJECTS. 
 
 Ophthalmoscope shows in right eye diffuse haziness of vitreous, 
 serous inflammation of choroid and retina, with effusion under and 
 detachment of latter, as represented by diagram. Optic nerve of left 
 eye very hyperaemic, V. only -gfo, owing to macula, remnant of 
 small pox. 
 
 May 5th. Has consented to come into the hospital for treatment. 
 
SEROUS RETINITIS. 
 
 24S 
 
 He has been carefully examined by Drs. Allen, Wanstall and myself, 
 but no indicative symptoms could be found. On account of the success 
 of Gelsemium in several cases of serous choroiditis (non-traumatic) 
 in the hands of Dr. Norton, Gels. 30th was prescribed, dose every 
 three hours. Patient was put to bed, both eyes being carefully padded 
 with lint, and compress bandage applied ; bandage to be reapplied 
 three times in twenty-four-hours. Sol- Atropine instilled to insure com- 
 plete rest to the accommodation. Low diet. 
 
 14th. Since last date has been constantly in bed. Optic nerve 
 very slightly hyperaemic ; few opacities in vitreous ; detachment as 
 per diagram and sharply defined. 
 
 Fig. 12. 
 
 NO VISION. 
 
 ^ I X 
 
 THIS PART OF FIELD 
 CLEAR. 
 
 - 20 
 "200* 
 
 Vessels of normal size. Rv.= -££$ ; Lv: 
 
 Heretofore both eyes have been constantly bandaged; now, 
 yielding to supplication of patient, allow left eye to be free. 
 
 25th. Field the same ; vitreous becomes quite hazy after moving 
 the eye; vision not quite as good ; condition has slightly retrograded 
 since allowing one eye free. Now bandage both eyes and confine in 
 bed, except one-half hour each day for exercise. Gelsem. 30th. 
 
 April 5th. Ophthalmoscope shows slight opacities in vitreous. 
 Field of vision perfect. 
 
 Rv. (floating). V.= jft; with + 36, ^ nearly. 
 
 On the former site of detachment is an exudative choroiditis, 
 quite circumscribed (see Fig. 13). Macula lutea, cloudy; nerve, slightly 
 hyperaemic. 
 
246 PRACTICE OF MEDICINE. 
 
 Fig. 13. 
 
 THE ABOVE CUT REPRESENTS THE PATCH OF EXUDATION REMAINING 
 
 8th. Continued and remarkable improvement, very slight hazi- 
 ness of fundus ; no flocculi ; nerve still slightly hypersemic. 
 V=|-§- without glasses. During the last few days of treatment, I 
 experienced much difficulty in retaining the patient in the hospital. 
 On the evening of the 8th he surreptitiously took his departure. 
 
 May 19th. I am in receipt of a letter from the gentleman, dated 
 May 17th, saying that since he left the hospital, there has been grad- 
 ual improvement. For the first three weeks he kept the bed most of 
 of the time ; since which time he has been working at his trade 
 (joiner) ; experiences some difficulty in doing fine work. 
 
 In recording this most satisfactory result, I experience much em- 
 barrassment in deciding how much, if any, credit to give Gelsemium 
 as an agent in attaining the desired end ; undoubtedly the recent in- 
 vasion, bandaging and complete rest, were active factors. I would 
 suggest its use in serous inflammations of the iris, choroid, and retina, 
 in those cases not requiring other interference, and its effects noted, 
 that there may be no doubt as to its efficacy. 
 
 Note by the Author. — This is a very interesting case, and the 
 comments upon it by Dr. Boynton are judicious. That Gelseminum 
 exerted a favorable influence cannot, we think, admit of question ; 
 at the same time there is no doubt that the immediate instillation of 
 Atropine, by diminishing intra-ocular tension, though attended by 
 
EXUDATIVE RETINITIS. 247 
 
 some risk, contributed powerfully to promote absorption ; and also, 
 that the bandaging, rest, and recent invasion, had, as Dr. B. surmises, 
 much to do with the speedy recovery of the patient. On the whole, 
 we regard this as being in some respects a model case, the treat- 
 ment reflecting great credit upon the surgeons of the N. Y. Ophthal- 
 mic Hospital. 
 
 2.-EXUDATIVE OR PARENCHYMATOUS RETINITIS. 
 
 SYMPTOMS. — This form of retinitis is characterized by 
 inflammatory changes in the parenchyma of the retina, whereby 
 the membrane undergoes cell proliferation, hypertrophy, fatty 
 or colloid degeneration, and sclerosis. The optic disc is gen- 
 erally of a greyish-red or pink color, and its boundaries are so 
 indistinct that in many cases its position can only be recog- 
 nized by the course of the central vessels, as they emerge from 
 the hollow in which they are imbedded in the centre of the 
 disc. In these cases the retina loses to a great extent its 
 transparency, and becomes dull and dirty looking, with perhaps 
 some appearance of striae, or of dark and light spots, which 
 give it more or less of a marbled appearance. As a general 
 rule, however, it presents a somewhat uniform, but very fine 
 granular appearance, in which the natural tint of the subjacent 
 choroid is entirely hidden, and the vessels more or less deeply 
 veiled. Extravasations of blood, in the form of points or 
 small spots, frequently occur, either lying superficially on the 
 veins, or situated more deeply, in which case they have a some- 
 what indistinct or blurred appearance. When the hemorrhagic 
 extravasations are large or very numerous, they constitute a 
 distinct form of the disease known as Retinitis apoplectica, 
 (which see). 
 
 The pathological changes above sketched vary considera- 
 bly in different cases, according to their nature, seat and 
 extent. Thus, if the exudation is seated in the more external 
 or choroidal layers of the retina, the vessels will not present 
 
248 PRACTICE OF MEDICINE. 
 
 the indistinct and interrupted appearance that they will when 
 it occupies the inner layers, since in the latter case they are 
 necessarily more or less hidden by the exudation. We also 
 find that, when thus situated, the exudations generally present 
 the appearance of light cream-colored or greyish-white non- 
 striated spots or patches, over which the retinal vessels are 
 seen to pass without interruption. In these cases the in- 
 flammatory process frequently originates in the choroid 
 instead of in the retina, to which it subsequently extends 
 by cell proliferation, giving rise to fatty or colloid degen- 
 eration of the external layer, with sclerosis of the external 
 limiting membrane. When, on the other hand, the exuda- 
 tions are seated in the inner portion of the retina, they 
 are generally somewhat striated, and the vessels instead of 
 passing straight over them are more or less interrupted, or 
 concealed from view. At first the inflammatory changes con- 
 sist, chiefly, of hypertrophy of the stroma and connective 
 tissue fibres, the latter of which may increase so rapidly as to 
 compress, and thereby cause more or less atrophy of the nerve 
 fibres. At the same time, the optic nerve fibres and ganglion 
 cells increase by proliferation, giving rise to sclerosis, and after- 
 wards, perhaps, undergoing fatty degeneration. The internal 
 limiting membrane also becomes hypertrophied and uneven, 
 occasionally exhibiting upon its inner surface minute eleva- 
 tions, caused by under-lying points of exudation. This variety 
 of retinitis frequently originates in inflammation of the ciliary 
 body and choroid, and is then associated with irido-cyclitis or 
 irido-choroiditis. 
 
 Uncomplicated cases are attended with little or no irrita- 
 tion, the chief subjective symptoms being a greater or less 
 obscuration of the visual field, corresponding to the points of 
 exudation. If these occupy the centre of the field, the injury 
 to vision will, of course, be much greater than when the centre 
 is clear, especially for small or near objects; the obscurity 
 
EXUDATIVE RETINITIS. 249 
 
 diminishing in proportion as the spots are removed from the 
 centre*. Where the exudative form is combined with the 
 diffuse, or where the entire retina becomes affected, the 
 obscurity is often general, and vision is sometimes reduced to 
 a mere perception of light. As a general rule, however, the 
 periphery of the retina escapes, and then, if the vitreous also 
 remains clear, the patient may be able to so adjust the optic 
 axis as to obtain a fair degree of eccentric vision. Moreover, 
 the exudations and hemorrhagic effusions may be absorbed, 
 the intra-ocular congestion be relieved, the oedema subside, 
 and then, if the choroid, retina and optic nerve are not too 
 much injured, the vision may decidedly and permanently 
 improve. (See Dr. Boynton's case, page 267). But such 
 favorable results do not always occur, especially in com- 
 plicated cases. Months and even years may elapse before 
 the disease makes any considerable progress, and then 
 new points of exudation may suddenly appear, accompanied 
 perhaps by marked symptoms of inflammation ; or the 
 accompanying irido-cyclitis, choroiditis, etc., may subside only 
 to burst out again with increased violence; and this may occur 
 again and again, each fresh attack or exacerbation developing 
 new points of exudation, until finally the inflammation has 
 run its course. In these cases the integrity of the retina is 
 never entirely restored. The portions of membrane corres- 
 ponding to the points of exudation are frequently transformed 
 into connective tissue, and although the process of degenera- 
 tion by which the transformation is effected is generally very 
 slow, it continues until the affected portion of the retina loses 
 all sensibility to light, in consequence, probably, of atrophy of 
 the nerve elements. In other cases the entire retina as well as 
 the choroid and optic nerve undergo atropic changes, and 
 vision is hopelessly lost. 
 
 *Micropsia, in which all objects appear smaller to the patient than they really are, 
 is sometimes observed in these cases. If, for example, the patient is told to draw a 
 certain figure, such as a circle, he will invariably draw it too small. 
 
 32 
 
2$0 PRACTICE OP MEDICINE. 
 
 ETIOLOGY. — The causes of exudative retinitis are prob- 
 ably the same as those which give rise to the diffuse form ; 
 indeed, the latter is generally developed along with the former. 
 In most cases it is due to some constitutional affection, such as 
 syphilis, diabetes, albuminuria, etc. It may also be caused by 
 some other disease of the eye, such as irido-cyclitis or chor- 
 oiditis ; or it may depend upon disturbances in the circulation, 
 such as occur in uterine or heart affections. Among other 
 probable causes, we may also mention, long exposure of the 
 eyes to intense light, tuberculosis, retinal hemorrhages, cere- 
 bral diseases, and even sympathetic influences. 
 
 PROGNOSIS. — This we have already sufficiently indicated. 
 During the progress of the disease, so long as the region of 
 the macula lutea remains clear, the sight may be sufficiently 
 good for the patient to recognize very small objects, and even 
 to read the finest print. At the same time it will be difficult 
 for him to distinguish large or distant objects, in consequence 
 of the field of vision being more or less interrupted and dimin- 
 ished. But sight is not generally entirely lost until the optic 
 nerve elements have become atrophied. Nor is the injury to 
 vision always proportionate to the changes observed in the 
 fundus. Tolerable, and even excellent, vision may frequently 
 be obtained after serous and hemorrhagic effusions have taken 
 place, and even after fatty degeneration has occured, as these 
 products are all capable of being absorbed. The affected 
 portions of the retina, however, rarely if ever become perfectly 
 normal. Permanent changes in both the choroid and retina 
 occur under the most favorable circumstances, and some impair- 
 ment of vision is always to be expected. 
 
 Treatment. — The treatment of exudative retinitis is 
 almost identical with that of cedema retinae, (which see). So 
 long as improvement can result from increased absorption, 
 benefit may be expected from the administration of Mercurius, 
 especially the Corrosivus. This remedy has frequently been 
 
SYPHILITIC RETINITIS. 25 1 
 
 found very effectual in promoting the absorption of patches of 
 exudation, and in clearing up the visual field, the results being 
 especially favorable when the disease is of syphilitic origin. 
 (See Retinitis syphilitica). Hemorrhagic effusions are often 
 quickly absorbed under the use of Belladonna, Crotalus and 
 Lachesis, especially the latter. (See Retinitis apoplectica). 
 Other remedies will be found under the nephritic variety, 
 (which see). When the disease has existed a long time, and 
 the choroid and retina are already much atrophied, of course 
 but little improvement can be expected. In this case, it is gen- 
 erally advisable to confine our treatment chiefly to the employ- 
 ment of such measures as are best calculated to preserve the 
 existing vision ; and for this purpose especial attention should 
 be paid to the patient's health, and to the observance of suita- 
 ble hygienic rules. Great care should also be taken to guard 
 against a renewal of the inflammation, by avoiding any of the 
 known causes, such as exposure of the eyes to bright light, 
 etc. Should relapses occur, they will require to be treated 
 according to specific indications, having reference more espec- 
 ially to the particular forms they may be found to assume — 
 as, for example, the inflammatory or hemorrhagic — and to the 
 causes which may be supposed to give rise to them. 
 
 3.-SYPHILITIC RETINITIS. 
 
 This is a peculiar form of diffuse retinitis, occuring in 
 persons whose constitutions have become tainted with secon- 
 dary syphilis. Authorities differ as to the diagnostic value of 
 its symptoms, Wells asserting that it is occasionally possible 
 to diagnose the nature of the malady from the ophthalmo- 
 scopic appearances alone, while Stellwag claims that the disease 
 has no peculiar symptoms, but that its syphilitic nature is 
 indicated solely by the presence or previous existence of the 
 symptoms of constitutional syphilis. We shall find that while 
 
252 PRACTICE OF MEDICINE, 
 
 the former statement is substantially true, it will frequently be 
 impossible to clear up the diagnosis until we have obtained a 
 knowledge of the history and constitutional condition of the 
 patient. 
 
 SYMPTOMS. — At first there are no characteristic symptoms. 
 There is generally more or less venous hyperaemia, but this is 
 sometimes only partial. As in simple serous retinitis, the 
 optic disc is slightly swollen and its margin rendered some- 
 what indistinct by the serous infiltration, which gives to the 
 disc and surrounding retina the appearance of being covered 
 with a delicate bluish-grey veil or mist. The opacity, which 
 is often extremely faint, is most pronounced along the course 
 of the vessels and in the vicinity of the optic disc, where it is 
 distinctly striated. Small, glistening white points generally 
 occur in the region of the macula lutea, which frequently 
 disappear and reappear every few days, accompanied with 
 corresponding changes in the vision. In this region, also, we 
 sometimes find the peculiar reddish-brown tint, or copper colon 
 so characteristic of syphilis. Occasionally we meet with white 
 spots or patches, either isolated or in the form of irregular 
 stripes, which, being seated in the innermost retinal layers, 
 may so compress some of the vessels as to give them the 
 appearance of white tendonous lines, or bands. Neither the 
 white spots, nor the punctated appearance in the region of the 
 macula lutea, are pathognomonic symptoms, as they both 
 occur in nephritic retinitis ; but in the latter affection, in addi- 
 tion to other peculiarities, they are readily distinguished by 
 being of a brighter and more glistening aspect. (See Retinitis 
 albuminurica). 
 
 Syphilitic retinitis is frequently complicated with choroid- 
 itis, and sometimes with irido-choroiditis and keratitis punctata, 
 or with syphilitic iritis. Not unfrequently it follows one or 
 more attacks of iritis. According to Stellwag, it is peculiarly 
 apt to occur if, during convalescence from specific iritis, or 
 
SYPHILITIC RETINITIS. 253 
 
 before entire removal of the disease, the eye is exposed to 
 functional sources of injury. 
 
 Hemorrhagic effusions sometimes occur, but they are 
 usually small and insignificant ; occasionally, however, they 
 are both numerous and extensive. They may be seated in 
 any of the layers of the retina, or upon its external surface, 
 between it and the choroid. The latter membrane frequently 
 undergoes extensive changes, consisting chiefly in atrophy of 
 the epitheliel layer and aggregation of the pigment cells, in 
 the form of small black spots interspersed with little grey 
 points ; or the atrophic changes may extend still deeper, and 
 involve the stroma of the choroid, giving rise to large grey 
 patches, bordered with pigment, through which the choroidal 
 vessels may be seen. 
 
 Vision is often greatly impaired ; and so rapidly does the 
 sight diminish, that the course of only two or three weeks we 
 have known the patient to be unable to read No. "L," Snellen. 
 As a matter of course, the disturbance of vision is greatest 
 when the region of the macula lutea is affected ; and, as already 
 stated, the fluctuation frequently corresponds with changes 
 which occur in the punctiform opacities of that region. The 
 visual field is only slightly diminished, but photopsies, and 
 that peculiar symptom, micropsia, are of frequent occurrence. 
 (See Exudative Retinitis. — Note). 
 
 PROGNOSIS. — Although, as a rule, the disease progresses 
 very slowly, and is subject to frequent relapses, the nerve 
 elements of the retina are not apt to be affected, and hence the 
 prognosis is generally favorable. In case, however, there 
 should be much hypertrophy of the connective-tissue element, 
 the latter may so press upon the nervous structure of the retina 
 as to give rise to more or less atrophy and permanent impair- 
 ment of vision. Moreover, the functional condition of the 
 retina is liable to be greatly injured by the frequent relapses to 
 which the disease is subject. 
 
254 PRACTICE OF MEDICINE. 
 
 Treatment. — The remedies which have proven eminently 
 curative in this affection, are Merciirins corrosivus and Kali 
 hydriodicum. They may be used either singly or in alterna- 
 tion, as may best suit the particular indications ; and if the 
 patient is brought under their influence at an early period of 
 the attack, the disease will generally be found to yield in the 
 most satisfactory manner. But if the inflammation has already 
 given rise to extensive tissue changes, but little good can be 
 expected of any internal treatment, especially if the nerve 
 elements are implicated. We notice, however, that Asafcetida, 
 Arum, Cinnabaris, Petroleum, Thuya, and a few other remedies, 
 have been recommended for this form of retinitis, and they 
 may prove serviceable in some cases, provided the specific 
 indications correspond with the constitutional as well as the 
 local symptoms ; for we confess that we have but little faith 
 in any but specific constitutional remedies in this affection. 
 
 4.-NEPHRITIC RETINITIS. 
 RETINITIS albumin urica, in bright's disease. 
 
 This form of diffuse retinitis derives its name from the 
 fact that it occurs in connection with Bright's disease of the 
 kidney, and that its ophthalmoscopic symptoms are, in many 
 cases, so peculiar and constant, as to enable us, from the retinal 
 appearances alone, to determine with certainty the coexistence 
 of the kidney affection. Having in the preceding sections 
 described the common characters of diffuse retinitis with 
 sufficient fullness, we shall give but a brief sketch of the re- 
 maining varieties of retinitis, confining our remarks chiefly to 
 the more important and characteristic. 
 
 Symptoms. — The symptoms of nephritic retinitis are, for 
 the most part, similar to those of the syphilitic variety; the 
 chief difference being that they are generally much more 
 strongly defined. Thus, the optic disc is more swollen, and 
 
NEPHRITIC RETINITIS. 255 
 
 its margin rendered more indistinct, by the serous infiltration, 
 which, extending for some distance beyond the disc, presents 
 the appearance of a bluish-grey or reddish-grey veil spread 
 over the fundus, and conceals to a greater or less extent the 
 details of the underlying choroid. The disc and surrounding 
 retina generally exhibit a distinctly striated appearance, which 
 is chiefly due to hypertrophy and sclerosis of the connective 
 tissue element. The retinal veins are enlarged, dark, and 
 somewhat tortuous ; but the arteries are normal, or slightly 
 contracted. Dark and light spots frequently appear in the 
 course of the vessels, in consequence of the varying depths of 
 the infiltration. The latter is sometimes so great, especially 
 in the vicinity of the optic nerve, as to render the optic disc 
 quite swollen and prominent, and conceal more or less com- 
 pletely the retinal vessels. Hemorrhagic effusions also take 
 place in different portions of the retina, and these are frequen- 
 tly numerous and extensive. This is, no doubt, partly due to 
 disease of the vascular coats, but chiefly to disturbances in 
 the general circulation arising from hypertrophy of the left 
 ventricle, which is generally present in Bright's disease, and to 
 congestion of the retinal circulation caused by the swelling of 
 the optic nerve. 
 
 But the most characteristic symptoms of nephritic retinitis 
 are met with at a more advanced state of the affection. We 
 then notice in the region of the macula lutea small, white, 
 glistening spots, presenting more or less of a stellate figure, 
 the characteristic appearance of which may afterwards be lost 
 in consequence of their becoming merged in the general exuda- 
 tion. We also observe a broad, glistening white band around 
 the optic entrance, but separated from it by a zone of greyish- 
 brown infiltration, the outer border of which is very irregular, 
 and broken up into circumscribed patches of exudation, or 
 extended along the retinal vessels towards the periphery, 
 especially on the inner side of the retina. At an earlier 
 
2 $6 PRACTICE OF MEDICINE. 
 
 period, or in less characteristic cases, these symptoms are less 
 prominent, the retina in the vicinity of the optic disc appearing 
 almost normal, and the peculiar white exudation, instead of 
 forming a broad, white ring about the optic disc, lying in scat- 
 tered patches, or extending along the course of the vessels. 
 Even in these cases, however, the exudation in the region of 
 the yellow spot has more or less of a stellate or streaky 
 appearance, characteristic of the renal affection. 
 
 The pathological changes just noticed are found to be due to 
 fatty degeneration of the cellular and connective tissue elements 
 of the retina, especially the latter, which, in the region of the 
 macula lutea, are so arranged as to converge towards the 
 centre of the yellow spot, and hence the peculiar stellate 
 appearance at that point. The striated appearances are due, 
 on the other hand, to sclerosis of the optic nerve fibres, and, 
 though much less conspicuous, are of far greater importance 
 than those arising from fatty degeneration, which, unlike the 
 former, are capable of being absorbed. Similar changes take 
 place in the coats of the retinal vessels, and also in the chorio- 
 capillaris, in consequence of which the diameter of both the 
 choroidal and retinal vessels is more or less diminished. 
 
 The sight is usually very much impaired, central vision 
 being the most, and peripheral the least, deteriorated. The 
 field of vision is but slightly if at all contracted, but it gener- 
 ally contains extensive gaps corresponding to the pathological 
 changes above noted. Sudden attacks of amaurosis sometimes 
 occur from uraemic poisoning, but these are easily distinguished 
 from the loss of vision arising from inflammatory changes in 
 the retina, which is gradually progressive, besides being accom- 
 panied by other symptoms of uraemia, such as headache, 
 vertigo, sickness, convulsions, loss of consciousness, paralysis, 
 etc. Although frequently attended with symptoms of derange- 
 ment of the digestive functions, such as anorexia, nausea, 
 sickness, etc., the impairment of vision is often the first symp- 
 
NEPHRITIC RETINITIS. 257 
 
 torn that attracts the attention of the patient ; and it is not 
 perhaps until an opthalmoscopic examination reveals the true 
 nature of the complaint that the disease of the kidney is sus- 
 pected. As a general rule, however, nephritic retinitis does not 
 appear, or is not recognized, until the kidney disease is fully 
 developed, and is most frequently met with in the later stages 
 of the chronic affection, after amyloid degeneration has set in. 
 
 ETIOLOGY. — The nature of the connection between neph- 
 ritic retinitis and Bright's disease of the kidney, is not known. 
 By some, the disease of the retina is supposed to be due to 
 the congestion arising from hypertrophy and dilatation of the 
 left ventricle, which is a common accompaniment of nephritic 
 retinitis. This view would seem to be supported by the fact 
 that hemorrhagic extravasations are not only of constant 
 occurrence in this form of the affection, but appear at the very 
 commencement of the disease. Others, again, refer the 
 disease to mal-nutrition of the retina caused by the presence 
 of urea in the blood. The retinitis and albuminuria are both 
 observed in the later months of pregnancy, the kidney affection 
 being dependent, no doubt, as suggested by Virchow, on 
 mechanical obstruction of the renal circulation. They also 
 occur after scarlatina, cholera, pyaemia, typhoid fever, etc., and 
 then the retinitis is referable to the coexisting albuminuria. 
 
 PROGNOSIS. — Nephritic retinitis very rarely results in 
 complete blindness, and, on the other hand, normal vision is 
 seldom regained after extensive pathological changes have 
 taken place in the substance of the retina. When these 
 changes are due simply to fatty degeneration of the connective 
 tissue elements, the patches may be absorbed and vision re- 
 stored ; but when atrophy of the optic nerve, or sclerosis of the 
 optic nerve fibres, ensue, vision is permanently impaired. 
 Those cases, on the contrary, that are secondary to the exan- 
 themata, or that occur in advanced pregnancy, or after the 
 excessive use of spirituous liquors, etc., admit of the sight 
 being fully restored. 
 
258 PRACTICE OF MEDICINE. 
 
 TREATMENT. — This should, of course, be chiefly addressed 
 to the kidneys. For this reason we have more confidence in 
 Phos. ac, and Plumb., in these cases, than in any other reme- 
 dies, but the following have also been recommended : 
 
 In acute nephritis : Canth., Chelid., Kali acet., Terebinth. 
 
 In chronic nephritis : Ars., Hepar, Phos. ac, Sulph. 
 
 In fatty degeneration: Ars., Canth., Phos. 
 
 In granular dege7ieration : Ars., Colch., Plumb. 
 
 /;/ amyloid degeneration: Ars., Phos. ac, Sulph. 
 
 For urcemic symptoms: Ferr., Opi. 
 
 From alcoholic drinks: Ars., Nux v. 
 
 In pregnancy: Apis, Colch., Gels., Kal., Merc. cor. 
 
 In scarlatina: Apis, Ars., Apoc, Hell., Merc 
 
 5.-LEUCJEMIC RETINITIS. 
 
 Comparatively little is known concerning this somewhat 
 rare form of retinitis. It was first described and figured by 
 Liebreich, in 1861, but its chief characteristics were first point- 
 ed out by Becker and Leber, in 1869. 
 
 Symptoms. — The chief characteristic symptoms of leucae- 
 mic retinitis are : a pale orange-yellow hue of the fundus, due 
 to an excess of the white blood corpuscles, and a pale pinkish 
 color of the retinal vessels, especially the veins, which are often 
 dilated and tortuous. The optic nerve entrance is also pale 
 from the same cause, and its margin is obscured by a serous 
 infiltration which extends a considerable distance from the 
 disc, in the vicinity of which the retina presents the usual 
 striated appearance. Small extravasations of blood likewise 
 occur in different parte of the fundus, but they, also, are of a 
 pale reddish color; whilst along the course of some of the 
 blood-vessels, and in the region of the macula lutea, are seen 
 white stripes and spots, due to an extravasation of the color- 
 less blood corpuscles, as first shown by Leber. The latter, in 
 
LEUCjEMIC RETINITIS. 259 
 
 his dissections, was unable to verify the observation of Reck- 
 linghausen relative to a varicose and hypertrophied condition 
 of the optic nerve fibres, but he satisfied himself thattherewasnot 
 a trace of fatty degeneration of the retina, as in retinitis albumin- 
 urica. In some cases, more or less atrophy of the retina has 
 been observed, the result of pressure arising from previous 
 intra-ocular hemorrhages. 
 
 Treatment. — This, to be of benefit, should be addressed 
 to the coexisting leucocythaemia. In the absence of any 
 experience, we would suggest a trial of the following remedies: 
 Ars., Calc, Chin., Ferr., Nat. m., 01. jec, Phos. ac. 
 
 6 -RETINITIS APOPLECTICA. 
 
 Hemorrhagic effusions are not, as we have seen, peculiar 
 to this form of retinitis, comparatively small extravasations 
 taking place occasionally in nearly every variety of the affec- 
 tion ; but hemorrhagic retinitis, so-called by way of eminence, 
 is distinguished chiefly by an extreme tendency to hemorrha- 
 gic effusions into the different layers of the retina. 
 
 Symptoms. — In retinitis apoplectica there is more or less 
 serous infiltration of the optic nerve and retina, but no exuda- 
 tive or degenerative changes, such as are common to other 
 forms of retinitis. Nor is the oedema generally very marked, 
 but only sufficient, in most cases, to render the disc slightly 
 indistinct, and its margin somewhat irregular and obscure. 
 The veins, on the other hand, are dark, tortuous, and very 
 much enlarged ; while here and there are seen numerous 
 extravasations of blood, which, by overlying the retinal 
 vessels, frequently interrupt their continuity. The arteries are 
 more normal in their appearance, but more or less contracted, 
 and in some cases, particularly in the vicinity of the optic 
 disc, are changed into narrow, tendon-like bands. 
 
 The hemorrhagic effusions may occur in any portion or 
 layer of the retina, and even in the optic disc itself ; but, for 
 
260 PRACTICE OF MEDICINE. 
 
 obvious reasons, they occur most frequently along the course of 
 the blood-vessels, between the inner and outer layers of the 
 retina, often pushing aside the elements of the latter, and mak- 
 ing their way to the more superficial layers, especially the cho- 
 roidal, towards which they are prone to extend. In these cases, 
 the patches of effusion will often be found to be situated be- 
 neath the retinal vessels, and to have a more distinctly circum- 
 scribed appearance than when seated in the internal portions of 
 the retina, where they are generally larger and darker, and 
 often hide a portion of the vessels from view. In some cases, 
 they break through the internal limiting membrane into the 
 vitreous, and give rise to dense opacities. The patches under- 
 go very little change in their appearance for a long time, but 
 finally the process of absorption sets in, and they gradually 
 become lighter and lighter, assuming at last a peculiar greyish 
 tint. In some cases, however, instead of undergoing absorp- 
 tion, they degenerate into dark, friable masses, giving rise to 
 black patches of pigment, often of considerable size. 
 
 Vision is, of course, more or less impaired ; but, unless the 
 hemorrhage takes place in the vicinity of the macula lutea, the 
 sight is not usually so much injured as the ophthalmoscopic 
 appearances would indicate. Sometimes, however, the attack 
 is very sudden, and the patient, after experiencing a sensation 
 of sickness and vertigo, may become nearly or quite blind 
 within a very few moments. The field of vision is generally 
 somewhat narrowed, and exhibits, here and there, spots or 
 spaces corresponding to the patches of effusion ; or in some 
 cases, it may be, to their shadows, as first suggested by Heymann. 
 
 ETIOLOGY. — The disease is frequently caused by disturb- 
 ances of the general circulation, such as are met with in cardi- 
 ac, hepatic and uterine affections, especially those arising from 
 hypertrophy of the left ventricle, disease of the aortic valves, 
 and menstrual suppression. It may also arise from tumors, or 
 any other impediment to the return of venous blood from the 
 
RETINITIS APOPLECTICA. 261 
 
 eye, situated within the orbit or cranium. A more frequent 
 cause, however, especially in elderly people, is atheromatous or 
 fatty degeneration of the coats of the retinal vessels, in which 
 case, as Wells observes, the cerebral vessels would be likely to 
 be similarly affected. 
 
 PROGNOSIS. — This should be particularly guarded, owing 
 to the great tendency of the disease to relapses, which, if fre- 
 quently repeated, greatly impair the function of the retina, and 
 lead, sooner or later, to atrophic changes in the retina and optic 
 nerve. 
 
 Treatment. — The above enumeration of causes shows 
 that the treatment should be addressed to them, and to the 
 general condition of the patient, rather than to the pathologi- 
 cal state of the retina, over which remedies can exert but little 
 direct influence. Thus, if the heart is at fault, Cactus, Gel- 
 seminum, and other cardiac remedies, will be indicated ; portal 
 obstruction will call for Mercurius, Nux v., Podophyllum, etc. ; 
 and menstrual suppression will require such remedies as Aco- 
 nite, Belladonna, Senecio, Sepia, etc. Phosphorus has been 
 recommended for the hemorrhagic diathesis, and Arnica, Cro- 
 talus and Lachesis to promote absorption of the extravasa- 
 tions. 
 
 7.-KETINITIS PIGMENTOSA. 
 
 PIGMENT DEGENERATION OF THE RETINA. 
 
 Although much diversity of opinion exists regarding the 
 pathology of this affection, some regarding it as a peculiar form 
 of choroiditis, some referring it to chronic perivasculitis of the 
 retinal vessels, and some to chronic inflammation of the retina 
 itself, we shall find it most convenient to describe it as retinitis 
 pigmentosa, the name by which it is generally known. 
 
 Symptoms. — The disease is chiefly characterized by the 
 appearance of numerous spots of black pigment in the inner 
 
262 PRACTICE OF MEDICINE. 
 
 layers of the retina. These spots are of various forms and 
 sizes, most of them having a branched or stellate appearance, 
 which has led to their being compared, not inaptly, to bone 
 corpuscles. The deposits first make their appearance at the 
 periphery of the fundus, generally on the inner or nasal side of 
 the retina, and thence gradually extend in opposite directions, 
 forming a more or less broad band in the middle zone, leaving 
 the central, and perhaps the temporal, portion of the retina 
 unaffected ; ultimately, however, the remaining portions of the 
 membrane, including the region of the macula lutea, may be- 
 come involved in the degenerative changes. The retinal ves- 
 sels are often greatly contracted, and their walls thickened, the 
 smaller branches being obliterated, or changed into narrow 
 tendon-like bands. In many cases, however, the vessels, in 
 some parts of their course, instead of being bright and trans- 
 parent, look like fine, black lines, owing to the presence of pig- 
 ment in their walls. This circumstance, in connection with the 
 fact that the pigment is generally deposited along the course 
 of the vessels, has led many ophthalmologists to refer the dis- 
 ease to degenerative changes in their coats — an opinion which 
 seems to be confirmed by a case of Schweigger's, in which, as 
 stated by Wells, he found, on microscopical examination, that 
 the pigmentation was confined to the retinal vessels, the coats 
 of which were thickened and the smaller branches obliterated, 
 these changes extending beyond the pigmentation. But the 
 choroid, retina, and optic papilla also become degenerated, the 
 former being more or less deprived of its pigment epithelium, 
 so that its vessels are rendered visible, and the retina under- 
 going atrophy of its nerve elements and hyperplasia of its con- 
 nective tissue elements. To complete the picture, the external 
 limiting membrane of the retina becomes destroyed, and the 
 granular layer, being no longer confined, becomes more or less 
 mixed with the pigment cells of the epitheliel layer of the 
 choroid; and as these find their way more freely into the retina in 
 
RETINITIS PIGMENTOSA. 263 
 
 some places than in others, they become heaped up, here and 
 there, into little black masses of pigment, which give to the 
 retina its peculiar tessellated or mottled appearance. 
 
 The subjective symptoms in this affection are no less strik- 
 ing than the objective, the disease being characterized from its 
 commencement by hemeralopia, or night-blindness, and by a 
 marked circular contraction of the field of vision. The former 
 is due to a torpid condition of the retina, resulting from an in- 
 sufficient supply of blood, in consequence of the diminished 
 number and calibre of its vessels ; and the latter arises, in all 
 probability, from pigmentation of the retina. As a conse- 
 quence of these changes, the patient may be able to see well 
 enough in a direct line during the day, or in a bright light ; 
 but as soon as night approaches, or the field of vision is less 
 strongly illuminated, the sight becomes very much impaired. 
 When the visual field becomes greatly contracted, the manner 
 of the patient is rendered somewhat awkward and uneasy, in 
 consequence of his being obliged to roll his eyes about in 
 every direction in order. to direct the visual axis upon each 
 individual object. As long as the region of the macula lutea 
 is unaffected, the sight may remain good for central vision ; 
 but as soon as this region is invaded, which generally occurs 
 between the ages of 35 and 50, the sight deteriorates, the retina 
 and optic nerve gradually become atrophied, and, sooner or 
 later, the disease leads to complete blindness. The affection 
 generally occurs in both eyes, and is frequently both hereditary 
 and congenital. Although the pigment degeneration may not 
 appear until after puberty, the disturbances of vision generally 
 occur at a much earlier period, and in all cases the disease 
 dates from infancy or early childhood. 
 
 ETIOLOGY. — It is evident, from the above, that the etiology 
 of this affection is not well understood. As already stated, 
 the disease is generally hereditary. It is found to be frequent- 
 ly associated with deaf-mutism, and other congenital malform- 
 
264 PRACTICE OF MEDICINE. 
 
 ations, and is especially liable to occur from the intermarriage 
 of relatives. 
 
 PROGNOSIS. — This is very unfavorable, the disease, as al- 
 ready stated, ending, sooner or later, in complete blindness. 
 
 TREATMENT. — This can, of course, only be palliative ; 
 but, if proper attention is paid to the general health, and the 
 eyes guarded against all injurious influences, undue exertion, 
 etc., the course of the disease, which is always very slow, may 
 be such as not to produce blindness for many years. Kali 
 hydriodicum, Mercurius corrosivus, and a few other remedies, 
 have been recommended, and may, in some cases, prove tem- 
 porarily beneficial ; but care should be taken not to push them 
 beyond the point of healthful reaction, as their continued use 
 has sometimes led to rapid deterioration of the central vision. 
 
 ART. XIV. — NEURITIS OPTICA. 
 
 Inflammation of the optic nerve, according to Stellwag, 
 may be either partial or general ; may be limited to a few bun- 
 dles, or embrace its entire thickness ; may be confined to the 
 orbital or cranial portion of the nerve ; may embrace the en- 
 tire nerve of one or both eyes ; may extend from the retina 
 along one or both nervous tracts to the corpora geniculata 
 {neuritis ascendens) ; or it may originate within the cranium 
 and descend to the optic papilla {neuritis descende?is) ; in short, 
 it may assume a great variety of forms and degrees, depending 
 chiefly upon its anatomical relations. A certain degree of 
 optic-neuritis is generally associated with different forms of 
 retinitis, and has already been described. We shall here treat 
 only of the idiopathic affection, of which there are two princi- 
 pal forms, namely, (1) ascending, and (2) descending optic-neu- 
 ritis. 
 
PRACTICE OF MEDICINE. 265 
 
 1.-ASCENDIN& OPTIC-NEURITIS. 
 
 ENGORGED PAPILLA, ISCILEMIA OF THE DISC. 
 
 SYMPTOMS. — This form of optic-neuritis begins at the 
 optic disc and extends upwards along the course of the nerve, 
 but generally stops short at the lamina cribrosa. It is chiefly 
 characterized by great oedema and swelling of the papilla — 
 which, however, may be only partial — by numerous and exten- 
 sive extravasations of blood within and around the disc, and 
 by great enlargement and tortuosity of the retinal veins, which 
 are dark and engorged with blood, while the arteries, on the 
 other hand, are very much contracted, and sometimes almost 
 entirely empty. 
 
 Etiology. — The engorgement of the papilla is generally 
 due to an obstruction in the central vessels of the retina, caused 
 by tumors, or other diseases, within the orbit or cranium. This 
 obstruction soon gives rise to oedema and swelling of the optic 
 nerve, hypertrophy of the connective tissue elements, and, 
 finally, to more or less inflammation of the optic nerve fibres 
 
 The researches of Schwalbe, Schmidt, and other recent ob- 
 servers, have thrown new light upon the etiology of this affec- 
 tion, and have so far disproved the old notion that the engorg- 
 ed papilla is generally due to certain cerebral conditions, which 
 impede the venous circulation of the optic nerve by an increase 
 of intra-cranial tension, or by direct pressure upon the cavern- 
 ous sinus, as to render it highly probable that the engorgement 
 is due rather to a veritable dropsy of the optic nerve sheath, 
 caused by the passage of the arachnoidal fluid between the ex- 
 ternal and internal sheaths of the optic nerve to the lamina 
 cribrosa and papilla, where it is arrested, and gives rise to more 
 or less strangulation and swelling. The congestion and conse- 
 quent oedema are, of course, still further increased by the un- 
 yielding scleral ring surrounding the swollen papilla. Manz 
 thinks that dropsy of the sheath, and consequent engorgement 
 
266 PRACTICE OF MEDICINE. 
 
 of the papilla, may occur, not only in cerebral affections, ac* 
 companied by serous effusions, but by any cause, such as an 
 intra-cranial tumor, capable of displacing the normally exist- 
 ing arachnoidal fluid, and forcing a portion of it into the sheath 
 of the optic nerve. 
 
 Mixed forms of optic-neuritis frequently occur, in which 
 the symptoms of engorged papilla are not so pronounced and 
 characteristic as above represented, but which shade off, as it 
 were, into those of 
 
 2 -DESCENDING OPTIC-NEUEITIS. 
 
 NEURO-RETINITIS, NEURITIS DESCENDENS. 
 
 Symptoms. — This form of optic-neuritis, as its name 
 indicates, commences extra-ocularly, the inflammation extend- 
 ing downwards to the optic papilla. The swelling and 
 hyperaemia of the disc are much less than in the engorged 
 papilla, and the veins are less dilated and tortuous ; the 
 arteries, on the other hand, especially those of the retina, are 
 generally very much contracted. The optic disc is reddish 
 and swollen, its outline indistinct and more or less obscured by 
 hemorrhagic effusions having a striated appearance, some of 
 which are only apparent, consisting of newly-developed and 
 closely arranged microscopic blood vessels. The optic disc 
 and retina are diffusely clouded, the latter somewhat exten- 
 sively, constituting what is called nearo-retinitis. White spots 
 sometimes appear in the region of the macula lutea, which 
 renders the disease liable to be mistaken for nephritic retinitis; 
 but, as pointed out by Von Graefe, the arrangement of the 
 spots in neuro-retinitis is different, being situated much nearer 
 to the optic disc ; moreover, the oedema of the retina in the 
 vicinity of the disc is greater, the swelling of the optic nerve 
 is also greater, and the veins are larger and more tortuous. 
 (See Nephritic Retinitis). 
 
 The sight is often much impaired, but the diminution of 
 
DESCENDING OPTIC-NEURITIS. 267 
 
 vision does not always correspond to the extent of the morbid 
 changes, being in some well-marked cases of optic neuritis 
 perfectly normal. Occasionally, however, the sight diminishes 
 very rapidly, so that in the course of a few hours or days the 
 patient may be unable to distinguish light from darkness. In 
 most cases, the field of vision is more or less contracted ; and 
 this condition is generally associated with a sluggish and 
 dilated state of the pupil. 
 
 A great variety of subjective symptoms are met with in 
 different cases, such as headache, vertigo, loss of memory, 
 vomiting, impairment of the special senses, epileptic attacks, 
 paralysis, etc. These symptoms generally point to a cerebral 
 origin of the neuritis, and are often the occasion of much 
 suffering; the headache, especially, is often very severe and 
 protracted, and generally extends over the whole head. The 
 patient is also frequently annoyed with photopsies and chrom- 
 opsies, due chiefly, no doubt, to disturbances in the circulation. 
 
 ETIOLOGY. — Optic-neuritis frequently originates in cere- 
 bral meningitis, the inflammation extending to the optic nerve, 
 and giving rise to descending neuritis. It has also ocurred in 
 connection with cerebro-spinal meningitis, with intra-cranial 
 tumors, abscesses, syphilitic deposits, hydatid cysts, blood-clots, 
 etc. According to Jackson, optic-neuritis should be looked 
 for in every form of cerebral disease, especially those that give 
 rise to cerebral fever. In some cases the disease appears to 
 be hereditary. The disease also occurs in young and delicate 
 females, and is then generally traceable to some menstrual 
 disturbance, or disorder of the central nervous system, such as 
 spinal irritation, chorea, etc. 
 
 PROGNOSIS. — This is generally unfavorable, most cases of 
 optic-neuritis resulting sooner or later in atrophy of the nerve 
 and loss of vision. ** The prognosis is said to be more favorable 
 in the case of children than in adults ; also, that acute and 
 rapidly progressing cases afford, as a rule, a more favorable 
 
268 PRACTICE OF MEDICINE. 
 
 prognosis than the chronic and gradual. So far as the general 
 prognosis is concerned, those are especially favorable in which 
 the affection is due to some temporary and removable cause, 
 such as menstrual irregularities, spinal irritation, etc. But 
 when the brain is affected, the question of vision is merged in 
 the more important one of saving the patient's life, and then 
 the case belongs to the domain of general practice. 
 
 Treatment. — More good will generally be accomplished 
 by suitable hygienic measures, and by attention to the general 
 health, than by any specific treatment of the eye symptoms. 
 Whenever practicable, the removal of the cause, whether it be 
 an inflammation or tumor in the orbit, or functional disturban- 
 ces of the circulation, such as arise from menstrual irregularities, 
 will generally give the most prompt and lasting relief. In the 
 great majority of cases, however, the treatment will of necessity 
 be merely palliative, and will require to be mainly directed to 
 the relief of the patient's sufferings. 
 
 In the absence of any precise indications, the following 
 list of remedies is suggested, the selection to depend upon the 
 general action of the remedy and the exigencies of each 
 particular case: — Apis, Ars., Aur., Bell., Bry., Cact., Cim., 
 Collin., Con., Croc, Gels., Kali iod., Lach., Lept., Merc, Nux v. 
 Phos., Puis., Spig., Sulph., Zinc. 
 
 ART. XV. — INFLAMMATION OF THE ORBITAL TISSUES. 
 
 Under this head we shall describe, very briefly, (i) inflam- 
 mation of the capsule of Tennon (Bonnet's capsule); (2) 
 inflammation of the cellular tissue of the orbit ; and (3) 
 periostitis of the orbit. 
 
PRACTICE OF MEDICINE. 269 
 
 1 -CAPSULITIS TENONII. 
 
 INFLAMMATION OF THE CAPSULE OF TENNON. 
 
 The ocular capsule, known as the capsule of Tennon or 
 Bonnet, is sometimes subject to inflammation. 
 
 SYMPTOMS. — There is, generally, considerable pain in and 
 around the eye, and in some cases it is severe, extending to the 
 face and corresponding side of the head. The globe is some- 
 what protruded and its motions impaired, but the most marked 
 symptom is a greater or less degree of chemosis, the ocular 
 conjunctiva being red and swollen, and accompanied with con- 
 siderable episcleral injection. The eyelids, also, are somewhat 
 swollen and inflamed, but the conjunctival secretion 
 is but little if any increased. At the same time, the cornea, 
 iris and other tissues of the eye remain unaffected. Choroid- 
 itis and hyalitis are said in some cases to attend or precede 
 the affection, but as a general rule vision continues unimpaired 
 throughout the progress of the case. The disease usually 
 runs a slow but safe course, the effusion between the capsule 
 and sclera being absorbed. 
 
 ETIOLOGY. — Cold and erysipelas are said to be the chief 
 causes, especially the former. It may also be of traumatic 
 origen, as in irido-choroiditis following cataract operations, or 
 the inflammation sometimes excited by the operation for 
 strabismus. 
 
 Treatment. — When the disease is of catarrhal or rheu- 
 matic origin, warm fomentations will be appropriate, and 
 will generally give great relief. If on the other hand the 
 disease is due to trauma, cold applications will be required. If 
 the inflammation is very severe, Aconite and Belladonna, 
 either singly or in alternation, may be employed, aided, if 
 necessary, by a Belladonna lotion or ointment. 
 
270 PRACTICE OF MEDICINE. 
 
 2.-CELLULITIS ORBITJE. 
 
 INFLAMMATION OF THE CELLULAR TISSUE OF THE ORBIT. 
 
 SYMPTOMS. — Inflammation of the orbital cellular tissue 
 is generally of a very acute character, and, as in other forms 
 of cellulitis, soon terminates in suppuration and abscess. 
 Owing to the unyielding nature of the cavity in which the 
 parts are lodged, the inflammatory swelling, which is always 
 very great, and especially so after suppuration has set in, gives 
 rise to the most intense and agonizing suffering within the 
 orbit, the pain extending to the surrounding parts and often 
 to the whole head. The eyelids are red, hot, and very much 
 swollen, the conjunctivae much injected, and accompanied in 
 most cases with great chemosis, in the centre of which the 
 cornea is deeply imbedded. The swelling of the orbital 
 tissues causes more or less protrusion of the globe, and 
 although this is not at first very perceptible, it gradually 
 increases, until at last the palpebral are unable to cover the 
 organ, and the latter stands out, more or less, from between 
 them. Pressure upon the globe, or any attempt to move it, 
 excites intense pain, and therefore the patient keeps the eye per- 
 fectly still. As suppuration occurs the pain slightly abates, 
 becomes intermittent and throbbing, and is attended with 
 manifest rigors. These symptoms are generally accompanied 
 with considerable fever, especially at night ; and if the inflam- 
 mation extends to the brain, delirium, vomiting, and other 
 cerebral symptoms, ensue. If the suppuration is extensive 
 the pus ultimately makes its way to the surface, either present- 
 ing at the orbital margin, or under the conjunctiva where it 
 passes from the lid to the globe. In some cases the inflamma- 
 tion spreads to the globe, and then the symptoms of panoph- 
 thalmitis are added to those already described. (See Suppurative 
 Choroiditis. Even when the suppuration is confined to the 
 orbital tissues, the vision is often greatly impaired, either by 
 
CELLULITIS ORBITS * IJt 
 
 the stretching of the optic nerve or by the pressure upon it, 
 and the field of vision is also more or less contracted. The 
 retinal veins are frequently dilated and tortuous, the retina and 
 optic disc more or less infiltrated with serum, and when the 
 disease is protracted it sometimes gives rise to optic-neuritis. 
 
 But inflammation of the orbital cellular tissue is some- 
 times far less acute, and may even be of a chronic character. 
 In these cases the symptoms are proportionably less severe. 
 Matter forms and makes its way to the surface more slowly, 
 the eye gradually protrudes from between the lids, which 
 become somewhat red and swollen, and finally perforation 
 occurs and the pus is evacuated. 
 
 ETIOLOGY. — Orbital cellulitis may be induced by sudden 
 atmospheric changes, by exposure to cold and wet, or by other 
 physical causes. It may also arise from the extension of 
 inflammation from neighboring parts, as in purulent conjunc- 
 tivitis, panophthalmitis, erysipelas of the head and face, etc. 
 Occasionally the inflammation supervenes upon severe consti- 
 tutional diseases, such as typhus fever, purperal fever, pyaemia, 
 etc. But the most frequent causes are of a traumatic charac- 
 ter, such as penetrating, contused, or incised wounds of the 
 orbital tissues, injuries received from the lodgement of foreign 
 bodies in the orbit, operations upon the lachrymal sac, eyelids, 
 eye, etc. 
 
 PROGNOSIS. — This varies according to the nature and 
 extent of the complications. If, as is not unfrequently the 
 case, the cellulitis becomes complicated with periostitis of the 
 orbit, it may result in caries or necrosis of the latter, in which 
 case the pus may find its way into the antrum Highmorianum, 
 or into the cranium ; or the inflammation may extend back- 
 ward along the periosteum directly to the membranes of the 
 brain, and give rise to cerebral inflammation or abscess. Life, 
 as well as vision, may also be jeopardized by inflammation and 
 suppuration of the globe, or by such an impairment of the 
 general health as to preclude recovery. 
 
272 PRACTICE OF MEDICINE. 
 
 Treatment. — During the first stage, or before suppura- 
 tion sets in, cold compresses should be employed, the latter 
 being conjoined with the internal use of Aconite, unless the 
 symptoms call for some other remedy, such as Apis, Bell., Bry., 
 Rhus, etc. But if suppuration has already set in, warm appli- 
 cations, such as fomentations and poultices, will be required. 
 The latter will generally be found to be the most convenient, 
 not only for the purpose of promoting suppuration, but to 
 facilitate the discharge of pus:, which should always be evac- 
 uated at the earliest possible period, either through the 
 conjunctiva, or if this is impracticable, then through the lid 
 itself. The internal remedies best adapted to this stage are : 
 Ars., Hep., Lach., Merc, Sil., Sulph. 
 
 If there should be any doubt as to the presence of pus in 
 the orbital cavity, the upper lid may be retracted, and a small 
 exploratory incision made, by passing a narrow-bladed knife 
 (PL I. Fig. 13) through the conjunctiva, above the upper surface 
 of the globe, into the orbit, and if pus oozes out, the opening 
 should be enlarged so as to permit of its free evacuation. In 
 order to avoid injuring the globe, care should be taken to 
 direct the edge of the instrument slightly upward in making 
 the incision. A warm emollient poultice should then be 
 applied, and if this fails to keep the opening patulous, the lips 
 of the wound should be carefully separated with a probe, or, ii 
 necessary, a small tent may be inserted, being careful to remove 
 it at least once a day. If the sinus is a long one, and 
 especially if it seems indisposed to heal, a mild astringent 
 lotion should be injected every time it is dressed. A careful 
 examination should also be made from time to time, in order 
 to discover the condition of the bone, and if necrosis is found 
 to exist, the sequestrae should be removed as fast as they may 
 become detached. 
 
 Diet and Regimen. — The general health of the patient 
 should receive careful attention, and the diet should be of the 
 
PERIOSTITIS OF THE ORBIT. 273 
 
 most nutritious and liberal character. Long-continued suppu- 
 ration may demand the use of malt liquors, especially if the 
 patient's health has been already undermined by serious ill- 
 ness. 
 
 3. -PERIOSTITIS OF THE OBBIT. 
 
 Orbital periostitis may be either acute or chronic. The 
 former is generally attended by high inflammatory 
 
 Symptoms. — The symptoms of acute orbital periostitis 
 are similar to those of orbital cellulitis, except that they are 
 generally somewhat less severe, and the protrusion of the globe 
 is more or less oblique, as respects the antero-posterior diame- 
 ter of the ball, instead of being direct. Moreover, the move- 
 ments of the globe are less restricted in some directions than 
 in others, owing to the periostitis being confined to a particu- 
 lar part of the orbit. Where the sensations of the patient and 
 the obliquity of the globe are not sufficient to determine the 
 seat of the disease, it may frequently be detected by gently 
 pressing the globe back into the orbital cavity in different di- 
 rections, the pain and swelling corresponding to the seat of 
 the inflammation. The cellular tissue, as well as the bone 
 itself, also become more or less inflamed, the former sometimes 
 to a great extent, in which case pus is formed in considerable 
 quantity, causing marked protrusion of the eye, and a corre- 
 sponding limitation of its movements. 
 
 In chronic periostitis, the symptoms are the same as in the 
 acute form, but much less severe. Thus, the orbital and circum- 
 orbital pain, the redness and swelling of the lids, the chemosis, 
 the conjunctival and episcleral injection, and the ocular protru- 
 sion, are generally less pronounced, while the course of the 
 disease is more insidious and protracted. The pain, which is 
 usually most severe at night, is always increased when pressure 
 is made on the globe in the direction of the swelling, which' 
 
274 PRACTICE OF MEDICINE, 
 
 may often be detected in this manner. More or less suppura- 
 tion generally occurs, the matter sometimes accumulating be- 
 neath the periosteum and separating it from the bone, in which 
 case the latter is apt to become necrosed. If this should occur, 
 the inflammation or the pus may extend into the frontal sinus, 
 or into the cavity of the cranium, giving rise to either menin- 
 gitis or abscess of the brain. In other cases, the periosteum 
 swells and forms nodes, or tumors, which, after the inflamma- 
 tion has run its course, generally disappear, leaving, perhaps, 
 only a little thickening of the periosteum ; sometimes, however, 
 the tumors ossify and become permanent. 
 
 ETIOLOGY.— Acute periostitis is frequently due to the 
 same causes that give rise to orbital cellulitis, and is often as- 
 sociated with it. Operations on the lachrymal sac are especially 
 apt to give rise to it. So, also, are concussions and injuries of 
 the orbit, whether made by blows, by cutting instruments, or 
 by the lodgement of foreign bodies within the orbital cavity. 
 Sometimes the disease is secondary, the inflammation extend- 
 ing from the frontal sinus, or other neighboring cavities. The 
 chronic form, on the contrary, is frequently due to syphilis. 
 Many cases occur, also, among scrofulous and badly-nourished 
 children. 
 
 PROGNOSIS. — Orbital periostitis generally ends in recov- 
 ery, though in some cases, especially when the roof of the orbit 
 becomes carious, the inflammation may travel tc the brain and 
 cause death. In most cases, however, the caries and necrosis 
 are limited to the margin of the orbit, resulting, when healed, 
 in contraction of the integuments, and, in many cases, causing 
 more or less ectropium. But the worst results, so far as the in- 
 tegrity of the eye is concerned, are experienced when the pos- 
 terior portion of the orbit becomes carious, for this always 
 gives rise to extensive suppuration of the orbital tissues, and 
 not unfrequently affects the optic nerve, destroying its function 
 by inflammation, or so compressing it as to lead to atrophy. 
 
DACRYO-ADENITIS. 275 
 
 TREATMENT. — Simple periostitis requires similar treat- 
 ment to that recommended for inflammation of the cellular 
 tissue of the orbit (which see). It is especially important that 
 all collections of matter should be evacuated as soon as possi- 
 ble after they are detected, and that care should afterwards be 
 taken to favor the escape of pus and other morbid products. 
 When the disease can be traced to some dyscrasia of the sys- 
 tem, anti-scrofulous or anti-syphilitic remedies will generally 
 be indicated, such as Cist, c, Kali iod., Kali brom., Merc, pro- 
 toiod., Nit ac, 01. jec„ Sulph., etc. 
 
 ART. XVI.— INFLAMMATION OF THE LACHRYMAL APPARATUS. 
 
 Diseases of the lachrymal organs are frequently met with, 
 but inflammation of these parts is comparatively rare. Ery- 
 sipelatous inflammation frequently occurs at the internal angle 
 of the eye, and the attendant swelling, being situated over the 
 lachrymal sac, may give rise to symptoms resembling, in some 
 respects, those of inflammation of the sac itself ; but it gener- 
 ally subsides without involving these parts to a degree sufficient 
 to cause suppuration, or any other unpleasant consequences. 
 We shall embrace what we have to say concerning inflamma- 
 tory affections of the lachrymal organs under the two heads of 
 (1) Dacryo-adenitis, and (2) Dacryo-cystitis. 
 
 l.-DACRYO-ADENim 
 
 INFLAMMATION OF THE LACHRYMAL GLAND. 
 
 SYMPTOMS. — Acute inflammation of the lachrymal gland 
 is seldom an idiopathic affection. It is characterized by great 
 heat, redness and swelling, such as accompanies the formation 
 of acute abscess in other parts. Sometimes the inflammatory 
 products are absorbed, and the swelling subsides ; but, in most 
 cases, suppuration occurs, and generally continues long after 
 
2J6 PRACTICE OF MEDICINE. 
 
 the opening of the abscess. The suppurating cavity is com- 
 paratively deep, and usually opens and closes several times be- 
 fore it becomes permanently healed. In some cases, however, 
 the opening remains patulous, and a small fistulous sinus is 
 formed, through which the lachrymal secretion continues to 
 ooze. But dacryo-adenitis is most frequently of a chronic 
 character, and runs a very slow and tedious course. It usually 
 manifests itself by the appearance and gradual development of 
 an irregular, more or less hard, and immovable swelling at the 
 outer and upper portion of the orbit. When the tumor is large, 
 it pushes the globe downwards and inwards, and sometimes 
 impedes its movements, especially in the opposite direction. 
 The tumor is not generally painful, nor sensitive to the touch ; 
 but, if the swelling is of considerable size, or if the inflamma- 
 tion is at ail acute, it maybe both painful and tender, especially 
 on pressure. In some cases the upper lid is red and cedema- 
 tous, the palpebral conjunctiva injected and somewhat swollen, 
 and the ocular conjunctiva, perhaps, chemotic. Occasionally, 
 both glands become inflamed at the same time, and then the 
 deformity is symmetrical. 
 
 Etiology. — In most cases, dacryo-adenitis is the result of 
 a blow, or fall ; but it may also be due to cold, or it may spring 
 from chronic inflammation of neighboring parts. 
 
 Treatment. — In the acute form, Aconite, Belladonna and 
 Baryta internally, in connection with cold or ice-water com- 
 presses externally, will favor resolution of the inflammation ; 
 but if suppuration threatens it should be encouraged by the 
 use of hot fomentations and poultices, and as soon as pus forms 
 it should be let out by making a free incision into the abscess. 
 Hepar, Merc, and Silex are the internal remedies most fre- 
 quently indicated after suppuration sets in. In the chronic 
 form, Bar. iod., Kal. iod., and Phytolacca should be tried ; but, 
 if the swelling remains, and especially if it impairs the mobili- 
 ty of the eye-ball, or causes its displacement, the tumor should 
 be extirpated. 
 
PRACTICE OF MEDICINE. 277 
 
 2.-DACRY0-CYSTITIS. 
 
 INFLAMMATION OF THE LACHRYMAL SAC. 
 
 SYMPTOMS. — Acute inflammation of the lachrymal sac is, 
 when fully developed, a very painful affection — much more so 
 than the limited extent of membrane involved would lead us 
 to expect ; moreover, there is generally much constitutional 
 disturbance, or feverishness, attending the disorder — peculiari- 
 ties which are chiefly due, no doubt, to the vascularity of the 
 affected membrane, and the unyielding character of the bony 
 canal in which the latter is inclosed. A dull, shooting pain is 
 first felt in the region of the lachrymal sac, at the inner angle 
 of the eye, at which point there appears a small, hard, circum- 
 scribed swelling, which afterwards becomes hot, red and tense, 
 and so sensitive that the patient cannot bear to have it touched. 
 The neighboring parts also frequently become red and swollen, 
 the oedema extending to the eyelids and face, and even to the 
 temple. The conjunctiva is more or less injected and swollen, 
 especially the large fold of that membrane, and there may also 
 be some chemosis. The nose generally appears dry and stop- 
 ped up, in consequence of the closure of the nasal duct, which 
 prevents the passage of fluids into the nostrils. At this time, 
 the appearances are such that the disease is liable to be mis- 
 taken for erysipelas of the face. This is especially true of 
 the lids, which are extensively infiltrated with serum, and are 
 red and glistening. But a close examination of the parts will- 
 reveal a marked prominence and redness in the region of the 
 sac, the circumscribed enlargement of which is also apparent 
 to the touch. 
 
 After a time, varying from a few days to as many weeks, 
 according to the violence of the inflammation, suppuration of 
 the sac occurs ; the swelling becomes still more prominent, and 
 if left to itself often bursts and gives exit to pus, or pus 
 
278 PRACTICE OF MEDICINE. 
 
 mingled with tears and mucus, though the latter do not gen- 
 erally begin to be discharged until after the inflammation has 
 somewhat receded. After perforation occurs, the pain, 
 swelling, and other inflammatory symptoms, rapidly subside ; 
 and in the course of a few weeks more, if circumstances favor, 
 the opening may heal up, and complete recovery take place. 
 Usually, however, the persistent flow of muco-purulent matter 
 and tears wholly prevent the closure of the opening, or if not, 
 the closure is but temporary, as the inflammation soon relapses, 
 and leads again to perforation, and so the process is continued, 
 until what is called a fistula lachrymalis, or more properly a fis- 
 tula of the lachrymal sac, is established. Sometimes, especially 
 in chronic cases, more than one external opening is formed, in 
 consequence of the cellular tissue in the vicinity of the sac 
 breaking down into small abscesses, which finally open in the 
 usual manner by perforation. 
 
 More frequently, however, the inflammation does not 
 advance to suppuration and the formation of fistulae. The 
 natural secretion, so to speak, of the mucous membrane, 
 becomes so altered by the inflammatory process as to resemble 
 pus, and in this state either escapes spontaneously through 
 the puncta lachrymalia, or is forced out whenever pressure is 
 made on the distended sac. The relief thus obtained causes 
 the inflammation to recede ; the secretion gradually becomes 
 thinner and more natural, and at last changes into clear mucus. 
 As the congestion and tumefaction abate, the sac and duct 
 again become pervious, the lachrymal secretion takes its 
 natural course into the nose, and the disease is at an end. 
 
 ETIOLOGY. — Dacryocystitis is generally a secondary 
 affection, being due to an extension of the inflammatory pro- 
 cess from the conjunctival or nasal mucous membrane, as in 
 granular conjunctivitis, nasal catarrh, periostitis and caries of 
 the nasal bones, etc. It is especially apt to occur under these 
 circumstances in scrofulous and syphilitic patients. It is 
 
DACRYOCYSTITIS. 279 
 
 frequently associated with erysipelas, but whether as cause or 
 effect is uncertain. It also frequently follows blennorrhea of 
 the sac. When idiopathic, it is generally of catarrhal origin. 
 
 TREATMENT. — If seen at the commencement, we should 
 endeavor to prevent the formation of an abscess, by the local 
 use of cold or ice-water compresses, and the internal adminis- 
 tration of such remedies as Aconite, Belladonna, Baryta, etc.; 
 but as soon as pus appears in the lachrymal sac, we should try 
 to avert perforation, and secure a ready exit for the discharge, 
 by slitting the upper canaliculus with Weber's knife, (PI. II, 
 Fig. 38), and then, if the opening into the sac is contracted, 
 passing the knife into the latter, and dividing its neck. Gentle 
 pressure upon the walls of the sac will then cause the free 
 escape of its contents, the pus continuing to ooze out of the 
 opening, and welling up freely whenever the slightest pressure 
 is made upon the swelling. A probe should now be used to 
 dilate the nasal duct, so as to restore the passage into the nose. 
 But if suppuration has already progressed so far as to render 
 perforation inevitable unless otherwise relieved, it is better to 
 lay the sac open, by making a free incision into it, in a down- 
 ward and outward direction, and thus give exit to the pus. 
 A warm-water dressing, or a poultice, should now be applied, 
 and the wound kept open until the discharge ceases, which 
 will generally occur as soon as the inflammation subsides, and 
 the nasal duct is rendered pervious. If the lachrymal pas- 
 sages remain closed after the inflammation abates, the canali- 
 culus should be divided, and the nasal duct dilated by a probe, 
 as already described. The same operative procedures should 
 be had recourse to, in case perforation has already taken place. 
 If the ulcerated opening fails to heal readily, and becomes 
 fistulous, its edges should be stimulated from time to time 
 with sulphate of copper, when it will soon close. If, after the 
 perforation has healed, the lining membrane of the sac con- 
 tinues to secrete muco-purulent matter, the passage should be 
 
280 PRACTICE OF MEDICINE. 
 
 syringed out daily with a solution of alum or sulphate of zinc, 
 of the strength of one or two grains to the ounce of distilled 
 water, or a weak preparation of Hamamelis or Muriate of 
 Hydrastia, may be used in the same manner. These injections 
 will not only clear the sac of irritating secretions, but will 
 diminish the discharge by lessening the inflammatory process. 
 The injections should be made every day, or every other day, 
 as may be found most beneficial ; and, if necessary, they should 
 be gradually strengthened as improvement occurs. Any con- 
 venient syringe will answer to inject the fluid, but it will 
 generally be necessary to first pass a silver canula, by one of 
 the canaliculi, through the sac into the duct, and to this the 
 nozzle of the syringe should be attached. Or, if preferred, 
 we may introduce Spier's lachrymal catheter (PL II, Fig. 39) 
 through the inferior punctum and canaliculus, and inject the 
 sac through the upper canaliculus, by means of an Anel's 
 syringe the injection passing out again through the catheter 
 lying in the inferior canaliculus.* If the parts are tense 
 and hypertrophied, it may be necessary to facilitate the 
 introduction of the tube, by previously dividing the neck of 
 the sac and the internal palpebral ligament. This is most 
 readily effected by first slitting up the canaliculus with 
 
 Weber's beak-pointed knife, (PI. II, Fig, 38), and after passing 
 the point of the instrument quite down into the sac, turning 
 its cutting edge forwards and outwards, and incising the 
 ligament from within. 
 
 The internal treatment for blennorrhcea of the lachrymal 
 passages may be gathered from the following indications : 
 
 Discharge thin and acrid : Alum., Ars., Arum t., Cinnab., 
 Merc. 
 
 Discharge thin and bland : Euph., Sil. 
 
 Discharge thick and bland : Calc, Puis. 
 
 Discharge very profuse : Arg. nit., Euc. g., Hepar, Nat. m., 
 Merc. 
 
 Obstinate : Calc, Fluor, ac, Petrol., Sil. 
 
 Occasionally useful. — Brom., Calend., {topically), Hydras, 
 Kali iod., Lach. Sulph. 
 
 See Am. Horn.. Obs. t vol. viii, p. 360. 
 
DISEASES OF THE EYE. 28 1 
 
 ART. XVII. — ADDITIONAL THERAPEUTIC INDICATIONS. 
 
 The remedies mentioned in the preceding pages are those 
 upon which the author has hitherto chiefly relied in the treat- 
 ment of ophthalmic inflammation ; but as the list is in some 
 instances somewhat meagre, we have gleaned from our hom- 
 oeopathic literature the following additional therapeutic hints, 
 which will no doubt be found serviceable in particular cases * 
 
 Agaricus. — Spasmodic action of the muscles of the eye- 
 lids and globe ; twitching of the lids, accompanied with great 
 heaviness ; twiching and jerking of the eyeballs, with soreness, 
 aching, and outward pressure. Spasmodic movements gen- 
 erally disappear during sleep, but return on waking. Great 
 weakness of the eyes ; vision soon becomes obscured, espec- 
 ially for near objects ; everything appears blurred and 
 indistinct. 
 
 This remedy has cured muscular asthenopia, with weak- 
 ness of the internal recti ; also anaemia of the choroid, retina 
 and optic nerve. 
 
 Ailantus gland. — Conjunctivitis, with aching, burning, 
 smarting and roughness ; purulent discharge, with agglutination 
 of the lids in the morning. 
 
 This new remedy is said to have cured chronic gono- 
 rrhoea! ophthalmia. 
 
 Alumina. — Burning sensation in the eyes, with or without 
 lachrymation, especially at night ; itching and smarting of the 
 lids and canthi ; nightly agglutination ; weakness of the upper 
 lids, which hang down as if paralyzed ; conjunctiva red and 
 inflamed ; edges of the lids itch and burn ; cilia drop out ; 
 photophobia ; squinting, and dimness of vision. 
 
 In blepharitis ciliaris ; trachoma ; muscular asthenopia, 
 with weakness of the internal recti ; amaurosis. 
 36 
 
282 ADDITIONAL 
 
 Amy I nit. — Eyes staring; conjunctiva bloodshot; pupils 
 dilated ; vision obscured ; chromopsia ; veins of the optic 
 disc enlarged, varicose and tortuous. 
 
 In exophthalmic goitre, by olfaction. 
 
 Asafcetida. — Crampy, drawing and boring pains around the 
 brows ; stitching and burning pains in the eyes, with dryness, 
 and sensation as if sand was in the eye ; pressure in the eyes ; 
 heavy feeling in the eyelids, as if sleepy. 
 
 Ciliary neuralgia, keratitis, iritis, irido-choroiditis, and 
 retinitis, are said to have been benefited by this remedy, 
 especially syphilitic cases. 
 
 Asarum. — Severe burning in the lids, with or without 
 watering of the eye; conjunctiva deeply injected ; violent con- 
 gestive headache. 
 
 Chronic blepharitis and asthenopia, attended with severe 
 headache, are reported as having been cured by this remedy. 
 
 Aurum mnr. — Vascularity and opacity of the cornea ; 
 ciliary injection ; photophobia; tearing pains in the globe, 
 especially the left ; complete loss of vision. 
 
 Several cases of diffuse keratitis, accompanied with the 
 above symptoms, have been reported cured by low attenuations 
 of this remedy ; also a case of amaurosis, with great prostra- 
 tion, occurring suddenly after a severe attack of scarlatina. 
 
 Baryta tod. — Drs. Liebold and Woodyatt report cases of 
 diffuse and obstinate phlyctenular keratitis, in scrofulous 
 subjects, successfully treated with this remedy ; the lymphatic 
 glands "feel like a string of beans between the muscles." 
 
 Calcarea iod. — Severe ciliary irritation, pain, photophobia, 
 lachrymation, spasm of the lids. 
 
 Reported serviceable in nearly every form of scrofulous 
 inflammation of the eye, particularly chronic blepharitis, 
 phlyctenular and suppurative keratitis, especially when com- 
 
THERAPEUTIC INDICATIONS. 283 
 
 plicated with enlargement of the glands of the neck and 
 throat. 
 
 Cedron. — Eyes protruding ; pupils fixed and dilated ; 
 dimness of vision, especially at night ; objects appear red at 
 night and yellow in the day time ; pressive and shooting pains 
 in the forehead and temples, worse over the left eye. 
 
 Supra-orbital neuralgia, especially when dependent upon 
 iritis, choroiditis, and other intra-ocular troubles, appears to 
 have been frequently relieved by this remedy. 
 
 Chelidonium. — Violent pressive and shooting pains in the 
 eyes ; neuralgic pains in the brows and lids ; feeling of sand 
 in the eyes, especially on movement ; redness, burning and 
 swelling of the eyelids, with morning agglutination ; yellow- 
 ness of the sclerotica ; dimness of vision, with faintness ; 
 flickering and brilliant specs before the eyes. 
 
 Intermittent ciliary neuralgia, catarrhal conjunctivitis, 
 and rheumatic amaurosis, are reported as having been cured by 
 this remedy. 
 
 Cicuta. — Diplopia ; things look black ; eyes protrude, 
 with a staring look ; pupils first contracted, then considerably 
 dilated ; when standing or walking, the sight vanishes, and 
 objects appear to advance, recede, and waver, from vertigo. 
 
 Cicuta has cured double vision, vertigo, blepharitis with 
 agglutination of the lids, and photophobia ; but its chief value 
 appears to be in spasmodic affections of the eyes and lids. 
 
 Clematis. — Smarting pain in the eyes and in the margins 
 of the lids ; burning pain in the lids and canthi ; stitches and 
 burning in the inner canthus, with weak sight and lachrymation. 
 
 Chronic blepharitis and conjunctivitis, keratitis, iritis, and 
 kerato-iritis, occuring in scrofulous subjects, have been cured 
 or greatly benefited by this remedy. 
 
 Comocladia. — Aching soreness in the globes, which feel 
 heavy and larger than natural ; painful pressing-out sensation, 
 
284 ADDITIONAL 
 
 as if something was pressing on top of the eyeballs ; severe 
 pain in the balls, extending to the head ; pains increased by 
 warmth. 
 
 In ciliary neuralgia associated with asthenopia, and 
 chronic iritis. 
 
 Crocus. — Burning in the eyelids ; burning and smarting in 
 the eyes, as from smoke ; spasmodic twitching of the lids, 
 especially the upper ; aching in the eyeballs, with epiphora, 
 worse on reading ; upper lids feel heavy ; pupils dilated ; 
 sight obscured, as by a mist, worse for central vision. 
 
 This remedy seems to have relieved a variety of ophthal- 
 mic troubles, chiefly menstrual, or occurring in hysterical 
 women ; such as nictation, with epiphora ; nightly twitching 
 of the lids, with lachrymatfon ; asthenopia, associated with the 
 above symptoms, or when attended with a sensation as if the 
 patient had been weeping ; pains in the eye and head, occur- 
 ring in sclero-choroiditis posterior, etc. 
 
 Crotalus.- — Yellow, sunken appearance of the eyes ; pres- 
 sure in and above the orbits ; oozing of blood from the eyes, 
 which appear ecchymosed ; frequent vanishing of sight, 
 especially in damp weather, or when reading. 
 
 In ciliary neuralgia and amblyopia, occurring in women, 
 and aggravated at the menstrual period ; it also appears to be 
 indicated in retinal hemorrhages, as first pointed out by 
 Dr. Liebold. 
 
 Croton tig. — (Edematous swelling and itching of the 
 eyelids ; weakness of the eyes, with lachrymation ; violent 
 stinging and burning pains in the eye, with inflammatory 
 redness and irritation of the conjunctiva ; violent inflammation 
 of the eye occurred on the second day, attended with ulcera- 
 tion of the ocular conjunctiva, irritation of the iris with 
 contraction of the pupil, conjunctival and episcleral injection, 
 profuse lachrymation, photophobia, and violent pains, disturb- 
 ing the nights rest. 
 
THERAPEUTIC INDICATIONS. 285 
 
 Phlyctenular ophthalmia and keratitis, either with or 
 without ulceration of the cornea, are said to have yielded 
 speedily to this remedy, especially when the characteristic 
 eruption also appeared on the lids and face. 
 
 Cyclamen. — Dilatation of the pupils, with obscuration of 
 sight ; stupefaction, with sensation of a fog before the eyes. 
 
 Amblyopia, diplopia, hemiopia, and convergent strabis- 
 mus, are said to have been relieved by this remedy. 
 
 Fluoric ac — Violent itching in the canthi ; increased 
 lachrymation ; sensation as of cold wind blowing in the eyes ; 
 vision disturbed by dark, floating opacities. 
 
 Lachrymal fistula, of a years duration, and dark spots 
 before the eyes, caused by movable opacities of the vitreous, 
 are reported to have been relieved by this remedy. 
 
 Hamamelis. — Painful inflammation of the eyes and lids, 
 with extreme congestion ; ecchymosis of the lids ; intra-ocular 
 hemorrhage. 
 
 This remedy, used locally as well as internally, has been 
 successfully employed in traumatic conjunctivitis, keratitis and 
 iritis, caused by burns, splinters, blows, etc.; also in ulceration 
 of the cornea, and in internal hemorrhages, especially when 
 of traumatic origin. 
 
 Kali bicli. — Conjunctiva deeply injected, with heat and 
 uneasiness ; eyelids inflamed and swollen ; papillae of the 
 palpebral conjunctiva enlarged ; cornea ulcerated ; photopho- 
 bia and dimness of vision. 
 
 Trachoma, pannus, corneal opacities, and rheumatic iritis, 
 the latter in a syphilitic patient, have been successfully treated 
 by this remedy. 
 
 Kalmia. — Sensation of stiffness in the eyelids, and in the 
 muscles around the eyes ; itching in the eyes ; glimmering 
 before the eyes, exactly in the axis of vision ; dimness and 
 loss of vision, especially on looking down, worse in the 
 morning. 
 
286 ADDITIONAL 
 
 Sclero-choroiditis anterior, asthenopia with stiffness of the 
 recti muscles, and retinitis albuminurica, have all been cured, 
 or greatly benefited, by the internal administration of Kalmia. 
 
 Lycopus virg. — The chief symptom is a painful pressure 
 in the eyeballs. 
 
 Lycopus has relieved protrusion of the eyes, with tumul- 
 tuous action of the heart, and is even reported to have cured 
 exophthalmic bronchocele. 
 
 Phytolacca. — Burning, smarting and itching in the eyes, as 
 if sand were in them, with profuse lachrymation ; dull, heavy 
 pain in the eyeballs, worse from motion, light, and reading ; 
 an eruption (probably enlarged papillae) on the conjunctiva; 
 eyelids cedematous and agglutinated. 
 
 This remedy is reported to have cured catarrhal ophthal- 
 mia, with lachrymation and photophobia ; also granular 
 conjunctivitis, with circum-orbital pain and soreness ; great 
 benefit is also said to have resulted from its internal adminis- 
 tration in a case of traumatic suppurative choroiditis, in which 
 the lids were enormously swollen, the conjunctiva chemosed, 
 and the anterior chamber filled with pus. 
 
 Primus sp. — Lancinating and shooting pains in and around 
 the eye, and in the corresponding side of the head ; pain in 
 the eyeball as if it were crushed or wrenched ; pain in the 
 globe as if it were pressed asunder ; sharp, piercing pains, 
 extending to the eye ; aggravation of the pains from motion. 
 
 This remedy not only seems to relieve almost every form 
 of ciliary neuralgia, but to be of great value in the treatment 
 of various ophthalmic disorders of which this symptom is a 
 prominent feature, such as irido-cyclitis, choroiditis, chorio- 
 retinitis, etc. 
 
 Ruta. — Feeling of heat and sensation as of fire in the 
 eyes, with soreness when reading by candle-light ; pressure on 
 the upper wall of the orbits, with tearing pain in the eyeballs ; 
 dimness of vision from exerting the eyes too much by reading 
 or fine work. 
 
THERAPEUTIC INDICATIONS. 2%J 
 
 In asthenopic symptoms arising from over-exertion of 
 the eyes. 
 
 Santonine. — Dimness and loss of vision ; giddiness ; 
 troubled sight, with dilatation of the pupils ; convulsive 
 twitchings of the eyes and lids. 
 
 This remedy is reported to have been successful in a con- 
 siderable number of cases of asthenopia, amaurosis, and 
 cataract (?). 
 
 Senega. — Swelling, burning and pressure of the eyelids, 
 with burning pain in the margins ; eyelashes in the morning 
 full of hard mucus ; illusions of sight ; extreme sensitiveness 
 of the eyes to light. 
 
 Senega appears to act very beneficially in blepharitis and 
 conjunctivitis, attended with the above symptoms ; and is said, 
 also, to have promoted absorption of hypopya, and of less 
 fragments after cataract operations. 
 
 Staphysagria. — Itchings of the margins of the eyelids ; 
 pimples around the inflamed eye ; sticking shocks in the eye- 
 ball, as if it would burst ; illusions of sight ; dilation of the 
 pupils; aching and pressure in the eye; lachrymation and 
 photophobia. 
 
 This is an old and well-known remedy for blepharitis, 
 styes, and small tarsal tumors ; and it is also reported to have 
 cured several cases of the so-called "arthritic ophthalmia." 
 
 Sticta. — Burning in the eyelids, with soreness of the ball 
 in closing the lids, or turning the eyes. 
 
 In catarrhal conjunctivitis, with profuse but mild discharge. 
 
 Zinc phos. — Retinal hyperemia ; extreme sensitiveness of 
 the eyes to light ; photopsia, photophobia, and chromopsia. 
 
 In hyperesthesia and hyperemia of the retina. 
 
288 PRACTICE OF MEDICINE. 
 
 TABLE A. 
 
 OPHTHALMIC SYMPTOMS. 
 
 i. Agglutination— Bell., Calc, Care, v., Caus., Euphorb., 
 Hep., Kali, Lyc, Nat. m., Nux v., Phos., Puls., Rhus., Ruta, Sep., 
 Silic, Staph., Bry., Ign., Stann., Alum., Croc, Nit. ac, Plumb., 
 Sulph., Thuja. 
 
 2. Burning — Ars., Arn., Bell., Bry., Calc, Con., Cham., 
 Croc, Dig., Rhod., Ruta, Spig., Spong., Thuja., Alum., Canth., 
 Ferr., Graph., Ign., Kali, Nit. ac, Plumb., Puis., Rhus. Sep., Staph., 
 Sulph., Aeon., Agar., Aur., Bar., Chin., Dros., Hell., Lyc, Mur. ac, 
 Nux v., Phos., Silic, Strain. 
 
 3. Dryness — Bry., Staph., Sulph., Ver at., Bell., Puis., Agar., 
 Bar., Caust., Croc, Euph., Kali, Lyc, Nat. m., Nux v., Phos., Spig. 
 
 4. Lachrymation — Acon., Arn., Bell., Bry., Calc, Caust., 
 Chin., Coloc, Digit., Euph., Ferr., Graph., Hep., Ign., Kali a, 
 Lyc, Merc, Nat. m., Nux v., Phos., Puls , Rhus, Ruta, Spig., 
 Spong., Stram., Sulph., Verat. a. Alum., Ars., Bar., Chelid., Con., 
 Croc, Rhodod., Seneg., Sep., Sil., Stan., Staph., Zinc, Agar., Camph., 
 Canth., Carb. v., Cina, Coff., Hell., Lach., Op., Petr., Ph. ac, Plat. 
 
 5. Neuralgia — Atrop., Bell., Cedr., Cham., Prunus sp., 
 Spig., Chin., Cinnab., Sil., Asafcet., Bry., Cimicif., Crotal., Ign., Mez., 
 Nat. m., Plat., Sulph., Thuj. 
 
 6. Pupils, Dilated — Acon., Bell., Calc, Chin., Cina, Croc, 
 Hep., Hyosc, Ign., Ipec, Sec c, Spig., Stram., Verat., Zinc. 
 Agar., Am., Hell, Nux v., Ph. ac, Puis., Ars., Aur., Caust., Con., 
 Cupr., Dig., Mur. ac, Nit. ac, Petr., Plumb., Stann. 
 
 Pupils, Contracted — Arn., Camph., Cham., Chin., Cic, Hyosc, 
 Ign., Puls., Sulph., Verat., Aeon., Agar., Ars., Aur., Bell., Cina, 
 Cocc, Dros., Plumb., Sec c, St) am., Calc, Canth., Digt., Hell., Mur. 
 ac, Ph. ac, Stann., Thuj. 
 
 7. Redness, Inflammatory. — Acon., Apis, Arn., Ars., Bell., 
 Bry., Calc, Cham., Chin., Digt., Euphr., Ign., Merc, Nat. m., Nit. 
 ac, Nux v., Phos., Ph. ac, Puls., Rhus, Sep., Silic, Spig., Sulph., 
 Verat., Coloc, Cupr., Euphorb., Ipec, Kali, Lyc, Staph., Bar., 
 
OPHTHALMIC SYMPTOMS. 289 
 
 Camph., Canth., Carb. v., Con., Dulc, Ferr., Graph., Hep., Hyosc, 
 Op., Plumb. 
 
 8. Smarting— Agar., Con., Merc, Nux v., Rhus,Val., Alum., 
 Canth., Chin., Graph., Sep., Staph., Ars., Bell., Bry., Calc, Carb. v., 
 Caust., Croc., Dros., Euphor., Hell., Hep., Kali, Lye, Mur. ac, 
 Nit. ac, Phos., Ph. ac. Sulph., Thuj. 
 
 9. Swelling— Ars., Rhus, Stram., Bry., Carb. v., Hep., Nux, v. 
 Phos., Plumb., Ruta, Sulph. 
 
 10. Ulceration, Tarsal— Spong., Sulph., Am., Calc, Cham., 
 Lyc, Phos., SiL, Staph., Alum., Bar., Caust., Kali, Nit. ac, Sep. 
 
 11. Ulceration, Corneal. — Arg. n., Ars., Aur., Calc, 
 Graph., Hepar., Kali bic, Merc, Aeon., Canth., Cinnab., Nat. m., 
 Silic., Sulph., Apis, Arn., Cham., Chin., Cimicit., Con., Crot. tig., 
 Ham., Puis.. Rhus. 
 
 12. Vision, A. — Amblyopia: Bell., Phos., Zinc, Gels., Merc, 
 Sant., Aeon., Alum., Arn., Ars., Aur., Bar., Bov., Calc, Chel., Chin., 
 Crot., Cyclam., Ign., Kali, Lye, Nat. m., Puis., Ruta., Sep., SiL, 
 Sulph., Thuj. 
 
 B. — Chromopsia. — Bell., Con., Croc, Digit., Kali, Alum., 
 Ars., Calc, Cann., Canth., Hep., Hyos., Merc, Ph. ac, Phos., Sep., 
 Spig., Stram., Zinc. 
 
 C. — Diplopia. — Bell., Digit, Euphorb., Hyosc, Puls., Sec. c, 
 Sulph., Verat., Aur., Cic, Stram., Agar., Graph., Nit. ac, Merc, 
 Petr. 
 
 D. — Hemiopia. — Aur., Lith. c, Lyc, Mur. ac, Nat. m., Sep., 
 Bov., Cyclam., Digt., Calc, Chin., Lob., Viola od. 
 
 E. — Hemeralopia. — Hyos., Ranun., Verat., Arg. nit., Digt., 
 Sulph., Bell., Chin., Lyc, Merc, Puis., Stram. 
 
 F. — Photophobia. — A con., Arn., Ars., Bell., Bry., Cham., 
 Chin., Con., Euphr., Graph., Hep., Ign., Merc, Nux v., Puls., 
 Sep., Sulph., Cic, Cin., Croc, Sant., Alum., Camph., Coff., Hell., 
 Kali, Lyc, Mur. ac, Nit. ac, Ph. ac, Sil. 
 
 G. — Pholopsia. — Bell., Bry., Spig., Bar., Caust., Kali, Sil, 
 Verat., Ars., Aur., Calc, Coloc, Croc, Digt., Dulc, Nat. m. Nux v., 
 Op., Petr., Ph. ac, Staph., Stram. 
 
 H. — Vitreous Opacities. — Kali iod., Sil., Sulph., Calc, Nat. 
 m. Nit. ac, Phos., Sep., Arn., Bell., Carb. v., Caust., Ham., Kal., 
 Lach., Lyc, Merc, Petr., Prunus, Sol. n. 
 
29O PRACTICE OF MEDICINE. 
 
 TABLE B. 
 
 OPHTHALMIC INFLAMMATION. 
 
 i. Conjunctivitis — Apis, Arg. nit., Bell., Euphr., Merc, 
 Puls., Rhus, Sep.. Sulph., Am., Ars., Calc, Cham., Cinnab., Graph. , 
 Hepar., Ign., Nux. v., Sang., Spig., Zinc, Alum , Chelid., Croc, Cupr., 
 Euphor., Kali bic, Nat. m., Sen., Thuj. 
 
 2. Blepharitis — Acon., Alum., Apis, Arg. nit., Ars., Calc, 
 Caust., Cinnab. . Euphr., Graph., Hepar, Merc, Nat. m., Petr., 
 Puls., Sep., Silic, Aur., Cham., Crot. fig, Merc, Nux v., Psor., Rhus, 
 Staph., Tellur., Bell., Clem., Colch., Kali, Lye, Phos. ac, Sang., 
 Seneg., Viola trie. 
 
 3. Keratitis — Acon., Apls, Arg. nit., Arn., Ars.. Aur., Calc, 
 Canth.. Cham., Chin., Cimicif., Con..tCrot. tig., Euphr., Graph., 
 Ham., Hepar., Kali bic, Merc, Nat. m.. Nux v. Puls., Rhus, 
 Sec c, Sil., Sulph., Aur. m., Bar., Sep., Thuj., Vaccin., Alum., 
 Bell., Caust., Chin., Kreos., Nit. ac, Seneg. 
 
 4. Episcleritis. — Acon., Kal., Merc, Silic, Thuj., Puis., 
 Cocc. , Spig., Sulph. 
 
 5. Iritis. — Acon., Arn., Ars., Aur.. Bell., Bry., Calend., 
 Cedr., Chin., Clem., Con., Euphr., Gels., Ham., Hepar., Kali iod., 
 Merc, Nit. ac, Nux v., Petr., Rhus, Silic, Spig., Sulph., 
 Terebinth., Thuj. Arg. nit., Asafcet., Cinnab., Nat. m., Puis., Cocc, 
 Crot. tig., Hyos., Led., Plumb., Stilling., Zinc. 
 
 6. Cyclitis — Kali iod., Merc, Bell., Bry., Rhus, Silic. 3 Apis., 
 Ars., Aur., Prunus sp., Thuj. 
 
 7. Choroiditis — Aur., Bell., Bry., Gels., Kali iod., Merc, 
 Nux v., Phos., Prunus sp., Puls., Sulph., Apis, Ars., Hepr., Phyt., 
 Rhus t., Acon., Coloc , Ipec, Psor., Ruta, Sil., Sol. nig. 
 
 8. Glaucoma. — Bell., Bry., Cedr., Coloc, Phos., Pru. sp., 
 Rhododen., Spig., Kali iod., Merc, Phyto., Arn., Ars., Aur., Cham., 
 Cocc, Collin., Con., Crot. tig., Gels, Ham.. Nux v., Sulph. 
 
 9. Retinitis — Bell., Bry., Cact., Con., Merc, Nux v., Phos., 
 Puls., Apis, Asafcet., Ars., Aur., Gels., Kalm., Kali iod., Aeon., 
 Collin., Croc, Lach., Leptan., Spig., Sulph., Zinc. 
 
 10. Orbital Cellulitis. — Acon., Apis, Hepar., Lach., Merc, 
 Rhus., Calc, Kali iod., Caust., Sil., Sulph. 
 
 11. Dacryocystitis — Acon., Hepar, Merc, Puls., SiL.,Arumt., 
 Arg. nit., Euphr., Petr., Cinnab., Hydras., Nat. m., Sang., Stilling., 
 Sulph. 
 
 12. Fistula Lachrymalis — Arg. nit., Brom., Fluor, ac, 
 Calc, Lach., Petr., Nat. m., Silic, Sulph. 
 
SYMBLEPHARON. 2CjI 
 
 DIV. II. 
 
 RESULTS OF OPHTHALMIC INFLAMMATION. 
 
 Many of the consequences of ophthalmic inflammation have 
 already received the attention at our hand which their rela- 
 tive importance, and the general object we have had in view, 
 has seemed to demand. Others, however, have been but 
 briefly noticed, or only incidentally referred to, and will there- 
 fore require to be separately considered. But as we have 
 already devoted as much space to the subject of inflammation 
 as we can well spare for that purpose, we shall aim in what 
 follows to be as brief and practical as possible. 
 
 1.-SYMBLEPHAE0N. 
 
 This term denotes a more or less extensive adhesion of 
 the mucous membrane of the lids to that of the globe. The 
 adhesions may be direct and close, so as to cause very great 
 limitation of the movements of the ball ; or they may consist 
 of narrow bridges of connection, either slender and chord-like, 
 or thin and membranous. These loose attachments are 
 supposed to be formed by the movements of the globe, and 
 consequent stretching of the original adhesions. The affection 
 may be produced by any cause which gives rise to ulceration of 
 the two opposed conjunctival surfaces, whether it be the acci- 
 dental introduction of caustic substances, such as lime or 
 mortar, between the lids, or the destruction of the superficial 
 epithelial layers by the knife or caustic, as in careless oper- 
 ations for the removal of trachoma, pterygium, etc. 
 
 Treatment. — When the adhesions are extensive, it is 
 almost impossible to prevent their ultimate reunion after sep- 
 aration. Surgeons of the highest eminence have recorded 
 their repeated attempts and failures in this direction. The 
 difficulty seems to lie in the contraction of the new formations, 
 
292 PRACTICE OF MEDICINE. 
 
 and the consequent difficulty of permanently separating the 
 granulating surfaces. Almost every form of mechanical contri- 
 vance has been made use of to prevent the junction of the raw 
 surfaces ; and for this purpose shields of metal, glass, ivory, 
 and other substances, have been interposed between the lids 
 and globe ; but as contraction takes place during the process of 
 cicatrization, the interposed substance is gradually pushed out, 
 and although the case may seem to do well at first, the operation 
 is almost certain, in the end, to prove a failure. Probably Mr. 
 Wordsworth's glass shell, mentioned by Wells, which has a 
 central opening for the cornea, and resembles an aitificial eye, 
 would, as the inventor claims, be successful in many cases, 
 provided it were worn continuously for a sufficient length of 
 time ; for it should be remembered that, as in the case of 
 burns, the new formation is imperfectly organized and liable to 
 absorption, and consequently, as pointed out by Walton, con- 
 traction continues for some time after the completion of the 
 cicatrix. 
 
 Of the many operative procedures that have been devised 
 for symblepharon, the following appear to be the most reliable, 
 and may be adopted in moderate cases with reasonable pros- 
 pect of success : 
 
 1. That of Amussat, which consists in freely dividing all 
 existing adhesions, and then daily carrying the point of a 
 probe, or of a cutting instrument, to the extremity of the 
 division ; this is continued until the pyogenic surfaces are cica- 
 trized, and can no longer grow together. 
 
 2. Petrequin's ligature process, which consists in carrying 
 a double ligature through the adhesion, one portion of which is 
 tied with great firmness close to the sclerotica, and the other 
 with a less degree of compression near the lid. As the former 
 sloughs away at an earlier period than the latter, the part near 
 the eyeball heals before the other, and the cicatrization be- 
 comes too far advanced to admit of its reattachment to the 
 outer part. 
 
ANCHYLOBLEPHARON. 293 
 
 3. Arlt's process, which consists in first passing two liga- 
 tures through the symblepharon close to the cornea, and after 
 carefully dividing the adhesions as far back as the retro-tarsal 
 fold, doubling down the symblepharon so as to bring its con- 
 junctival surface in apposition with the raw surface of the 
 globe, and then passing the ligatures through the lid close to 
 the orbital border, tying them on the outside. After the orbi- 
 tal wound has healed, if the shrunken remains of the symble- 
 pharon prove troublesome to the patient, they may be safely 
 snipped off with a pair of scissors. 
 
 4. Teale's method by transplantation. This consists in 
 first separating the adhesions in the usual manner, beginning at 
 the margin of the cornea, and then interposing one or more flaps 
 of conjunctiva previously dissected from neighboring portions 
 of the globe. The flaps are adjusted in their new positions by 
 means of fine silk ligatures, "and their vitality is further pro- 
 vided for by incising the conjunctiva near their base, in any 
 direction in which there seems to be undue tension." He also 
 stitches together the margins of the gap from which the trans- 
 planted conjunctiva has been removed. In adjusting the flaps, 
 great care should be taken to prevent the doubling in of their 
 edges, which would be likely to prevent the full success of the 
 operation. 
 
 2 -ANCHYLOBLEPHARON. 
 
 This term denotes a firm adhesion of the two lids, which 
 may be either complete or partial, congenital or acquired. In 
 the majority of cases the adhesion is partial, and is usually 
 limited to the outer angle. The union is generally of a mem- 
 branous nature, especially in congenital cases ; but when com- 
 plicated with symblepharon, or when caused by severe mechan- 
 ical or chemical injuries, it is apt to be thick and tendinous. 
 
 Treatment. — If the adhesion is membranous, or if it is 
 
294 PRACTICE OF MEDICINE. 
 
 limited to one or more points, the lids should be carefully 
 separated upon a director, and readhesion prevented by care- 
 fully drying the edges, and then touching the raw surfaces with 
 collodion, as first suggested by Walton ; but if the union is 
 large and broad, and especially if it is confined to the palpebral 
 angle, the most appropriate and effective treatment is the oper- 
 ation of Canthoplasty, (which see). 
 
 3.-BNTR0PIUM. 
 
 By entropium is meant a more or less extensive inversion 
 of the lids. It is usually complicated with trichiasis, or turning 
 in of the cilia, which is generally regarded as constituting the 
 first degree of entropium. We recognize two principal forms 
 of the affection ; the spasmodic, which usually occurs in 
 elderly people, and hence is frequently called senile entropium; 
 and the chronic, which is generally due to inflammatory and 
 structural changes in the conjunctiva and tarsal cartilages. 
 The former, which is frequently temporary, is generally met 
 with in the lower lid, but it may also occur in the upper. The 
 affection is often accompanied with great irritation from the 
 friction of the cilia against the globe, which frequently gives 
 rise to inflammation, and leads sooner or later to ulceration 
 and opacity of the cornea. 
 
 Treatment. — The most simple and effective treatment 
 for spasmodic entropium, particularly in senile cases, is the 
 operation of canthoplasty, care being taken to make the incision 
 oblique instead of horizontal, so as to relax the orbicularis 
 muscle to the fullest extent. Generally, the incision should 
 be in a downward direction, because it is usually the lower lid 
 that is affected. If this fails to keep the lid in its natural 
 position, its external surface should be painted with collodion, 
 the contraction of which in drying is sometimes sufficient, 
 even without the operation, to prevent the lid from again 
 becoming inverted. 
 
entropium. 295 
 
 When the central part of the lid is greatly relaxed, as it 
 usually is in old cases, some surgeons, in order to equalize the 
 tension, instead of extending the edge of the lid, as above 
 recommended, remove a triangular piece of integument from 
 the central, or most relaxed portion. An incision is first made 
 about one and a half lines from the free border of the lid, and 
 parallel with it, extending on either side to within one or two 
 lines of the commissure. Two oblique incisions are then 
 made from points about midway between the centre and the 
 two extremities of the horizontal incision, converging towards 
 the orbital border, so as to include a triangular portion of the 
 integument, which is dissected up and removed. The sides of 
 the wound are then united by two or three fine sutures, the 
 horizontal incision being left to itself. When healed, the 
 cicatrix will be in the form of the letter T. In very bad 
 cases, especially where there is a narrowing of the palpebral 
 fissure, it is best to combine this operation with that of can- 
 thoplasty, above described. 
 
 In case there is much contraction and incurvation of the 
 tarsal cartilage, it may also be found necessary to remove a 
 portion of the latter, which is best done by turning back the 
 upper angles of the V-shaped incision in the operation just 
 described, as far as the ends of the horizontal incision, and then 
 cutting out a wedge-shaped portion of the cartilage, by mak- 
 ing two nearly parallel incisions into it along the palpebral 
 margin nearly down to its inner surface, at the same time 
 sloping them towards each other so as to meet near its posterior 
 surface. The strip to be removed is then seized with a pair 
 of forceps, and detached with a few touches of the scalpel. 
 The extent to which this "grooving process" should be carried, 
 will depend, of course, upon the degree of contraction and 
 dislocation of the cartilage. 
 
 If these operative procedures fail to rectify the position 
 of the lids, there remains no other resource than to remove the 
 hair-follicles, as described under Trichiasis, (which see). 
 
2g6 PRACTICE OF MEDICINE. 
 
 4.-ECTR0PIUM. 
 
 Ectropium is the reverse of entropium ; that is, it is a 
 turning out of the eyelid, so that more or less of its conjunc- 
 tival surface is exposed. It is generally confined to the lower 
 lid, though it may affect both. There are various degrees of 
 the affection, ranging from a slight eversion of the border of 
 the lid, to one in which the entire surfaces are reversed. Of 
 course this malposition of the lids interferes with the proper 
 discharge of the tears, so that the eye is always more or less 
 suffused and watery ; and in severe cases, especially of the 
 lower lid, they frequently pour over the side of the cheek, 
 inflaming and excoriating the latter, and even increasing the 
 ectropium, by causing contraction of the integuments. In 
 fact, it is this contraction of the skin near the edges of the 
 lids, during cicatrization from long-continued excoriation, 
 burns, wounds, etc., that most frequently gives rise to ectro- 
 pium. But severe forms of conjunctivitis, especially the 
 purulent and granular, also produce it, in consequence of the 
 extensive swelling and hypertrophy of the conjunctiva, the 
 eversion being aided by the action of the orbicularis. Other 
 causes are : paralysis of the portio dura, chronic blepharitis, 
 or lippitudo, abscess of the lids, abscess and caries of the 
 orbit, especially of its margin, intra-orbital tumors, cancerous 
 growths, and exophthalmos. 
 
 Treatment. — If the cause of the displacement can be 
 removed, acute and recent cases will, as a general rule, require 
 no additional treatment, except the simple replacement of the 
 lid, and its retention in the normal position by a compress 
 bandage. But when the eversion is of long-standing, the tar- 
 sus becomes more or less elongated, so that the lid will no 
 longer fit the globe, even after it is restored to its natural 
 position. It then becomes necessary to narrow the palpebral 
 
ECTROPIUM. 297 
 
 fissure by the operation of tarsoraphia. This operation, devised 
 
 by Walther, may be performed as follows : — The operator 
 
 ascertains the extent of the surplus tissues, by first reducing 
 
 the dislocated lid, and then, having put its border slightly on 
 
 the stretch, pinches up the loose tissues at the outer canthus, 
 
 until the margins of the two lids fit each other, marking with 
 
 ink the boundaries thus included. He then inserts a horn or 
 
 ivory spatula between this portion of the lids, and, beginning 
 
 at the outer canthus, makes a crescent-shaped incision along 
 
 the previously-marked boundary, through the skin and cellular 
 
 tissue, to the point where the two lids should meet. He then 
 
 shaves off this portion of the lids, including its cilia, as far 
 
 back as the outer canthus, being careful not to leave any of 
 
 the hair follicles behind, as these would grow again. The two 
 
 raw surfaces are then brought together, and secured by three 
 
 or four interrupted sutures. In order to lessen the strain upon 
 
 the sutures, adhesive strips may be applied in such a manner 
 
 as to draw the integuments towards the junction of the lids, 
 
 which should be that of a straight horizontal line. When 
 
 there is a marked difference in the length of the tarsal edges, 
 
 it is generally necessary before completing the operation, in 
 
 order to prevent a bulging of the fascia and cartilage, under 
 
 the sutures, to excise a portion of the latter, in shape like an 
 
 Italic V ; the edges of the incision should then be included in 
 
 the suture. 
 
 For ectropium resulting from cicatrices near the margin of 
 
 the lids, and causing their eversion by traction, a great variety 
 
 of operations has been devised, most of which are simple 
 
 modifications of the following, which is known as DiefTen- 
 
 bach's :— The cicatrix, or so much of it as may be necessary, 
 
 is removed by a triangular-shaped incision, the base of which 
 
 is turned towards the ciliary margin, and the apex to the 
 
 cheek. The incision which forms the base of the triangle, is 
 
 then extended on each side at right angles to the sides of the 
 
 former triangle, and the flaps thus formed are raised a little 
 38 
 
298 PRACTICE OF MEDICINE. 
 
 from the subjacent parts, brought together so as to fill the 
 triangular space previously occupied by the cicatrix, and the T- 
 shaped wound thus formed united by fine sutures. In case the 
 ciliary margin remains too much relaxed, tarsoraphia may be 
 advantageously united with this operation. 
 
 For such exceptional cases of ectropium and lagophthal- 
 mos as will not admit of being successfully treated by the 
 above operations, the reader is referred to the larger works on 
 ophthalmology, particularly those of Wells and Stellwag, 
 where he will find a great variety of blepheroplastic operations 
 fully illustrated and described. 
 
 5.-TRICHIASIS. 
 
 This is a disease in which the eyelashes are inverted, or 
 turned inward toward the globe. The malposition may affect 
 the whole or only a portion of the cilia, which are always more 
 or less degenerated and distorted. Supernumery cilia are 
 not uncommmon in these cases, as many as four or five having 
 been found to spring from the same hair-follicle. These gen- 
 erally have the appearence of new hairs, being for the most 
 part short, fine and colorless. In some cases the cilia appear 
 to be arranged in two distinct rows, and then the disease is 
 called distichiasis. The misplaced cilia are generally turned 
 inwards, and by constantly sweeping against the globe excite 
 considerable irritation, which is accompanied, in some cases, 
 by severe lachrymation and photophobia. If the abnormal 
 friction is allowed to continue, vascular keratitis sets in, and 
 this is followed by pannus. It may also cause severe spasm 
 of the lids, which in turn may give rise to some degree of 
 ectropium. 
 
 ETIOLOGY. — The most frequent causes of trichiasis are 
 those which give rise to structural changes in the edges of the 
 lids, such as blepharitis ciliaris, purulent and granular ophthal- 
 mia, cicatricial contractions, etc. 
 
 Treatment. — This is either palliative or radical. The 
 
TRICHIASIS. 299 
 
 palliative treatment consists in removing the misdirected cilia, 
 as fast as they grow, with forceps. If this treatment is con- 
 tinued for a sufficient length of time, it may finally result in 
 atrophy of the hair-follicles, and thus prove radical ; but as a 
 general rule the cilia continue to grow, and require to be ex- 
 tracted as often as they are reproduced. The radical treatment 
 consists in either giving to the cilia a more natural and harm- 
 less direction, or else in extirpating the bulbs of the inverted 
 lashes. The latter is generally the most successful method ; 
 but the loss of the cilia is so disfiguring to the patient, 
 especially in the upper lid, that the operation should, if possi- 
 ble, be avoided. Sometimes we can succeed in turning the 
 cilia away from the globe, by merely pinching up a fold of the 
 integument near the ciliary border, and excising it. When 
 this will answer the purpose, it is the best plan to adopt, as it 
 not only preserves the cilia, but the success of the operation is 
 confirmed by the subsequent contraction, and the subsidence of 
 the irritation and swelling. If this fails to meet the indication, 
 we may frequently succeed by first making perpendicular incis- 
 ions down to the cartilage at the extremities of the trichiasis, 
 and then uniting them at the ciliary margin by carrying an in- 
 cision along the edge of the lid, between the meibomian ducts 
 and cilia ; after which sufficient of the integuments should be 
 excised to evert the cilia, and with them any coexisting entro- 
 pium. If this procedure, which is a modification of Von 
 Graefe's operation, will not suffice, then the best method, not- 
 withstanding the resulting deformity, is to remove the hair 
 bulbs. This operation is both tedious and painful, especially 
 when a considerable number of the cilia are misplaced, and 
 therefore it is better to perform it when the patient is under the 
 influence of chloroform. A horn or any other suitable spatula is 
 first placed under the lid, and is held there by an assistant, 
 who at the same time raises the lid from the globe, and causes 
 its edge to be somewhat everted. Then the edge of the lid 
 is split, or divided into two layers, to the depth of about two 
 
300 PRACTICE OF MEDICINE. 
 
 lines, with a scalpel or other suitable knife, (PI. I, Fig. 22), 
 being careful not to continue the incision into the lachrymal 
 puncta. The incision should be made close to the surface of 
 the cartilage, so that all the hair-follicles may be included in 
 the anterior layer. The integument is then divided behind the 
 hair-bulbs, by a horizontal incision extending down to the 
 fascia, which, if the trichiasis involves the whole of the lashes, 
 should meet the free border of the lid at an obtuse angle, two 
 lines beyond the commissure. The portion thus included may 
 then be liberated with a few touches of the scalpel ; and if any 
 of the hair-bulbs still remain, they should be carefully excised, 
 otherwise some of the cilia will be reproduced. Sutures are 
 not required, but a wet compress should be applied, and in a 
 few days the wound will be healed. Should there have been 
 any coexisting entropium, or rolling in of the edge of the 
 lid, it will be corrected by contraction of the cicatrix. 
 
 6.-XEE0PHTHALMIA. 
 
 This affection, sometimes called xerosis conjunctivae, con- 
 sists in a dry or cuticular state of the conjunctiva, which loses its 
 character of a mucous membrane, and no longer secretes. 
 The surface of the membrane becomes rough, scaly, and of a 
 greyish-white color, being sometimes finely granulated, at 
 others resembling cicatricial tissue. The opposed surfaces are 
 so dry, rough and stiff, as greatly to hinder the movements of 
 both the eye and lids ; and this is still farther increased by 
 contraction of the conjuctiva, and by a greater or less accum- 
 ulation of hardened epitheliel scales within the narrowed 
 conjunctival sac. In the great majority of cases, also, there 
 is partial symblepharon, the lids adhering to each other and to 
 the caruncula ; the puncta are frequently obliterated ; and the 
 upper lid is sometimes so much shortened, that the eye cannot 
 be shut, producing the state of lagophthalmus. When the 
 globe or lids are moved, the ocular conjunctiva is thrown into 
 folds round the cornea. No moisture is perceived on rubbing 
 
PTERYGIUM. 301 
 
 the cornea, the surface of which is generally rough, uneven, 
 and greatly deficient in sensibility. The cornea is generally 
 obscure, the opacity being so great, in some cases, that the 
 color of the iris and the state of the pupil cannot be recog- 
 nized. Not only the cornea, but also the conjunctiva, becomes 
 anaesthetic, dust and dirt accumulating between the lids, and 
 exciting little or no irritation. 
 
 Etiology. — This incurable affection is generally caused 
 by chronic granular conjunctivitis ; and is most apt to result 
 from neglected or badly treated cases, especially when deep 
 scarification and too severe caustics are employed. It also 
 follows diphtheritic conjunctivitis, especially when the latter is 
 attended with sloughing. Symblepharon accompanied with 
 severe inflammation, trichiasis, entropium, logophthalmos, and 
 injuries resulting from burns, strong acids, etc., are among the 
 less frequent, but occasional causes. 
 
 Treatment. — This is merely palliative, the best we can do 
 being to mitigate, or temporarily relieve the dryness of the 
 conjunctiva, by the frequent use of some bland fluid, such as a 
 weak solution of glycerine, milk, artificial serum, etc. These 
 collyria act beneficially by washing away the hardened epithe- 
 lium from the surface of the cornea, and thus render the latter 
 more transparent. 
 
 7.-PTERYGIUM. 
 
 This term, which is derived from a Greek word signifying 
 a wing y is used to denote an hypertrophied condition of the 
 conjunctival and episcleral tissues. It is usually situated at 
 the inner canthus, and is of a triangular form, the base at the 
 semilunar fold, and the apex near the margin of the cornea, 
 towards the centre of which it gradually advances. It presents 
 more or less of a tendinous or fibrous structure, and is traversed 
 in the direction of its length by numerous nearly parallel 
 bloodvessels. It is divided into two principal forms, according 
 to the greater or less degree of hypertrophy exhibited at 
 
302 PRACTICE OF MEDICINE. 
 
 different periods of its growth. While thin, transparent and 
 delicate, it is called pterygium tenue or membranaceum, but 
 when it becomes thick and fleshy, it is termed pterygium 
 crassum or carnosum. It is generally somewhat loosely con- 
 nected with the subjacent parts, so that it can be easily raised 
 with the forceps ; but if the conjunctival portion contains any 
 considerable amount of ligamentous or tendinous tissue in its 
 structure, it is thereby rendered less yielding, and may even 
 impede to some extent the movements of the globe. 
 
 Pterygium usually occurs about the middle period of life, 
 and makes its appearance quite insensibly, the disease 
 frequently making considerable progress before the patient is 
 aware of its existence. 
 
 Its growth is generally very slow, the pterygium advancing 
 gradually to the margin of the cornea, where its progress is 
 sometimes arrested ; in other cases it extends more or less on 
 to the cornea, but it seldom passes beyond the centre. The 
 corneal portion is less vascular and more compact and tendin- 
 ous than the conjunctival, especially the extreme point of the 
 pterygium, which not unfrequently appears round and bead-like. 
 
 Etiology. — The chief cause of pterygium appears to be 
 some injury which irritates the ocular conjunctiva, such as may 
 result from prolonged exposure to wind, dust, heat, etc. 
 Hence its usual seat at the internal canthus, where the con- 
 junctiva is most exposed to the operation of such agencies. 
 Hence, also, its frequent occurrence among the inhabitants of 
 hot climates, and among sea captains, stone-cutters, masons, 
 etc. Pterygium may also result from phlyctenular keratitis, 
 superficial ulceration of the margin of the cornea, or any other 
 cause capable of giving rise to inflammatory hypertrophy of 
 the conjunctival and episcleral tissue. 
 
 Treatment. — If the pterygium is small, or thin and 
 vascular, it may yield to Arg. nit., Ars., Calc, Chin., Lach., 
 Nux mos., Psor., Ratan., Spig., Sulph., or Zinc, all of which 
 have proved beneficial in particular cases. But if the occupa- 
 
PTERYGIUM. 303 
 
 tion or habits of the patient are such as to favor its growth, it 
 will be necessary to abandon them before any internal treat- 
 ment will be likely to prove successful. If symptoms of 
 severe irritation exist, they should be allayed by appropriate 
 treatment ; and for this purpose much good sometimes results 
 from the use of mild astringent collyria, especially if there is 
 any catarrhal or other form of ophthalmia connected with it. 
 
 But if the pterygium is large and thick, and especially if 
 it is composed of true connective tissue, these means are 
 insufficient, and we can only remove it by resorting to opera- 
 tive procedures. But since these are not always perfectly 
 successful — the cicatrix or some portion of hypertrophied 
 tissue remaining, which may even necessitate a further opera- 
 tion — so long as the pterygium does not interfere, nor seem 
 likely to interfere, with vision, or with a free and unrestricted 
 movement of the globe, it should not be operated upon. On 
 the other hand, if the morbid growth has so far encroached on 
 the cornea as to impede vision, or if it should threaten to do 
 so, and especially if its size and character are such as to limit 
 to any considerable degree the movement of the globe, we 
 should remove the pterygium by one of the following methods: 
 
 (1). Excision. — The patient having been brought under 
 the influence of an anaesthetic, the lids separated by the 
 stop-speculum (PL II, Fig, 33), and the globe turned slightly 
 in the direction of the pterygium, and there held by a^suitable 
 instrument, (PI. I, Fig, 16), the operator seizes the growth with 
 a pair of reliable forceps, and raises it sufficiently to pass a 
 pointed narrow-bladed knife (Fig. 13) under it, with which he 
 first excises the corneal, and then the scleral portion, dissecting 
 the latter toward the palpebral fold to a distance of one and 
 a half or two lines from the margin of the cornea, thus far 
 following exactly the edges of the pterygium, and keeping 
 close to the surface of the cornea and sclerotica. From this 
 point the dissection is continued toward the base of the 
 pterygium, not by following the edges of the latter, as before, 
 
304 PRACTICE OF MEDICINE. 
 
 which would form a triangular wound, but by two converging 
 incisions, meeting in front of the reflection, so as to give the 
 wound somewhat of a rhomboidal shape. Having removed all 
 hypertrophied tissue, the edges of the wound should be closed by 
 two or three fine sutures. A protective bandage should then be 
 applied, and in three or four days the sutures may be removed. 
 
 (2). Ligation. — The lids having been separated and the 
 globe fixed as above described, the operator raises the ptery- 
 gium with a pair of forceps, and passes a fine curved needle, 
 armed with a double silk ligature, beneath it from border to 
 border, first near the margin of the cornea, and afterwards at 
 the base of the pterygium. The thread now forms a double 
 loop on one side of the pterygium, by cutting one thread of 
 which, the ligature, after the removal of the needle, is divided 
 into three portions, an outer, middle, and inner one. The ends of 
 the inner thread are first tied, then those of the outer, and 
 finally the two ends of the middle one, which are both on the 
 same side of the pterygium. At the expiration of four or five 
 days, the ligated portion of the pterygium may be easily 
 detached with the forceps. 
 
 (3). Transplantation. — This operation, which was first 
 introduced by Desmarres, and afterwards greatly improved by 
 Knapp, is now generally performed in the following manner : — 
 The corneal portion of the pterygium is first dissected off, and 
 excised. Two curved incisions are then made in the direction 
 of the retro-tarsal folds, from the upper and lower borders of 
 the base of the pterygium. The latter is next divided into 
 two equal portions by a horizontal incision extending to its 
 base. After this, two small conjunctival flaps are formed, one 
 on either side of the wound, for the purpose of covering it. 
 The contraction of the flaps causes the two curved incisions to 
 gape sufficiently to receive the corresponding halves of the 
 pterygium, where they are secured by fine sutures. Finally, 
 the conjunctival flaps are brought together over the former 
 seat of the pterygium, and there united. 
 
DISEASES OF THE EYE. 305 
 
 8.-0PACITIES OF THE COENEA. 
 
 Under the head of Keratitis will be found a general 
 description of the nature, situation, and extent of the various 
 forms of corneal opacity. They may be summarized as 
 follows : 
 
 (1). Epithelial or Nebulous Opacities. — These are thin and 
 superficial, appearing like a mist or cloud upon the surface of 
 the cornea. They are sometimes so fine as to be extremely 
 difficult of detection, unless the cornea is examined with a 
 convex lens or by lateral illumination. 
 
 (2.) Parenchymatous Opacities. — These thicker and 
 deeper-seated forms of opacity are named, from their color, 
 leucoma. When "complete," the entire cornea has a whitish or 
 bluish-white appearance, very much resembling the sclera, the 
 surface frequently retaining its normal lustre. When "partial," 
 the opacity is more or less cloud-like, the border being irregular, 
 and gradually shaded off into the unaffected portions of the 
 cornea. The color varies from a greyish or bluish transparency 
 to a yellowish, or even chalky-white tint. 
 
 (3). Tendinous or Cicatricial Opacities. — These are more 
 or less superficial, according to the depth of the original ulcer. 
 They generally have a tendinous or glistening-white appear- 
 ance, especially the central portions. The edges are frequently 
 indistinct, owing to their being surrounded by an epithelial 
 cloudiness, the result of recent inflammatory changes, which 
 in the course of time becomes absorbed. 
 
 (4). Calcareous Opacities. — These opacities, consisting of 
 the carbonate and phosphate of lime, are of a brownish tint. 
 They are situated just under the epithelium, and have an 
 irregular and somewhat indistinct outline, shading off more or 
 less gradually into the normal transparent cornea. 
 
 PROGNOSIS. — This depends chiefly upon the duration, 
 nature, and extent of the opacity. When recent, and especially 
 
306 PRACTICE OF MEDICINE. 
 
 when occurring in young and vigorous patients, they almost 
 always disappear sooner or later without treatment. Ten- 
 dinous and cicatricial opacities never disappear altogether ; 
 but at first they are generally surrounded by a cloudy border, 
 which clears up in the course of time, the remaining opacity 
 being lessened in extent, and its effect on vision greatly 
 diminished. 
 
 Treatment. — The cure of recent cases of corneal 
 opacity is frequently hastened by the internal use of the 
 following remedies. — Apis, Cannab., Chel., Crotal., Euph., 
 Hep., Merc, Puis, n., Rhus and Sulph. Even old cases of 
 leucoma are reported to have -been greatly benefited by the 
 persistent administration of Ac. nit., Aur., Calc, Cup. al., 
 Hep., Kali bic, Kali iod., Merc, Nat. sul., Sil., Spong., and 
 Sulph. Of these, the following have also been employed 
 externally : — Cup. al., Kali bic, Kali iod., Merc, and Nat. sul. 
 There being no characteristic eye symptoms in these cases by 
 which to make the selection, the indications will have to be 
 sought for in other organs ; but if there is no derangement of 
 the patient's health to guide us, we may, if all inflammatory 
 symptoms have disappeared, endeavor to promote absorption 
 by the cautious use of irritants, such as Merc, dulc, Nat. sul., 
 etc, a small quantity of which may be daily dusted into the 
 eye. Or we may make use of irritating collyria, beginning 
 with weak solutions of the sulphate of zinc or copper, and 
 either changing or gradually strengthening them as the eye 
 becomes accustomed to their use. For this purpose we have 
 generally found nothing better than a collyrium of Kali iod, 
 (grs. ij — v ad § j). The action of these agents is often 
 increased by the instillation of Atropine, which promotes 
 absorption by diminishing the intra-ocular tension. Calcareous 
 opacities should be carefully scraped off with a scalpel, as 
 recommended by Dixon and Bowman. As this is a very 
 painful operation, and denudes the cornea of epithelium, it 
 
STAPHYLOMA OF THE CORNEA. 30? 
 
 should be done with the greatest care, and only a small 
 quantity removed at a time ; a little olive or other bland oil 
 being afterwards applied to the eye. 
 
 In old and incurable cases, vision may sometimes be 
 improved by diminishing the intensity of the diffused light by 
 means of stenopaic spectacles. These are so constructed as 
 to permit only the central rays to pass, thus cutting off the 
 irregularly refracted rays from the periphery. These specta- 
 cles, while they often answer very well for near objects, as in 
 reading, writing, sewing, etc., are not adapted to general use, 
 the field of vision being too much contracted to permit of 
 freely moving about, as in walking, driving, etc. 
 
 If these means fail of restoring serviceable vision, then our 
 only resource is an artificial pupil, made behind a transparent 
 part of the cornea ; selecting for this purpose the operation of 
 iridectomy, iriodesis, iridoenkleisis, or corydialysis, according 
 as one or the other may best suit the condition of the cornea 
 and the optical principles involved in the case. See Operations 
 for A rtificial Pupil. 
 
 9.-STAPHYL0MA OF THE COENEA. 
 
 There are three principal forms of corneal staphyloma, 
 namely, (i), kerato-conus, or conical cornea; (2), kerato-globus, 
 or buphthalmos ; and, (3), staphyloma of the cornea and iris. 
 The first two forms are chiefly due to a weakening and thin- 
 ning of the corneal tissue, and the last to ulceration and 
 sloughing of the cornea, followed by prolapse and subsequent 
 adhesion of the iris. 
 
 A.— Conical Cornea. 
 
 KERATO-CONUS. 
 
 This form of staphyloma, if considerable, may be easily dis- 
 tinguished by viewing the eye in profile, when the conical shape 
 
308 PRACTICE OF MEDICINE. 
 
 of the cornea will be readily perceived. Slight cases, however, 
 may be either entirely overlooked, or mistaken for amblyopic 
 forms of myopia, unless we make an ophthalmoscopic examin- 
 ation, when the smallest amount of conicity may be detected. 
 In these examinations we use only the mirror, through which, 
 if we view the cone exactly in the line of its axis, all the 
 light will be reflected, and we shall see a bright red space, 
 surrounded by a dark zone, and this again surrounded by 
 another circle, which is red. If viewed obliquely, the part of 
 the cone opposite to the light will be darkened. If we 
 examine the interior of the eye, we can only see a small 
 portion of the fundus ; while the retinal vessels and the border 
 of the optic nerve entrance appear distorted and more or less 
 indistinct. The slightest movement of the eye or mirror 
 greatly increases the distortion, the irregular refraction through 
 the cornea frequently giving a curled or twisted appearance to 
 the vessels, and also to the border of the optic disc. 
 
 Vision is always more or less impaired, and, in many 
 cases, is insufficient to serve any useful purpose, the distortion 
 and confusion of the retinal images being too great to admit 
 of much improvement by any kind of stenopaic apparatus. 
 Moreover, the apex of the cone seldom remains transparent, 
 but sooner or later becomes hazy or opaque, and, in some cases, 
 even tendinous or cicatricial. 
 
 Etiology. — Inflammation is supposed to be one of the 
 chief causes of kerato-conus ; but it cannot be the sole cause, 
 as many cases occur in which no signs of inflammatory action 
 ever appear. Neither is the bulging forward of the cornea due 
 to intra-ocular pressure, for such eyes are almost always ab- 
 normally soft. It appears to be due, rather, to a weakening 
 and thinning of the cornea, the latter becoming more and 
 more attenuated as the staphyloma increases. 
 
 Prognosis. — The development of conical cornea is gen- 
 erally very slow. It is often interrupted in its course, stop- 
 
STAPHYLOMA OF THE CORNEA. 309 
 
 ping short at a certain point, then resting, perhaps, for years, 
 and then increasing again without any apparent cause. Or it 
 may cease at any stage of development and become perma- 
 nently stationary. It is a singular circumstance in these cases 
 that, however thin the apex of the cone may become, it never 
 gives way unless it is accidentally ruptured. The disease is 
 seldom monocular, but generally affects both eyes, either sim- 
 ultaneously or in succession. 
 
 Treatment. — It is highly probable that the progress of 
 kerato-conus may, in some cases, be checked by the persistent 
 use of proper homoeopathic remedies, even in cases in which 
 there is no co-existing inflammation ; but, as yet, we are 
 obliged to confess that we know of no internal remedy on 
 which we can place reliance as a curative agent is these cases. 
 It is true that Drs. Allen and Norton, in their work on ''Oph- 
 thalmic Therapeutics," say that Calc. iod. has seemed to act 
 favorably in their hands, and that "decided benefit has been 
 obtained from its use in checking the progress of both conical 
 cornea and staphyloma." The same remedy is even reported 
 by H. Goullon to have cured a case of kerato-conus ; but this 
 may well be taken cum grano salts, as we cannot conceive of 
 the possibility of materially reducing the conicity of the cor- 
 nea, except by incision, and this is generally very far from 
 being a successful operation. Some diminution, however, may 
 result from lessening the intra-ocular pressure by means of an 
 iridectomy ; and, as we may in this manner possibly arrest the 
 progress of the disease, and at the same time improve the 
 vision, by making a pupil opposite the peripheral portion of 
 the cornea, where it still retains, to a great degree, its normal 
 curvature, it is the operation most frequently performed. The 
 iridectomy should be of only moderate size, and, as suggested 
 by Wells, should be made slightly upwards and inwards, so 
 that a part of the base of the artificial pupil may be covered 
 by the upper lid. When the conicity of the cornea is slight 
 
3IO PRACTICE OF MEDICINE. 
 
 and almost stationary, some prefer an iridodesis to an iridec- 
 tomy, with a view of displacing the pupil towards a portion of 
 the cornea which is less abnormally curved, so as to lessen the 
 diffusion and irregular refraction of the rays passing through 
 it. Others, again, make an iridodesis on opposite sides of the 
 pupil, so as to change the latter into a long, narrow slit, with a 
 view to render the aperture stenopaic ; but the operation is 
 said to offer no advantages over the ordinary method. 
 
 B— Kerato-Qlobus. 
 
 BUPHTHALMOS. 
 
 In this disease the entire cornea, and generally the ante- 
 rior portion of the sclerotica also, are bulged forward in such 
 a manner as to give a uniform spherical curvature to the cor- 
 nea, and a greater or less increase in the size of the whole an- 
 terior portion of the eyeball. This increase is often so consio^ 
 erable as to present an appearance similar to that of exoph- 
 thalmos, the front portion of the globe protruding between the 
 lids, and giving to the eye a peculiar staring expression, whence 
 it has derived the name of buphtlvalmos . The effect of the 
 enlargement is to increase the size of the anterior chamber in 
 every direction. Hence the disease was for a long time re- 
 garded as a dropsy of the anterior chamber {Jiydr ophthalmia 
 anterior). The iris is stretched so as to be proportionally en- 
 larged, the fibres appearing slightly separated, especially 
 towards the ciliary margin. It is frequently somewhat cupped, 
 particularly in a backward direction, and is occasionally tremu- 
 lous, perhaps from losing the support of the lens, which is 
 sometimes dislocated. The pupil is usually dilated and slug- 
 gish, and more or less of its margin is sometimes adherent to 
 the anterior capsule. The cornea may remain entirely trans- 
 parent ; but, in most cases, it is more or less clouded, especially 
 
STAPHYLOMA OF THE CORNEA, 311 
 
 on the periphery, and, in some instances, it is uniformly and 
 densely opaque. As the disease progresses, glaucomatous 
 symptoms supervene ; the tension increases, the optic disc 
 becomes excavated, the lens is rendered opaque, the vitreous 
 separates and becomes fluid, detachment of the retina occurs, 
 and atrophy finally ensues ; or else, in consequence of the 
 thinning of the anterior portion of the globe, the ball becomes 
 ruptured. In either case, the disease is almost certain to ter- 
 minate, sooner or later, in complete blindness. 
 
 ETIOLOGY. — The etiology of this disease is somewhat 
 obscure. It does not appear to be due to the increased intra- 
 ocular pressure, since glaucomatous symptoms do not generally 
 give rise to bulging of the cornea. Neither does it arise from 
 an increased secretion of the aqueous humor. It must, there- 
 fore, either originate in such an abnormal condition of the 
 cornea as would constitute a predisposition to the disease, or 
 else it must result from a weakening and thinning of the cor- 
 neal tissue in consequence of some severe inflammation, such 
 as vascular keratitis or pannus. The latter is probably the 
 chief factor in its production in most cases. 
 
 Treatment. — This is similar to the treatment recom- 
 mended for Glaucoma (which see). 
 
 C. —Staphyloma of the Cornea and Iris. 
 
 This form of staphyloma is one whose walls are compos- 
 ed, either wholly or in part, of cicatricial tissue, and is gener- 
 ally the result of ulceration. Partial staphyloma is, in the 
 majority of cases, only an advanced stage of what is called 
 staphyloma tridis, or prolapse of the iris. As the latter usually 
 occurs during the inflammatory process, the prolapsed iris soon 
 becomes covered with lymph, which gradually assumes a cica- 
 tricial character, and, being weaker or more extensible than 
 
312 PRACTICE OF MEDICINE. 
 
 the normal cornea, readily yields to the intra-ocular pressure, 
 and gives rise to "partial" staphyloma. The growth of the 
 staphylomatous protrusion is generally slow and subject to 
 many interruptions ; but, if not permanently checked, it may 
 gradually extend until it involves a considerable portion of the 
 cornea ; and, if the original perforation was extensive, it may 
 even implicate the whole of the corneal tissue, and thus be 
 transformed into a "total" staphyloma. The walls of the pro- 
 jection may preserve, to a great degree, their former transpa- 
 rency and delicacy, in which case, either through mechanical 
 violence or a sudden contraction of the recti muscles, they fre- 
 quently burst. But, in most cases, as the staphyloma enlarges 
 the walls increase in thickness, and, when it protrudes between 
 the lids, the external irritation frequently excites more or less 
 inflammatory action, which tends still further to augment the 
 size of the morbid growth. 
 
 ETIOLOGY. — As already stated, the most frequent cause of 
 staphyloma of the cornea is ulceration. But it may also be 
 produced by wounds and injuries, or by any operation, such as 
 flap extraction, which becomes complicated with prolapse of 
 the iris. Total staphyloma is frequently caused by ulceration 
 or sloughing of the entire cornea. 
 
 TREATMENT. — Internal remedies can have no beneficial 
 effect upon staphyloma of the cornea, unless it be in retarding 
 its development by lessening inflammatory action. In this 
 way some good may possibly result, in particular cases, by the 
 administration of such remedies as the inflammatory compli- 
 cations may specially indicate. The most approved treatment 
 for partial staphyloma, especially if recent, is iridectomy. 
 This operation at once lessens the intra-ocular pressure, and 
 thus not only arrests the bulging of the* cornea, but may also 
 cause it to diminish in size. At a later stage of the affection, 
 glaucomatous symptoms may set in, and then, of course, iri- 
 dectomy should on no account be omitted. Fortunately for 
 
STAPHYLOMA OF THE CORNEA. 313 
 
 the success of the operation, the place of election in these 
 cases is generally opposite the most transparent portion of the 
 cornea, namely, the periphery. In some cases of partial 
 staphyloma, it is advisable to combine iridectomy with the 
 methodical use of a pressure bandage ; but if, for any reason, 
 the latter is not well borne, or if it seems to excite pain or un- 
 easiness within the eye, it had best be dispensed with, and the 
 eye simply shaded. 
 
 Total staphyloma does not admit of any restoration of 
 vision, the only object of treatment being to improve the per- 
 gonal appearance of the patient, and relieve him from an an- 
 noying and painful disfigurement by removing the projection. 
 
 Of the numerous methods of operating in these cases, we 
 shall only mention two, namely, (1) Excision and (2) Borelli's 
 operation. 
 
 1. EXCISION. — The lids being widely separated by an 
 assistant, the point of a cataract knife (PL I., Fig. 29), with the 
 edge turned downward, is made to penetrate the base of the 
 staphyloma in such a manner that, when pushed forward and 
 made to cut its way out, it shall divide the lower two-thirds of 
 the staphyloma in the plane of its base. The collapsed 
 growth is then seized by forceps, and the remainder divided 
 with scissors ; or, if the operator prefers, a flap may be formed 
 from it with which to cover the opening at the base of the 
 staphyloma. A pressure bandage is then to be applied, and 
 the resulting inflammation moderated by rest and the internal 
 administration of Aconite. 
 
 2. Borelli's Operation. — This consists in transfixing 
 the tumor by two needles, in such a manner as to form a cross. 
 A ligature is then passed round the staphyloma, behind the 
 needles or pins, and firmly tied. In the course of three or 
 four days the tumor generally sloughs off, and in a week or so 
 afterwards the wound is healed. If the staphyloma is small 
 or partial, its whole base should be included within the liga- 
 
V 
 
 314 PRACTICE OF MEDICINE. 
 
 ture ; but if large or total, only a part of it should be em- 
 braced, and care should also be taken not to draw the ligature 
 too tight, otherwise it may cut through the walls of the tu- 
 mor, or suppurative choroiditis may supervene and destroy the 
 eye. 
 
 1Q-ANTERI0E SCLERO-CHOROIDAL STAPHYLOMA. 
 
 Sclero-choroidal staphyloma may affect the anterior, later- 
 al, or posterior portion of the sclerotica, but is mostly confined 
 to the anterior and posterior zones. The latter has already 
 been described under the head of "Sclero-Choroiditis Poste- 
 rior." The former is no more a primary affection than the 
 latter, but is a secondary effect of an inflammation of the an- 
 terior part or the whole of the uveal tract ; in other words, it 
 may proceed from a partial or total sclero-choroiditis. The in- 
 creased tension of the globe distends the sclerotica from with- 
 in, while the resistance of the membrane is probably dimin- 
 ished by its participation in the inflammation. In this way 
 the sclerotica becomes thinned, and raised into prominences of 
 various magnitude. These vary in size from that of a small 
 grain to a filbert ; or the whole anterior portion of the scle- 
 rotica may be raised into one irregular, mulberry-like tumor 
 round the cornea, and then the disease is called "Annular 
 Staphyloma." As the staphyloma increases, the sclerotica be- 
 comes more and more atrophied and discolored, the affected 
 part assuming a dusky, bluish-grey appearance, due to the 
 shining through of the choroid. The growth of the tumor is 
 sometimes very rapid, and is then usually attended with severe 
 pain and other symptoms of acute inflammation ; but, as a 
 general rule, the progress of the disease is very slow and grad- 
 ual, its course corresponding with that of the inflammatory 
 affection on which it depends. When the latter becomes 
 
OPACITIES OF THE VITREOUS HUMOR. 315 
 
 chronic, the staphyloma generally remains stationary, or slowly 
 progresses ; but during periods of exacerbation, the eye be- 
 comes painful and the disease makes perceptible progress. 
 
 TREATMENT. — During the early stages of the affection, 
 the treatment is the same as that for Choroiditis (which see). 
 But when the staphyloma has existed for some time, and is 
 large, we may have to remove it by an operation. For this 
 purpose we may adopt either of the methods described under 
 the head of "Staphyloma of the Cornea and Iris." 
 
 II -OPACITIES OF THE VITEEOUS HUMOR. 
 
 Opacities of the vitreous are of two distinct forms, or 
 classes — the diffuse, and the filiform or membranous. The dif- 
 fuse variety presents itself in the form of a greyish mist or 
 nebulosity, scattered here and there through the vitreous hu- 
 mor, or spread out like a veil over the fundus, and giving a 
 blurred appearance to the vessels of the retina and optic disc. 
 This form developes rapidly, extends quickly through the en- 
 tire vitreous, and clears up just as quickly, appearing and dis- 
 appearing from time to time, according to the condition of the 
 vascular envelope of the vitreous, which serves as the develop- 
 ing membrane. When these changes occur very suddenly, 
 there is reason to apprehend the most serious consequences, as 
 they are frequently succeeded by detachment of the retina. 
 If, however, the inflammation on which the opacity depends 
 takes a permanently favorable turn, the vitreous may clear up 
 and return to its normal condition 
 
 Associated with the diffuse form, we frequently meet with 
 various circumscribed opacities, both filiform and membranous, 
 consisting of the debris of cells, or the remains of blood 
 effusions, floating about in the vitreous, and assuming a great 
 variety of forms. Examined with the ophthalmoscope, they 
 are seen to be dark, fixed or floating bodies, of a filiform, 
 
3l6 PRACTICE OF MEDICINE. 
 
 reticulated or membranous character ; or they may be so fine 
 and numerous as to give an obscure and hazy appearance to 
 the whole fundus. 
 
 Treatment. — This to be successful must be directed to 
 the removal of the cause, which, as we have seen, is generally 
 some form of choroiditis, or other inflammatory affection of the 
 deeper structures of the eye. Arn., Gels., Ham., Kali iod., 
 Lach., Merc, and Sulph. have acted very favorably in many 
 cases, and are worthy of special attention. Ars., Bell., Caust., 
 Kal., Lye, Phos., Prun., SiL, and Sol. n. have also been recom- 
 mended, and deserve notice. The absorption of opacities 
 arising from extravasation of blood into the vitreous, has been 
 hastened by the application of a compress bandage. Benefit 
 often accrues, also, from attention to the general health, 
 especially when the affection is aggravated by some functional 
 derangement of the system. 
 
 12.-DETACHMENT OF THE RETINA. 
 
 AMOTIO RETINA. 
 
 Detachment of the retina occurs whenever serum is 
 effused between it and the choroid. At first it is always 
 partial, and confined to the periphery ; but it may afterwards 
 spread in every direction, especially towards the optic disc. 
 It usually takes place in the lower half of the fundus, 
 probably in consequence of the fluid immediately gravitating 
 to that part. The outline of the detachment, as viewed with 
 the ophthalmoscope, is generally somewhat irregular, varying 
 according to the amount of sub-retinal effusion. When the 
 detachment is large and prominent, it is frequently thrown 
 into folds, which are usually most conspicuous near the 
 circumference of the fundus, on which they sometimes cast a 
 distinct shadow. The color of the detached retina, which 
 
DETACHMENT OF THE RETINA. 317 
 
 chiefly depends upon that of the fluid beneath, is of a yellowish, 
 greenish, or bluish-grey tint, and often exhibits a marked 
 contrast with the usual bright red reflex of the normal retina. 
 These features of the disease are generally sufficiently 
 distinctive for the ready recognition of advanced cases ; but 
 in very slight degrees of detachment, a much closer inspection 
 is required to clear up the diagnosis. We notice, first, that the 
 vessels are darker than those on the normal retina ; that they 
 bend more or less abruptly over the border of the detachment, 
 and pursue a crooked and tortuous course on the folds, 
 between which they frequently disappear; that they quiver 
 with every movement of the undulating membrane ; and that 
 they are somewhat closer to the observer than those on the 
 normal retina. We notice also that those appearances are 
 generally more conspicuous the nearer we approach the 
 circumference of the fundus. 
 
 Vision is impaired in proportion to the degree of detach- 
 ment. The patient first notices a faint cloud waving before 
 him, at a point in the field of vision corresponding to the 
 sub-retinal effusion. Hence, if the detachment occurs in the 
 lower half of the fundus, the obscurity will be in the upper 
 half of the visual field, and vice versa. Objects generally 
 seem more or less distorted, exhibit slight wave-like or undula- 
 tory movements, and appear bordered with a colored ring. 
 The sight is likewise disturbed with photopsies, arising from 
 retinal irritation; and also by movable opacities of the vitreous, 
 which appear as black specks and spots, of various sizes and 
 shapes, floating about in the field of vision. 
 
 Etiology. — The causes which give rise to detachment 
 of the retina are not always manifest. Sometimes it can 
 be traced directly to a blow or fall. In other cases it is 
 found to arise from intra-ocular hemorrhage, occurring in 
 the course of some inflammatory affection of the choroid 
 or retina. Thus, we have seen it to occur very frequently 
 
3l8 PRACTICE OF MEDICINE. 
 
 in the course of sclero-choroiditis posterior, in consequence 
 chiefly of the elongation of the optic axis, which, by causing 
 a separation of the vitreous, favors the detachment of the 
 retina. It is also frequently associated with retinitis, 
 especially the exudative variety. 
 
 PROGNOSIS. — This is mostly unfavorable. Occasionally, 
 slight detachments may remain stationary, or may even 
 disappear, the sub-retinal fluid becoming absorbed, and the 
 affected membrane regaining its functions. But such favorable 
 results are not to be expected. In the vast majority of cases 
 the disease is progressive, the detachment slowly extending, 
 accompanied by frequent inflammatory attacks and exacerba- 
 tions, until finally it terminates in total blindness. When the 
 detachment is the result of accident, the disease is generally 
 limited to one eye, and is much more favorable;* but when 
 associated with myopia, or when it depends upon sclero- 
 choroiditis posterior, each eye is usually affected, the same 
 cause operating in both. 
 
 Treatment. — If seen shortly after the detachment 
 occurs, the patient should be confined to his room, and if 
 possible, to his bed. The eyes should also be carefully ban- 
 daged, as this not only serves to exclude the light, but hastens 
 absorption. Atropine should be immediately instilled, chiefly 
 with the view of preventing accommodation ; but its use 
 should not be pushed too far, as the sudden reduction of the 
 intra-ocular pressure is liable to excite temporary hyperaemia 
 of the vessels of the choroid and retina, and by causing an 
 effusion of blood, increase the detachment. 
 
 Gelseminum is one of our most promising internal 
 remedies for this affection, rapidly promoting absorption in 
 recent cases, both traumatic and inflammatory. Much benefit 
 has also been derived from the administration, in suitable cases, 
 of Apis, Ars., Aur., Bry., Dig., Hep., Kali iod., Merc, and Rhus. 
 
 *See Dr. Boynton's Case, p. 244, et. teg. 
 
HORDEOLUM. 319 
 
 Temporary improvement has been obtained by puncturing 
 the sac by means of a sickle-shaped needle, and permitting 
 the fluid to escape from beneath the retina. The needle is 
 passed perpendicularly through the sclerotica behind the lens, 
 and having penetrated seven or eight lines into the vitreous, 
 its point is turned towards the detachment, which is then 
 divided as the instrument is withdrawn. Especial care must 
 be taken not to cause intra-ocular hemorrhage by wounding 
 the choroid. The operation, though unattended with any 
 immediate danger, is not always successful ; and as it appears 
 in many cases to have "hastened the atrophy of the eye by 
 inciting a degenerative irido-choroiditis," its usefulness as a 
 remedial measure is, to say the least, very questionable. 
 
 DIV. III. OPHTHALMIC TUMORS. 
 
 In the technical sense of the word, a "tumor" is "a cir- 
 cumscribed substance produced by disease, and different in its 
 nature from the surrounding Jparts." In a broader and more 
 general sense, however, the term may be used to denote any 
 morbid enlargement of a part, whether different in its nature 
 from the neighboring tissues, or not ; and it is in this less- 
 restricted sense that we shall make use of it. 
 
 1 -HORDEOLUM, OR STYE. 
 
 This miniature boil is too familiar to need particular de- 
 scription. It is not, as was formerly supposed, an inflammation 
 of a Meibomian gland, but of the connective tissue of the edge 
 
320 PRACTICE OF MEDICINE. 
 
 of the lids. As a general rule, only one boil occurs at a time, 
 but in some cases there are several ; and it is no uncommon 
 thing for one to follow another in regular succession, thus 
 prolonging the disease for several months. The inflammation 
 is generally confined to the immediate vicinity of the stye, but 
 if highly acute it may extend to the entire lid, which becomes 
 very red and cedematous ; and even the ocular conjunctiva 
 may become inflamed and chemosed. In such severe cases 
 there is apt to be considerable feverishness and constitutional 
 disturbance. But generally the disease runs a less acute, and 
 in some cases a chronic course ; and although the swelling is 
 extremely sensitive to the touch, it soon terminates, either in 
 resolution, or, which is more common, in suppuration, the pur- 
 ulent matter being discharged from the apex of the stye, 
 mixed with small masses ol disintegrated connective tissue. 
 
 Hordeolum is generally regarded, and justly so, as an 
 indication of an unhealthy state of the constitution. It is most 
 commonly met with in scrofulous and enfeebled subjects, or in 
 those whose health is broken down, especially individuals 
 whose constitutions are undermined by dissipation, or in whom 
 there co-exists some derangement of the digestive or uterine 
 organs. 
 
 TREATMENT. — If seen sufficiently early, we may bring 
 about resolution by the use of cold compresses and Aconite ; 
 but in most cases it is advisable to hasten the suppurative 
 process by warm applications, giving at the same time Hepar 
 or Pulsatilla internally, and subsequently, Graph., Staph., 
 Sulph., or Thuja. The following remedies are also useful in 
 preventing the recurrence of styes : — Alum., Ambr., Caust, 
 Con., Ferr., Lye, Merc, Nat. m., Phos. ac, Rhus, Seneg., Sep., 
 Sil., and Stann. 
 
DISEASES OF THE EYE. 32 1 
 
 2.-CHALASI0N. 
 
 This is a small tumor, or cyst, originating in the tarsus, 
 and due to inflammatory or other changes of the Meibomian 
 apparatus. Its usual appearance is that of a small, rounded, 
 isolated tumor, about the size of a pea, situated just beneath 
 the conjunctiva or skin, and at a little distance from the edge 
 of the lid. It occurs most frequently in the upper lid, but 
 sometimes in the lower one, and more rarely in both. It 
 occasionally becomes inflamed and traversed by enlarged 
 vessels ; and if the inflammation is very acute, it may give 
 rise to suppuration and the formation of a small cystic abscess. 
 In most cases, however, the inflammation is of a chronic char- 
 acter ; and the contents of the cyst, instead of being purulent, 
 are sometimes glairy or gelatinous, sometimes curdy, and 
 sometimes fatty or sebaceous. 
 
 Debility seems to favor its development, as it is of frequent 
 occurrence after confinement or prolonged nursing ; but its 
 connection with an impaired state of health is not so evident 
 as in stye, with which it sometimes co-exists. It is of remark- 
 ably slow growth, many months elapsing before it attains its 
 full development. 
 
 Treatment. — If the tumor is soft and recent, we may 
 sometimes cure it by administering Merc, precip. rub., or Kali 
 iod., internally, at the same time that we use an ointment of 
 these remedies externally. We have known the tumor to dis- 
 appear without treatment, but this is a rare occurrence. In the 
 majority of cases, even after the faithful use of indicated rem- 
 edies and due attention to the general health, we have been 
 obliged to resort to the knife. The operation is very simple. 
 The lid having been everted, a crucial incision is made into the 
 tumor with a scalpel or narrow knife, and if the contents are 
 not sufficiently fluid to escape at once, they may be pressed 
 out with the fingers, or scooped out with any convenient instru- 
 
322 PRACTICE OF MEDICINE. 
 
 ment. No after-treatment is generally required. It is well to 
 inform the patient that he should not expect any reduction in 
 the size of the tumor for several days, and that the swelling 
 may even undergo a temporary increase, from bleeding within 
 the cyst. The inflammation excited by the operation will 
 cause contraction, and in the course of two or three weeks, the 
 cyst, and the thickened tissues around it, will disappear. If 
 the tumor return, which is very rarely the case, the operation 
 should be repeated, taking care to excite sufficient adhesive 
 inflammation to insure the obliteration of the cyst, by lightly 
 touching its interior with a pointed crayon of nitrate of silver ; 
 or, what is frequently more convenient, by dipping a silver 
 probe in nitric acid and cauterizing the cavity with the nitrate 
 of silver thus extemporaneously prepared. 
 
 3 -DERMOID TUMORS. 
 
 These were formerly called warts, moles and liorns. The 
 former are usually small, roundish and projecting. They are 
 of various degrees of consistency, some being quite soft and 
 fleshy, while others are hard and cartilaginous. They also 
 vary greatly in color, being in some cases white, in others yel- 
 lowish, red, reddish brown, or dark brown. The surface of the 
 wart or mole is sometimes smooth, sometimes rough or granu- 
 lar, and sometimes it has a number of short and delicate, or 
 long and coarse hairs springing from it. These tumors con- 
 sist, according to Virchow, "of a pad of connective tissue and 
 elastic filaments, covered by a thick layer of epithelium, in 
 which are situated the hair-follicles, either with or without 
 accompanying sebaceous glands." They may be confined to 
 the ciliary margin or to the outside of the lid, or they may 
 occupy both. They also occasionally appear on the conjuncti- 
 va, in the form of small, flesh-colored tubercles, either singly 
 
SEBACEOUS TUMORS. 323 
 
 or in clusters. These mucous warts bear a strong resemblance 
 to those that occur on the prepuce. Dermoid tumors of a pale, 
 whitish-yellow color, one or two lines in diameter, smooth or 
 lobulated, and either with or without projecting hairs, are also 
 sometimes met with on the cornea. 
 
 The so-called "horns," according to Wilson, are "accretions 
 of inspissated sebaceous matter on the edges of the lids, which 
 owe their origin to the drying and hardening, as fast as it es- 
 capes, of the contents of the follicles that furnish the material 
 for their growth." 
 
 TREATMENT. — Dermoid tumors are mostly congenital, and 
 generally require excision. Warts on the lids are said to have 
 disappeared under the use of one or more of the following 
 remedies, and if the patient is averse to having them snipped 
 off, which is a very trifling operation, there can be no harm in 
 trying them : Bar. c, Calc. c, Caust., Hep., Nit. ac, Kali bic, 
 Lye, Sep., SiL, Sulph. and Thuja. 
 
 4.-SEBACE0US TUMORS. 
 
 These are generally met with in infants and young child- 
 ren. They appear most commonly at the upper margin of the 
 orbit, near the external extremity of the eyebrow, but they are 
 sometimes seen at the internal or nasal end. When first no- 
 ticed they are about the size of a small pea, and are so loosely 
 covered by the integument that the latter may be easily 
 pinched up into a fold. They always grow very slowly, are 
 unattended by pain or redness, and seldom attain any consid- 
 erable magnitude, the largest not exceeding an inch or so in 
 diameter. When opened they are found to consist of a com- 
 pact cyst, the posterior wall of which is somewhat thickened, 
 and generally adherent to the periosteum of the orbit. The 
 contents of the cyst are sebaceous, containing fat molecules 
 
324 PRACTICE OF MEDICINE. 
 
 and broken-down epithelial cells, mixed in varying proportions 
 with short and imperfectly-formed hair. The tumor appears to 
 be congenital. 
 
 Treatment. — The proper treatment of sebaceous tumors 
 is operative. Perhaps by a careful selection of our drugs, 
 based chiefly upon constitutional symptoms, we may, in some 
 cases, effect their absorption ; but we have never witnessed 
 their removal in this way, and unless the general health can 
 be benefited by it, it is not worth while to waste time by de- 
 pending upon medical treatment. If, however, the patient is 
 opposed to operative procedures, we may try the following 
 remedies, which have received the endorsement of able physi- 
 cians : Bar. c, Calc. c, Graph., Hep., Nit. ac, Sil., and Sulph. 
 
 Sebaceous, like other subcutaneous cystic tumors, should 
 be carefully dissected out, or rather eneucleated, the handle, 
 instead of the edge, of the knife being used whenever practica- 
 ble ; for if the cyst be opened and its contents allowed to es- 
 cape, the accident will greatly increase the difficulty of remov- 
 ing the whole of the tumor. If this should happen, however, 
 it will be advisable to lighly cauterize the remaining portions 
 of the cyst with nitrate of silver, in order to prevent the return 
 of the tumor. 
 
 5.-CYSTI0 TUHOBS. 
 
 Vesicular and other cystic tumors, the contents of which 
 are sometimes watery and sometimes glairy, frequently occur 
 about the lids. When of long standing, they are often more or 
 less pedunculated, and either overlap the edge of the lid or ex- 
 tend back into the orbit. They are usually connected with 
 some portion of the conjunctiva, forming, for the most part, 
 small, pinkish, translucent tumors, the walls of which are gen- 
 erally very thin, and but loosely connected with the conjunc- 
 tiva. 
 
CYSTIC TUMORS. 325 
 
 Cysts of the iris are less frequently met with, and are 
 usually the result of some injury to that membrane. They 
 generally spring from the surface of the iris in the form of 
 small vesicles, which may be either translucent or opaque. 
 The contents may be limpid and transparent, sebaceous and 
 soft, or hard and •cartilaginous. In most cases they excite 
 considerable irritation and may even give rise to iritis. 
 
 Orbital cysts also occur, some of which, as above stated, 
 spring from the glandular structures of the conjunctiva, whilst 
 others are developed from the follicles of the lids. The 
 contents of these cysts are of the most varied character, serous, 
 glairy, sanguinous, fatty, etc. Some also contain hair, others 
 hydatids. The hydatids are the echinococci and the cysticerci. 
 The former, varying in size from a pea to a filbert, have been 
 known to exist in such quantities, that when emptied from the 
 cyst they filled a tea cup half full. These tumors generally 
 grow very slowly, and when small are usually attended with 
 but little inconvenience ; but as they increase in size the 
 eyeball gradually becomes more and more protruded, and the 
 sufferings of the patient are often most intense. 
 
 The cysticercus occurs most frequently within the eye. 
 It is occasionally seen in the anterior chamber, but its most 
 frequent seat is in or under the retina. At first it excites 
 severe irritation, but after a while the eye becomes accustomed 
 to its presence, and it may remain for weeks and months 
 without giving rise to any great inconvenience ; sooner or 
 later, however, it sets up violent inflammation, and the eye is 
 finally destroyed by irido-choroiditis. 
 
 Treatment. — Vesicular and other small cystic tumors 
 generally require nothing more than a simple puncture ; but 
 when of a certain size the cyst must be removed or the tumor 
 will be pliable to return. Cysts of the iris will also require 
 excision, together with the portion of membrane to which they 
 are attached, as simply puncturing or lacerating them proves 
 
326 PRACTICE OF MEDICINE. 
 
 unsuccessful. ' It should be remembered, however, that this 
 operation, even when combined with iridectomy, is not entirely- 
 devoid of danger, having in one instance given rise to severe 
 purulent cyclitis. The greatest care should therefore be taken 
 to guard against inflammatory complications, by removing 
 every portion of the cyst. Orbital cysts containing fluid 
 should be emptied of their contents, the operation being 
 repeated as often as may be necessary ; but other forms 
 should, if possible, be dissected out. 
 
 6.-FATTY AND OTHER TUMORS. 
 
 1. Milium. — This is a small white tumor, about the size 
 of the head of a large pin, and is generally seated at or near 
 the edge of the lid. The cyst wall consists of a thin but 
 dense membrane, containing a soft white substance like boiled 
 rice. These tumors usually occur in elderly persons, and 
 occasion little or no inconvenience, unless they happen to be 
 numerous, or appear in clusters. 
 
 2. Moluscum. — This tumor is of the same nature as 
 milium, but larger, and generally seated a short distance from 
 the edge of the lid. It posseses little or no elasticity, 
 retaining for some time any form into which it may be pressed. 
 In this respect it differs sensibly from the 
 
 3. Fatty Tumor. — This is of frequent occurrence about 
 the eyelids, and is firm and elastic to the touch ; it is further 
 characterized by being smooth, of a somewhat lobulated form, 
 and of extremely slow growth. It is occasionally observed 
 on the ocular conjunctiva, especially in the vicinity of the 
 lachrymal gland. In these cases it appears to be due to an 
 hypertrophy of the adipose tissue of the orbit. Sometimes 
 these tumors attain such proportions as to displace the eyeball, 
 and press injuriously upon the lachrymal gland. 
 
N^EVUS MATERNUS. 327 
 
 4. Polypi. — These are small condylomatous elevations, of 
 a pinkish color, attached to the conjunctiva by a distinct 
 pedicle, and generally seated near the semilunar fold They 
 sometimes attain the size of a pea or hazel nut, and protrude 
 between the lids. 
 
 Treatment. — Milia and molusca simply require to be 
 pricked, and their contents squeezed out. In removing fatty 
 tumors, care should be taken to sacrifice as little of the 
 conjunctiva as possible, and to unite the edges of the incision 
 by a fine suture. Polypi should be snipped off with scissors, 
 and the hemorrhage arrested by touching the cut surface 
 with nitrate of silver, which will also be likely to prevent a 
 return of the disease. 
 
 7.-NJEVUS MATERNUS. 
 
 TELANGIECTASIS. 
 
 This affection, the name of which is now restricted to 
 congenital tumors characterized by peculiar and excessive 
 vascularity, is generally met with on the eye-brow and upper 
 lid. It is also occasionally found on the conjunctiva, and 
 very rarely on the iris. These growths are generally divided 
 into an arterial or active, and a venous or passive form ; but 
 this distinction, is quite arbitrary, and we shall find it more 
 convenient to describe them according to the positions they 
 occupy, as cutaneous, subcutaneous, and mixed. The cutan- 
 eous variety varies bqth in depth and extent, appearing in 
 some cases like a mere stain, and in others like a circumscribed 
 mass of blood-vessels. The subcutaneous form, being deeper, 
 is not so well defined, and is either colorless or of a light 
 bluish tint, according to its depth from the surface. When 
 deep, it bears a close resemblance to the common fatty tumor. 
 
328 PRACTICE OF MEDICINE. 
 
 Most naevi may be diminished in size by pressure, the blood- 
 vessels being more or less emptied by it, but as soon as the 
 pressure is removed they refill. Some are firm and distinctly 
 pulsatile to the touch, while others are soft and impart no 
 arterial thrill to the fingers. They all become distended 
 when the patient stoops, screams or struggles, and when 
 superficial they assume at such times a very dark and tense 
 appearance. On account of their vascularity, they also bleed 
 profusely on the slightest injury. 
 
 TREATMENT. — Naevi after reaching a certain size frequently 
 remain almost stationary ; in other cases they slowly diminish ; 
 and sometimes they disappear altogether. Mere stains seldom 
 undergo natural resolution, but the bluish superficial naevus is 
 more apt to disappear spontaneously than the scarlet variety. 
 The process is said to be hastened in some cases by the use of 
 the following remedies : — Calc. c, Carb. v., Cund., Fluor, ac, 
 Lach., Lye, Nux v., Phos., and Thuja. 
 
 If it becomes necessary to interfere surgically, the best 
 plan is to endeavor to procure the obliteration of the naevus, 
 by exciting adhesive inflammation in it. This may be readily 
 accomplished by passing a number of fine silk threads, soaked 
 in a solution of the perchloride or persulphate of iron, across 
 the tumor in different directions, and leaving them in for a 
 week or two. The subcutaneous ligature is a less convenient 
 but very effectual operation. The ligature is applied in 
 different ways, according to the size and situation of the tumor. 
 If large, it is best to divide it into sections, corresponding to 
 the peculiar shape of the tumor, and ligature each portion 
 separately ; but if small, a single thread may suffice. Another 
 useful plan is to break up the substance of the growth 
 subcutaneously, by means of a cataract needle, repeating the 
 operation from time to time, and in the intervals to keep up 
 pressure upon it. But the most eligible method of operating 
 is by electrolysis, inasmuch as it leaves no scar or disfigure- 
 ment, and is not attended with any pain or danger. 
 
DISEASES OF THE EYE. 329 
 
 8.-FIBE0US TUMORS. 
 
 These tumors are met with in the eyelids, conjunctiva and 
 orbit. In the eyelids they form small, hard, circumscribed 
 elevations, which are sometimes painful to the touch. In 
 some cases they assume a cartilaginous or bony character. 
 They are mostly seated in the submucous tissue, and are 
 readily brought into view by everting the lid. 
 
 In the ocular conjunctiva these fibromata take the form of 
 Pinguecula. The latter consists of hypertrophied conjunctival 
 and episcleral tissue, and is generally situated close to the edge 
 of the cornea. It is a small, flat, roundish or triangular body, 
 of a yellowish-white color, and bears a slight resemblance to 
 pterygium, for which it is sometimes mistaken. It does not, 
 as might be inferred from its name and appearance, contain 
 any fat, but is made up chiefly of epitheliel cells and connective 
 tissue. Pinguiculae generally occur in old people, and are 
 probably due to a chronic irritation of the conjunctiva in 
 consequence of external injuries. 
 
 Fibrous tumors of the orbit spring from the periosteum, 
 to which they often adhere by a broad base ; but the more 
 movable ones are usually attached to the edge of the orbit by 
 one or more pedicles. Some of them are hard and smooth, and 
 some are soft and lobulated. The former are generally 
 small, circumscribed, and more or less movable. The latter, 
 which sometimes attain a very great size, extend in some cases 
 deeply into the orbit, and may even involve the bones of the 
 head and face. 
 
 Treatment. — The only successful treatment for fibrous 
 tumors is operative. We are convinced that much valuable 
 time is often lost by practitioners of our school, in vain 
 attempts to disperse such tumors by local applications and 
 medicines. Those attached to the orbit, if capable of being 
 readily extirpated, should be removed early, especially if they 
 
330 PRACTICE OF MEDICINE. 
 
 encroach upon, or are actually within its cavity. No such 
 operation should be undertaken, however, without duly 
 weighing all the circumstances of the case, some of which 
 may render the case exceptional. Thus, the history 
 and situation of a tumor may be such as not to threaten 
 mischief, when its removal would in all probability 
 injure or destroy the sight. In this case, of course, no good 
 surgeon would undertake an operation. On the other hand, 
 if the growth of the tumor gives rise to cerebral symptoms, 
 the surgeon should not hesitate to sacrifice the eyeball, if 
 necessary, in order to remove it, and even incur the risk of 
 exciting considerable inflammation. 
 
 9.-SAHC0MAT0US TUMORS. 
 
 Sarcoma occurs primarily in all parts of the eye and 
 surrounding tissues. It first appears in the form of nodules, 
 which frequently become quite large, and give to the growth a 
 very irregular appearance. It is characterized by a prepon- 
 derance of cellular elements, which vary greatly in form and 
 size, being spindle-shaped, stellate, oblong, circular, etc. 
 Sometimes the cells contain pigment, and then it is called 
 melanotic sarcoma. It is not of a benign character, neither 
 is it so malignant as cancer, but rather between the two, 
 developing first in homologous, and afterwards in heterologous 
 tissues. Its structure is equally diverse, sometimes approaching 
 one type and sometimes another of the connective tissue 
 group, giving it at various times more or less of a fibrous, 
 mucous, gliose, melanotic, medullary, cartilaginous, or bony 
 character. It appears much the most frequently in the 
 choroid, where it sometimes developes rapidly ; but generally 
 its growth is very slow and interrupted, giving rise to symptoms 
 of glaucoma, usually of a chronic character. Sometimes the 
 
GLIOMA RETINA. 33 1 
 
 disease originates in the ciliary body, and when it has become 
 sufficiently developed, makes its appearance in the anterior 
 chamber, in the form of a dark brown tumor; or it may extend 
 backwards in the same manner into the vitreous. It is also 
 frequently found in the orbit, being, according to Virchow, 
 generally developed from the adipose tissue behind the eye. 
 After a time it pushes the eyeball out of the orbit, and 
 appearing beneath the conjunctiva in the form of round, firm 
 protrusions, finally assumes a fungoid character. Or the 
 disease may grow inward, and after reaching the dura mater, 
 invade the cranium. After implicating the neighboring 
 tissues, the disease generally ends in metastasis. 
 
 Sarcoma is less common in childhood than in adult life ; 
 but it frequently developed from warts or maculae in the 
 integuments of the lids, which were either congenital or 
 observed in infancy. These often remain unchanged till old 
 age, when they suddenly become sensitive and painful, and 
 gradually take on the character of sarcomatous tumors. 
 
 Treatment. — The only safety in these cases is in complete 
 extirpation. If the tumor is intra-ocular, the sooner the eye 
 is enucleated after the disease is recognized, the better. 
 
 10 -GLIOMA EETINJE. 
 
 Glioma retinae is the name given by Virchow to the 
 medullary fungus of the retina, heretofore known as enceph- 
 aloid cancer, or fungus haematodes. It is mostly, and perhap? 
 entirely, a disease of childhood ; for while it is not a very 
 uncommon affection, not a single undoubted case of it, 
 according to Hirschberg, has, up to the present time, been 
 observed in persons over twelve years of age. 
 
 SYMPTOMS. — The loss of sight is usually the first symptom 
 that attracts attention. The pupil is then seen to be some- 
 
332 PRACTICE OF MEDICINE. 
 
 what widely dilated, and through it, upon careful examination, 
 may often be discerned a glistening-, yellowish reflection, 
 formerly called the "amaurotic cat's eye." Examined with 
 the ophthalmoscope, we find the affected portion of the retina 
 somewhat mottled, thickened and opaque. As the morbid 
 growth increases and becomes more prominent, it protrudes 
 more and more into the vitreous humor, where it presents the 
 form of a nodulated yellowish-white mass, over which ramify 
 numerous blood-vessels. The latter inosculate freely with 
 each other, and also with those more deeply seated, the growth 
 being characterized by great vascularity. The tumor con- 
 tinuing to enlarge, the lens becomes absorbed, or pushed 
 forward along with the iris towards the anterior portion of the 
 globe, where sooner or later perforation usually takes place, 
 and the morbid growth sprouts forth in the form of a dark-red 
 and easily-bleeding fungus. (Fungus hcematodes). 
 
 Sometimes the glioma appears first in the external layers 
 of the retina, and then it generally soon perforates externally. 
 This condition may be suspected if the movements of 
 the globe are much limited, and the eyeball protruded. 
 When the tumor penetrates deeply into the vitreous 
 humor, the intra-ocular tension increases, and this 
 furnishes a diagnostic sign of great importance. Primary 
 glaucoma being almost entirely a disease of adult life, 
 a marked increase of the intra-ocular tension occurring 
 in young children, should always excite suspicion. As 
 for the differential diagnosis between simple detachment 
 of the retina and that which occurs in glioma, we have only 
 to remember that in the former the intra-ocular tension 
 is often diminished. 
 
 Occasionally the disease, at a certain stage of its progress, 
 is very difficult to distinguish from simple choroiditis; in point 
 of fact, the disease sometimes assumes the character of an 
 irido-choroiditis, with commencing atrophy, the intra-ocular 
 
CARCINOMATOUS TUMORS. 333 
 
 tension being diminished, and the pupil obstructed by lymph. 
 These symptoms are generally due to suppurative choroiditis, 
 but in some rare cases they are said to be caused by suppuration 
 of the cornea. But here the similarity ceases. The atrophy 
 is often accompanied with severe paroxysms of pain, while 
 the eye is perhaps no more sensitive to the touch than usual. 
 At a later period the usual symptoms of glioma again manifest 
 themselves, and the disease progresses in the manner already 
 described. 
 
 That the disease is malignant we think there can be but 
 little doubt. The optic nerve frequently becomes implicated, 
 and in this way the affection may be propagated to the brain, 
 giving rise to secondary glioma or inflammation of that organ. 
 When once the adipose tissue of the orbit becomes implica- 
 ted, the progress of the disease is very rapid. 
 
 TREATMENT. — The only rational treatment for this, as well 
 as every other malignant disease of the eye, is the immediate 
 enucleation of the globe. Cases are on record in which, after 
 the lapse of several years, there was no return of the disease. 
 Care should be taken in performing the operation to excise 
 the optic nerve as far back as possible, in order to include the 
 whole of the diseased structure ; and if the disease is found to 
 have extended to the orbit, it would be well to apply the 
 chloride of zinc paste to the orbital cavity, as recommended 
 under 
 
 11- CARCINOMATOUS TUMORS. 
 
 Carcinoma differs but little in general appearance from 
 sarcoma. According to Virchow, "the disease is recognized 
 by the alveolar formation of its stroma, and the epithelial 
 character of its cellular elements." It may occur in any part of 
 the eye and surrounding tissues, but generally originates extra- 
 ocularly. It is of the most malignant and destructive nature, 
 
334 PRACTICE OF MEDICINE. 
 
 invading and destroying the most heterologous tissues, contam- 
 inating the circulation, and spreading both by assimilation and 
 metastasis. It is also a very painful disease, being 
 usually attended with more or less suffering from the 
 very commencement. It may be divided into three 
 principal forms, namely : (a) the epitheliel, (b) the medullary, 
 and (c) the scirrhus — melanotic cancer being only a variety of 
 of the medullary. 
 
 A.— Epitheliel Cancer. 
 
 This form of cancer, which is always supeiflcial, rarely 
 commences upon the lids or conjunctiva, but spreads to these 
 parts from the skin of the nose, forehead or cheeks, invading 
 most frequently the lower lid, near the inner canthus. It 
 seldom attacks the young, being much more common in those 
 somewhat advanced in life. It generally makes its appearance 
 in the form of small, hard, circumscribed elevations, or 
 tubercles, feeling like knots beneath the skin. These slowly 
 enlarge and increase in number, until by coalescence they 
 assume the form of warts or small thickened crusts. In this 
 condition they may remain for a long time, but sooner or later 
 itching or uneasiness begins to be felt, the surface is rubbed or 
 otherwise irritated, and then ulceration sets in. A thin 
 yellowish discharge oozes from the ulcerated surface, which 
 drys and forms a dark rough crust. The disease now begins 
 to spread in every direction. Sometimes the ulcer becomes 
 temporarily healed over, but it soon re-opens, and the ulceration 
 is renewed. In this way the malady proceeds, irregularly 
 but gradually eating its way along the surface and through 
 the lid, until ultimately it exposes the conjunctiva, and extends 
 perhaps to the orbit. Up to this time the disease is generally 
 attended with but little pain ; but as soon as it attacks the 
 deeper tissues, especially those of the globe, acute pain is felt, 
 
CARCINOMATOUS TUMORS. 335 
 
 resulting partly from exposure of the nerves, and partly from 
 pressure of the tumor upon them. 
 
 A striking peculiarity of epitheliel cancer is the slowness 
 with which it advances. Several years may pass before 
 ulceration sets in, and many more may elapse before it makes 
 any considerable progress, provided the general health of the 
 patient remains good, and the sore is judiciously treated. 
 Ultimately, however, the cancerous cachexia is induced, and 
 then, if not before, the disease advances with the most 
 destructive rapidity. 
 
 B— Medullary and Melanotic Cancer. 
 
 Medullary cancer is distinguished as intra- or extra-ocular, 
 according as it makes its first appearance in the choroid, or on the 
 walls of the orbit. It is easily recognized by its soft consistence, 
 and by the fungous character (f?mgns hcematodes) which it 
 presents after the tumor bursts from the orbit, or is released 
 from pressure by ulceration. When connected with the orbit, 
 the tumor may be closely adherent to the periosteum, or it 
 may be but loosely attached to it. It may increase rapidly in 
 bulk, invade and destroy the neighboring tissues, and extend 
 into the adjoining cavities and along the optic nerve to the 
 brain ; or it may protrude externally, and form luxuriant 
 fungous masses, giving rise to severe pain, and such a profuse 
 discharge and frequent hemorrhage, as to bring the 
 case to a speedy and fatal termination. On making a 
 microscopical examination of the tumor, we discover large 
 areolar spaces, filled with variously shaped cancer cells, similar 
 to those described under the head of sarcoma. Unlike 
 sarcoma, however, the medullary tumor makes a much more 
 rapid progress, leads much earlier to metastatic affections, and 
 is consequently far more apt to return after extirpation. (See 
 Glioma Re tines). 
 
 As melanotic cancer is but a variety of the medullary, and 
 
336 PRACTICE OF MEDICINE. 
 
 differs from it chiefly in containing a greater or less amount of 
 pigment in its cells, it is unnecessary to describe it in detail. 
 The amount of pigment may be so great as to give the tumor 
 a deep sooty-black color, streaked here and there with various 
 shades of brown or gray. It is the most dangerous variety of 
 cancer, and exceedingly prone to recur within a very short 
 time after extirpation. 
 
 C— Soirrhus Cancer. 
 
 Scirrhus is so called from the stony hardness which 
 characterizes it in whatever tissue of the body it may be found. 
 It seldom appears before the middle period of life, and generally 
 developes very slowly. Its occurrence in the orbit is 
 probably due to some injury or prior inflammation ; at least it 
 has been seen to follow a blow or other injury, but more 
 commonly it is preceded by repeated attacks of inflammation, 
 generally of an intractable nature. 
 
 TREATMENT OF CANCEROUS TUMORS. 
 
 The only proper treatment of any form of cancerous 
 tumor of the eye, consists in prompt eneucleation of the 
 eyeball, and the complete extirpation of the morbid growth. 
 In order to destroy any portions of the tumor which cannot be 
 reached with the knife, it is recommended to dress the raw 
 surface with the chloride of zinc paste, spread upon strips of 
 lint. The paste may be prepared by rubbing up one part 
 by weight of the chloride of zinc with four parts of flour, and 
 adding sufficient tincture of Conium to make a paste of the 
 proper consistency. 
 
DISEASES OF THE EYE. 33? 
 
 DIV. IV.— CATARACT. 
 
 Cataract is a partial or general opacity of the crystalline 
 lens, of its capsule, or of both the lens and capsule combined. 
 The first is called lenticular, the second, capsular, and 
 the third, capsulo-lenticular cataract. The term false cataract 
 was applied by the old authors to deposits of lymph in the 
 pupil which have become permanent. This condition, which 
 is almost always associated with lenticular cataract, has already 
 been sufficiently considered. (See Iritis) 
 
 Lenticular cataracts are divided into two general classes, 
 namely, (i) the cortical, or soft cataract; and (2) the nuclear, 
 or hard cataract. This classification, though not strictly 
 correct, is most convenient for obtaining a general notion of 
 the subject; while the exceptional forms will be best under- 
 stood by considering them in connection with those to which 
 they are most nearly related. 
 
 1 -SOFT CATARACT. 
 
 CORTICAL OR CONGENITAL CATARACT. 
 
 The characteristic feature of soft cataract is, that, although 
 the whole lens may be opaque, it contains no hard nucleus. 
 It occurs in subjects under thirty-five or forty years of age, 
 and is the most common form of congenital cataract. It is 
 divided into two principal varieties, the lamellar, and the 
 cortical. 
 
 A.— Lamellar Cataract. 
 
 Lamellar cataract is usually congenital, but as it interferes 
 very little with vision, it may long remain undetected. It is 
 distinguished by the fact that the opacity, which is generally 
 
338 practice of Medicine. 
 
 of a delicate greyish, or bluish-grey tinge, is partial, central 
 and uniform, being surrounded by a transparent or pellucid 
 border, and not increasing in density towards the pole, as 
 would be the case if the nucleus was affected. Examined by 
 the ophthalmoscope, when the light falls perpendicularly upon 
 the cataract, the opacity appears as a dark, sharply-bounded, 
 circular spot, through which the fundus presents a uniform 
 reddish-brown appearance, and beyond the edges of which the 
 details of the retina may be distinctly seen. But the diagnosis 
 is best made out by oblique illumination. The cataractous 
 portion of the lens then appears surrounded by a dark black 
 ring, caused by the heads of the ciliary processes shining 
 through the transparent margin of the lens. But this uniform 
 and sharply-bounded central opacity continues only so long as 
 the cataract is stationary. When progressive, the superficial 
 layers are affected with a cloudy or striated opacity, giving it 
 more or less of a radiated appearance, the striae extending 
 from the central portion into the cortex, and marked here 
 and there by various minute inequalities. The smaller the 
 opaque specks, and the fewer and more delicate the streaks, 
 the slower is supposed to be the progress of the cataract, and 
 vice versa. 
 
 A fair degree of vision is usually enjoyed by patients 
 affected with lamellar cataract ; but the sight is always greatly 
 improved by dilating the pupil with Atropine, in consequence of 
 bringing into use the peripheral or unaffected portion of the 
 lens. Thus, patients who, previous to dilatation of the pupil, 
 were barely able to make out the heaviest type, have after- 
 wards been able to read with ease the finest print. 
 
 B.— Cortical Cataract. 
 
 This "form of cataract may commence in any portion of 
 the cortical substance of the lens. Hence it may invade both 
 surfaces of the lens uniformly ; or it may commence at the 
 
CORTICAL CATARACT. 339 
 
 middle, or, which is more common, at the circumference, in the 
 form of small, greyish-white streaks, or radii, running towards 
 the centre, the intermediate lens substance being at first 
 transparent, or but slightly opaque. Shortly, however, a 
 general opacity sets in, which may, or may not, render the 
 striae invisible. Sometimes the stellate figure may be observed 
 in both the anterior and posterior cortical portion of the lens, 
 the remainder being transparent, or slightly dotted with opaque 
 points. This condition is easily recognized by lateral 
 illumination, the anterior streaks appearing just behind the 
 pupil, and the posterior further back, and having a concave or 
 meridional appearance. These appearances are especially 
 marked through the opthalmoscope, the spots and stripes 
 being projected in dark, well-defined opacities on the red 
 surface of the fundus. Unlike lamellar cataract, its progress 
 is usually rapid, particularly in children, in whom it often 
 matures in the course of a few weeks or months. At a later 
 period its rate of increase may be comparatively slow, 
 especially if the opacities are small and scattered. 
 
 Total or mature cortical cataracts are of a grey or bluish- 
 white tint, the color being most intense at the centre, in 
 consequence of the increased density at that point. The 
 stellate rays are broad, white, and sometimes slightly glistening. 
 If the cataract developes quickly, the lens swells so as to push 
 forward the pupillary margin of the iris, which is frequently 
 more or less dilated and sluggish. Viewed obliquely, we 
 discover that the more superficial layers of the cortical portion 
 of the lens are less dense than the central, proving that, 
 although soft, this is not a fluid cataract. In the latter the 
 white opacity is equally as dense at the periphery as at the 
 centre. It is of a milky-white or greyish color, devoid of 
 striae, and extends quite up to the capsule, the interior of 
 which is sometimes dotted with minute white opacities. 
 
 The consistency of cortical cataract, which is always soft, 
 
3 40 PRACTICE OF MKDICINE. 
 
 is in infancy and childhood almost fluid. It increases in 
 density up to the age of thirty or thirty-five, when the nucleus 
 loses to a greater or less extent its soft, pulpy character, and 
 becomes somewhat hard. In the course of time, secondary 
 changes may set in, disintegration and absorption of the 
 affected portions of the lens taking place, causing the latter to 
 contract, and the capsule to become more or less wrinkled. 
 After the more fluid parts are absorbed, the shriveled capsube 
 generally contains only broken-down lens substance, in the 
 form of small, chalky-white chips In children, the process of 
 absorption may continue until nearly the whole of the over- 
 ripe cataract disappears, leaving only a small, hard, chalky 
 layer or disc, which, from its resemblance to a dried seed-shell, 
 is called by the old writers "siliquose" cataract, (cataracta 
 siliqaata). After the age of twenty-five or thirty, the nucleus 
 becomes sufficiently hard to resist these secondary changes, 
 and the softening is chiefly confined to the cortical substance. 
 As soon as the latter becomes fluid, the hard nucleus sinks 
 
 down in it, and thus is formed the so-called "Morgagnian" 
 
 i 
 cataract. 
 
 2.-HABD CATABACT. 
 
 NUCLEAR OR SENILE CATARACT. 
 
 As the name indicates, this form of cataract is characterized 
 by the presence of a comparatively hard nucleus. It is 
 appropriately called "senile," as the change that produces it 
 never begins to take place until after the age of from thirty to 
 thirty-five, when the nuclear portion of the lens becomes 
 harder, and assumes a yellowish tint. The consolidation of 
 the nucleus, which takes place gradually, is at first a purely 
 physiological process, and may exist for years without any 
 deterioration of sight. It is only when vision becomes 
 
HARD CATARACT. 341 
 
 perceptibly impaired in consequence of a certain increased 
 density and opacity of the lens, that the process should be 
 regarded as pathological, although the distinction between the 
 two forms of hardness and opacity is merely one of degree. 
 When this stage is reached, the nucleus exhibits a more or less 
 greyish-yellow or brownish-yellow color, quite distinct in 
 appearance from the cortical portion of the lens, which at first 
 retains its normal transparency, except in the immediate 
 vicinity of the nucleus, where perhaps a so-called "arcus senilis 
 of the lens" occurs. Subsequently the cortical portion also 
 becomes affected, constituting what is called "mixed" cataract. 
 
 If we view nuclear cataract by lateral illumination, it will 
 appear as a yellowish, or more rarely as a brownish or black 
 opacity, somewhat distant from the pupil, the latter, owing to 
 the transparency of the cortical substance, often throwing a 
 shadow upon the surface of the opacity. Brown and "black" 
 cataracts are due to the absorption of hematine from the 
 aqueous humor. These forms are liable to be overlooked, on 
 account of the dark color of the pupil, unless the examination 
 is made with the ophthalmoscope or by lateral illumination. 
 
 Hard cataract at its commencement presents a stellate 
 appearance very similar to that of the cortical variety already 
 described ; the opaque streaks being arranged in the form of 
 radii, with clear portions of the lens between them. The 
 opacity generally begins at the periphery, and may be confined 
 to either surface of the lens, or may embrace both. The 
 central portion, as well as the spaces between the rays, may 
 remain for some time sufficiently transparent for the details of 
 the fundus to be seen ; but the opacity gradually extends 
 towards the centre of the lens, the intermediate spaces become 
 more and more clouded, and finally the entire lens becomes 
 affected. 
 
 Senile cataract occurs most frequently after the age of 
 fifty, and is apt, sooner or later, to affect both eyes. Its 
 
342 PRACTICE OF MEDICINE. 
 
 progress is sometimes slow, at others rapid. In its earlier 
 stages, it often remains for a long time almost stationary, and 
 then advances with great rapidity, reaching maturity perhaps 
 within a few weeks. It is generally more rapid the larger, 
 broader, and more numerous are the opaque spots and 
 stripes. Relatively, its progress is far more rapid in the 
 cortical substance than in the nucleus. 
 
 The secondary changes that sometimes occur in senile 
 cataract, are similar to those that take place in the cortical 
 variety, the chief difference being that the retrograde metamor- 
 phosis is confined to the cortex. Partial absorption takes 
 place, and scattered chalk-like spots are formed, usually at the 
 expense of the cortical substance, which diminishes somewhat 
 the thickness of the cataract. These collect into small masses, 
 and become attached to the inner surface of the capsule, which 
 sometimes appears like a thin veil streched over the hardened 
 nucleus and strewn with white granules. The softening of 
 the cortex may give rise to the so-called "Morgagnian" cataract, 
 as mentioned under the previous head. 
 
 The impairment of vision is frequently much less than the 
 degree of opacity would lead us to suspect. This arises in 
 some cases from the cloudiness being confined to the portion of 
 lens usually covered by the iris. The opacity being the same, 
 the clearness depends upon the nearness of the object, the 
 degree to which it is illuminated, and the amount of diffuse 
 light that is allowed to enter the eye. Hence, if the opacity 
 is chiefly limited to the centre of the lens, the patient will see 
 best when the diffuse light is cut off, and the pupil dilated ; 
 but if confined to the margin, the reverse will occur ; he will 
 see best in a bright light, and with a contracted pupil. 
 
DISEASES OF THE EYE. 343 
 
 3.-CAPSULAE CATARACT. 
 
 We have already alluded to the fact that; during the 
 secondary changes which take place in lenticular cataract, the 
 fluid and fatty elements become absorbed, and the harder 
 portions become attached to the inner side of the capsule, thus 
 rendering the latter apparently more or less opaque. But 
 since these white, chalky appearances are not situated in the 
 capsule itself, it is evident that the term "capsular" cataract 
 is not, strictly speaking, correct. This does not, it is true, 
 disprove the possibility of the capsule becoming cloudy, but so 
 far it has not been observed. Indeed, it is almost certain that 
 capsular cataract never occurs except as a complication of a 
 previous opacity of the lens ; the deposit being intra-capsular, 
 and depending on the condition of the lens substance. In 
 making this statement we do not lose sight of the fact, that, in 
 certain cases, the hyaline membrane undergoes a sort of 
 hypertrophy, or is apparently thickened by a deposit of trans- 
 parent layers, which may subsequently degenerate and become 
 opaque ; but as a general rule the capsule itself retains its 
 transparency. {Stellwag.) 
 
 By capsular cataract, therefore, we understand an opacity 
 of the capsule, generally due to opaque deposits upon its inner 
 surface, consisting mainly of chalky incrustations, or fragments 
 of cholesterine crystals, the capsule being somewhat wrinkled, 
 and perhaps thinned. The opacity is seated chiefly behind 
 the pupil, sometimes on the posterior half, but generally on 
 both halves of the capsule. Sometimes it consists in a simple 
 thickening and cloudiness of the capsule, dotted here and there 
 with small, chalky masses ; but in most cases the chalky 
 opacities predominate, and form a more or less complete 
 incrustation on the inner wall of the capsule. 
 
 "Central" capsular cataract is sometimes congenital, but in 
 
344 Practice of medicine, 
 
 most cases it is the result of an iritis, or of a perforating ulcer 
 of the cornea. When the latter is situated near the centre of 
 the cornea, the lymph effused in the ulcer comes in contact 
 with the corresponding portion of the capsule, in consequence 
 of the lens falling forward upon the cornea during the escape 
 of the aqueous humor, and a portion of the lymph adheres to 
 the capsule after the lens recedes from the cornea. This 
 interferes with the nutrition of the subjacent tissues, and the 
 latter become more or less cloudy and opaque. These 
 finally undergo the usual secondary changes, shrinking greatly, 
 and forming a cartilaginous, or more frequently a chalky 
 nodule, attached to the inner surface of the anterior capsule, and 
 imbedded, so to speak, in the surface of the lens. Sometimes 
 the cataractous nodule, instead of being rounded, is of an 
 irregular pyramidal shape, the apex projecting above the 
 surface of the capsule, and the base slightly imbedded in the 
 cortical portion of the lens. This form is called "pyramidal" 
 cataract. 
 
 Capsular opacities occurring at the posterior pole of the 
 lens, and hence termed "posterior polar" cataract, are some- 
 times caused by changes in the contiguous cortical substance 
 of the crystalline, or by deposits upon the internal surface of 
 the capsule, which take place in the manner already described. 
 But posterior polar cataract may also be due to inflammatory 
 or nutritive changes in the anterior portion of the vitreous 
 humor. These are distinguished by their smooth and shining 
 aspect, whereas the former are usually rough and granular. 
 They are generally dependent upon chronic inflammation of 
 the deeper tissues of the eye, being frequently met with after 
 certain forms of choroiditis and retinitis. 
 
DISEASES OF THE EYE. 345 
 
 4 -TRAUMATIC CATARACT, 
 
 We shall devote this section chiefly to the etiology of 
 cataract, beginning with the traumatic, Of the numerous 
 causes that give rise to its various forms, wounds and injuries 
 of the lens and its appendages are among the most important. 
 
 The opacity generally commences within a few hours after 
 the receipt of the injury. If the latter is slight, such for 
 example as a very fine puncture that does not penetrate 
 deeply, it may cause only a superficial cloudiness in the vicinity 
 of the wound, which may disappear, and leave no permanent 
 opacity ; but more frequently, the parts surrounding the wound 
 swell up, and if much aqueous humor is admitted, the whole 
 lens may enlarge, causing the wound in the capsule to gape ; 
 and if under these circumstances a portion of the cataractous 
 substance protrudes and becomes absorbed, the edges of the 
 wound may retract, so as to become cemented together by the 
 disintegrated remains of the cataract, and thus give rise to a 
 secondary traumatic cataract. Moreover, the swelling of the 
 lens may cause it to press injuriously upon the ciliary body 
 and iris, and thus lead, perhaps, to irido-cyclitis ; and if the 
 iris is badly lacerated, or if it becomes attached to the corneal 
 wound, it may even excite a general irido-choroiditis, with its 
 attendant consequences. The danger of secondary inflamma- 
 tion is considerably less in children than in adults, in conse- 
 quence of absorption being more rapid and the injurious 
 influences of shorter duration. But no such differences exist 
 in cases where the injury was caused by a foreign body, such 
 as a bit of percussion cap, which still remains in the eye. 
 Here the danger of destructive inflammation is always very 
 great. In such cases the surgeon should not fail to keep a 
 careful watch over the eye, and promptly adopt such measures 
 for its safety, and for that of its companion, as the exigencies 
 
34^ PRACTICE OF MEDICINE. 
 
 of the case may require. See Glaucoma, Sympathetic 
 Ophthalmia, etc. 
 
 Traumatic cataract may also result from a blow or fall, 
 which may or may not rupture the capsule of the lens, or 
 destroy the continuity of the ciliary processes. If the 
 rupture is partial or incomplete, it may escape detection for 
 years. A careful examination, however, will generally result 
 in discovering the mobility, oblique position, or sinking of the 
 lens, the tremulousness of the iris, etc. If the lens has become 
 completely dislocated, it may be forced into the anterior 
 chamber, between the iris and cornea, where, inclosed in its 
 capsule, it may remain for years without exciting any particular 
 inconvenience, though this is not generally the case ; or it may 
 be driven into the vitreous, where severe inflammation of the 
 internal tunics quickly occurs. Spontaneous and congenital 
 dislocations also occur ; and although the luxated lens may 
 remain transparent for years, it finally becomes cataractous. 
 
 Cataract has also been caused by entozoa perforating the 
 capsule and entering the lens. The monostoma lentis, the 
 filaria and distoma oculi humani, and the cystercercus, have all 
 been found in the crystalline lens. 
 
 Raphania, or ergotism, is an occasional cause of cataract. 
 The opacity developes slowly ; and as it generally affects the 
 young, the cataract is usually soft. The same is true of 
 diabetes, which is a very common cause of cataract. 
 
 Finally, while it most frequently results from the faulty 
 nutrition incident to old age, cataract is often both hereditary 
 and congenital, (cataracta adnata). The immediate cause in 
 these cases according to Stellwag, is supposed to be, "a faulty 
 development of the lens, which prevents the elements from 
 long maintaining themselves at the height of evolution, and 
 causes their premature destruction ; a proceeding that is 
 analogous to the early fall of the hair and decay of the teeth." 
 
DISEASES OF THE EYE. 347 
 
 TREATMENT OF CATARACT. 
 
 Whilst we are free to admit that the vast majority of 
 cataracts, especially the hard, can only be removed by 
 operative procedures, we see no reason to change the opinion 
 we have already expressed, namely, "that incipient cataract 
 has in some instances unquestionably yielded to homoeopathic 
 medication."* Even Stellwag, looking at the subject from the 
 Old School standpoint, says that "medical treatment may be 
 of service in so far as it is suited to remove direct or indirect 
 causes of cataract"; and adds, "it can scarcely be denied, that 
 with the removal of the cause, the development of the cataract 
 may be easily impeded, and its progress restricted. But if 
 this succeeds," he says, "it is evidently possible that the already 
 cloudy portion may be caused to disappear by regressive 
 metamorphosis and absorption, and a relative cure thus brought 
 about." *f- He also admits that "several creditable authors," 
 meaning Tavigno, Arlt, Faye, Himly, and others, "say they 
 have seen existing cataractous opacities clear up under the 
 systematic use of mercury, after frictions of iodide of potassium 
 ointment about the eyes, after the internal and external use of 
 Phosphorus, etc., etc." * Such admissions, coming as they do 
 from such high authority in the old school, if they do not serve 
 to convince, ought at least to render less positive the opinions 
 of those of our own school who not only still cling to the old 
 notion of the incurability of cataract, but who even claim it to 
 be impossible, under any circumstances, to cure — what ? senile 
 Cataract ? no, but even "incipient" cataract, by therapeutic 
 means. -|* Besides, it cannot be denied that a large 
 number of such cases are to be found in our literature, and 
 that some of them are vouched for by several of our most 
 
 *See Preliminary Observations. 
 
 t u Treat. on Dis. of the Eye," Fourth Am. Ed., 1873, p. 624. 
 
 Loc. cit. 
 
 +See ' Medical Advance," vol. iv, p. 249. 
 
348 PRACTICE OF MEDICINE. 
 
 distinguished authors, including such names as Kafka, Quadry, 
 Kirsch, Lilienthal, and others of equal note. We are, 
 therefore compelled to admit that, under some circumstances, 
 cataract is curable, or else of impeaching the integrity and skill 
 of some of the most noted and reliable authorities of both 
 the allopathic and homoeopathic schools of medicine.* 
 
 But in order to succeed by medical treatment alone, it is 
 requisite that the cataract should be of a favorable character, 
 that the remedy should be rightly selected, and that its 
 administration should be neither irregular nor transient. No 
 one would expect to effect a cure by internal treatment after 
 degeneration of the lens fibres had occurred ; nor, supposing 
 the case to be a proper one, and the remedy to be rightly 
 selected, would he look for a permanent and radical change 
 under several months. In all ordinary cases, therefore, we 
 shall be obliged to resort to operative measures ; but in 
 complicated cases, or those attended by circumstances contra- 
 indicating an operation, which are by no means rare, we should 
 give the patient the benefit of our improved system of practice, 
 and not, from any preconceived notions of its inefficiency, 
 deprive him perhaps of the only possible means of recovery. 
 Our chief difficulty will consist in selecting the proper remedy. 
 Aside from the pathological condition of the lens, we shall be 
 obliged to fall back upon the symptoms arising from complica- 
 tions, if any, or from the state of the patients health, especially 
 as regards any abnormal action of the heart, kidneys, or uterus, 
 or any other derangement which may in any wise affect either 
 the circulation or nutrition of the organ of vision. In the 
 absence of any such indications, we shall be compelled to 
 address our remedies to the pathological condition itself, and 
 for this we have no other guide than experience. The 
 
 *See a very able paper on this subject by Prof. Gilchrist, in the thirteenth volume of 
 the A merican Observer, p. 449, et seq. 
 
OPERATIONS FOR CATARACT. 349 
 
 remedies which have hitherto been employed with favorable 
 results, and which deserve special attention, are the following ; 
 — Amm. c, Bary. c, Calc. c, Cann. s., Caust, Chim. u., Graph., 
 Iod., Kali iod., Lyco., Magn. c, Merc, Phos., Physostig., Sec. 
 c, Sep., SiL, Sulph. 
 
 OPERATIONS FOR CATARACT. 
 
 Before proceeding to describe the various methods now 
 practiced for the removal of cataract by operation, we shall 
 briefly point out some of the principal circumstances and 
 conditions which may render it necessary or advisable 
 to either defer the operation, or abandon it altogether. 
 
 I. The most favorable cataract for operation is one that 
 has just reached maturity ; that is, the cataract is ripe without 
 being over-ripe. These terms are altogether relative. A cat- 
 aract is ripe for operation when the connection between the 
 cortex and nucleus of the lens is stronger or more intimate 
 than it is between the cortical substance and capsule. For, if 
 only the external layers of the lens are in a soft or fluid con- 
 dition, there can be no difficulty in removing the nucleus. 
 Nor can there be any great danger incurred, even if the cortical 
 layer is of normal consistency, provided the nucleus has ac- 
 quired such a degree of density as to readily prevent its sepa- 
 ration from the cortex, for then the latter may be safely de- 
 tached from the capsule. But if the superficial layers, without 
 being abnormally hard, have lost their transparency, and have 
 become intimately attached to the capsule, their separation can 
 only be effected by violent, and therefore dangerous means. 
 Hence such cataracts are said to be unripe for operation. For, 
 if any portion of the cortex remains in the capsule, it not only 
 swells up and irritates the iris, but is liable to proliferate, giv- 
 ing rise to a secondary cataract, if not to destructive inflamma- 
 tion of the eye. 
 
350 PRACTICE OF MEDICINE. 
 
 But a cataract may be over ripe ; that is, the lens may- 
 have undergone such retrogressive changes that the cortical 
 substance is either broken down into a creamy or chalky fluid 
 or pulp, filled with minute sand-like grains, or transformed to a 
 dry, cretaceous substance, portions of which are liable to re- 
 main in the eye, and thus render the operation extremely dan- 
 gerous. 
 
 2. Authorities differ as to the propriety of operating in 
 monocular cataract. All agree, however, that the operation 
 should not be undertaken unless a favorable result is almost 
 certain. The advantages, in case of success, are, first, the im- 
 provement in the personal appearance of the patient ; second, 
 the enlargement of the field of vision ; and, third, the preser- 
 vation of vision in case the other eye becomes cataractous. 
 On the other hand, in case of failure, if the inflammation ex- 
 cited by the operation should continue for a long period, or 
 until the other eye has become affected, the patient would be 
 deprived during this period of any service from the sound eye ; 
 there is also the danger of the latter becoming sympathetically 
 inflamed. 
 
 3. Surgeons also differ as to whether, in binocular cata- 
 ract, only one eye at a time should be operated on, or both at 
 once. Our practice has been to operate on one eye at a time, 
 and not to touch the other until the first has recovered ; thus 
 lessening the danger of inflammation, diminishing the shock to 
 the system, avoiding the risk of any sympathetic influence of 
 one eye upon the other, and furnishing an opportunity to dis- 
 cover any constitutional peculiarity or unfavorable tendency, a 
 knowledge of which would be of service in the subsequent 
 management of the case. Of course, if only one cataract is 
 ripe, there is no occasion to wait for the other to mature ; but, 
 if circumstances are favorable, we should promptly operate 
 upon the former, so as to enable the patient to follow his usual 
 avocations whilst the other is maturing. 
 
OPERATIONS FOR CATARACT. 351 
 
 4. It is highly important not to operate unless the eye is 
 in an otherwise healthy condition. The chief exception to this 
 rule is where an inflammation is kept up by a swollen or dislo- 
 cated lens, and then the urgency will depend upon the charac- 
 ter of the inflammation. Nor would it be safe to operate on 
 an eye that had recently been in a state of inflammation, 
 though chronic inflammation of the surrounding parts some- 
 times forms an exception. 
 
 5. It is also important that the state of the patient's 
 health should be such as to favor an operation, or at least such 
 as not to endanger the result. Hence the various cachexia, 
 such as scrofula, tuberculosis, syphilis, etc., as well as any other 
 condition, whether physical or mental, which greatly depresses 
 the vital powers, is to be regarded as endangering, and, to a 
 corresponding extent, contra-indicating an operation. It is es- 
 pecially important to determine whether the patient is suffering 
 from diabetes, as this is a very frequent cause of cataract, and 
 the lens does not generally become affected until late in the 
 disease, when the health is seriously impaired. If diabetes is 
 found to exist, we should be careful to ascertain whether there 
 is any co- existing affection of the retina or optic nerve, as this 
 would render the prognosis very unfavorable. 
 
 6. The season of the year is of but little consequence, 
 provided we avoid thermometrical extremes, and these chiefly 
 on account of their interfering with the comfort or exercise of 
 the pat'ent. Thus, in very hot weather the patient is apt to be 
 restless, and confinement in bed is much more difficult ; be- 
 sides, wounds rarely heal as readily in July and August as they 
 do in cooler months. On the other hand, very cold weather is 
 not only unfavorable for regular exercise prior to the operation, 
 but, by confining the patient to his room longer than is neces- 
 sary, often greatly protracts convalescence. 
 
352 
 
 PRACTICE OF MEDICINE. 
 
 1.-DISCISSI0N. 
 
 DIVISION OR SOLUTION OF CATARACT. 
 
 This operation is indicated in the cortical cataract of child- 
 hood, in certain forms of lamellar cataract, and in opacities of 
 the posterior capsule, especially such as result from linear or 
 flap extraction. 
 
 The operation consists in simply dividing or lacerating the 
 anterior capsule with a fine needle, so as to break up the cata- 
 ract and facilitate its absorption in the aqueous and vitreous 
 humors. It may be performed either through the cornea (kerat- 
 onyxis) or through the sclerotica (sclerotonyxis). The latter 
 is generally done with a Beer's, or spear-pointed cataract needle. 
 (PI. I., Fig. 10) ; but the former requires a round stop-needle — 
 that is, one the diameter of whose shaft gradually increases as 
 it recedes from the point, in order to prevent the escape of the 
 aqueous humor. 
 
 If the operation by scleroto- 
 nyxis is selected (Fig. 14, a.), 
 after dilating the pupil with 
 Atropine, separating the lids 
 by a stop-speculum (PI. IL, Fig. 
 33), or by the fingers of an as- 
 sistant, who also steadies the 
 globe with a double hook (PI. 
 I., Fig. 6), or, what is better, a 
 pair of fixing forceps (PL IL, 
 Figs. 36, 37), fastened to the 
 lower part of the ocular con- 
 junctiva, unless the eye can be 
 fully controlled by the fingers, the operator enters the needle 
 perpendicularly on the temporal side of the sclera, about a line 
 and a half behind the border of the cornea, and the same dis- 
 
 DISCISSION. 
 
discission. 353 
 
 tance below the horizontal diameter of the eye, the cutting 
 edges of the needle being directed antero-posteriorly, in order 
 to lessen, as much as possible, the danger of wounding any of 
 the larger vessels of the choroid. The point of the needle is 
 then pushed forward, with its side facing the cornea, through 
 the periphery of the lens into the anterior chamber, as far as 
 the upper and inner margin of the pupil. (See Fig. 14). Then, 
 in order to tear away as large a piece of the anterior capsule 
 as possible, and force it into the vitreous humor, where it will 
 create the least amount of irritation while being absorbed, the 
 operator lays the flat side of the needle directly over the center 
 of the capsule, and presses it slowly backwards towards the 
 vitreous. He then brings the needle back into the anterior 
 chamber, in order to tear away and break up so much of the 
 remaining portions of the capsule and lens as may be deemed 
 advisable. In infants and young children, in whom the lens is 
 very quickly absorbed, the capsule cannot be too freely divided ; 
 but in adults this is not the case, and in order not to cause too 
 great a swelling of the lens, or the admission of too many frag- 
 ments into the anterior chamber, either of which may give rise 
 to severe iritis or irido-cyclitis, it is best not to lacerate the 
 capsule too freely at one time, but to repeat the operation at 
 intervals of a few weeks, or whenever the process of absorption 
 requires to be hastened. 
 
 The operation by keratonyxis (Fig. 14, d) is performed by 
 passing the round stop-needle (represented in the cut), instead 
 of Beer's, somewhat obliquely through the middle of the upper 
 or lower outer quadrant of the cornea, in such a manner as to 
 avoid touching the margin of the iris during the division of the 
 lens. Care should be taken not to make the track of the wound 
 too long by entering the cornea too obliquely, as then the mo- 
 tion of the needle in breaking up the cataract would strain and 
 bruise the tissue of the cornea, and probably lead to more or 
 
 less corneal opacity. The extent to which the laceration and 
 
 45 
 
354 PRACTICE Of MEDICINE* 
 
 ■ -m 
 
 comminution of the capsule and lens should be Carried, will 
 depend chiefly upon the age of the patient. Thus, in infants 
 and young children, where, as above intimated, one operation 
 may be made to suffice, it should be much more extensive than 
 in adults, in whom, for reasons already stated, it would be safer 
 to repeat it. 
 
 Very little after-treatment is generally required. The pa- 
 tient should remain in a moderately darkened room for a day 
 or two, with the eyes lightly bandaged, care being taken to 
 keep the iris well out of the way of the lens by the instillation 
 of Atropine. If the lens should swell greatly, so as to cause 
 much irritation, and especially if symptoms of severe inflam- 
 mation should set in, the cataract should be immediately re- 
 moved by linear extraction. If this is rendered difficult or 
 hazardous, in consequence of any considerable portion of the 
 lens substance having fallen into the anterior chamber, or for 
 any other reason, it will be best to combine an iridectomy with 
 it, especially if the inflammation has already given rise to an 
 increase of intra-ocular tension, or impairment of vision. 
 
 2.-DEPRESSI0N. 
 
 RECLINATION OR COUCHING. 
 
 This operation, once so common, has deservedly fallen into 
 very general disrepute, and ought perhaps to be entirely aban- 
 doned. The danger lies in the depressed lens ultimately com- 
 ing in contact with the choroid, and exciting a destructive irido- 
 choroiditis. Stellwag, however, considers the operation "still 
 applicable in cases of a very large sclerosed nucleus, and pro- 
 portionately thin but tough cortex." 
 
 Depression may be performed with a curved Scarpa needle 
 (PI. I., Figs. 7, 8) or a Pancoast needle (Fig. 9). The prelimi- 
 
DEPRESSION. 355 
 
 nary steps of the operation are the same as for discission (which 
 see). The operator, holding the needle as a pen, with the con- 
 vexity upwards, introduces its point exactly in the transverse 
 diameter of the globe, and one and a half or two lines behind 
 the cornea. The point is first directed inwards toward the 
 center of the vitreous, but as it is carried forward it is made to 
 appear directly behind the pupil, and in front of the anterior 
 capsule. The needle is then gently pressed backwards against 
 the cataract, so that the lens may become loosened from the 
 zonula, and afterwards, by a half-circular turn, raised above the 
 lens, with its convexity upwards. The lens is then pressed 
 backwards and downwards out of the line of vision, the needle 
 gently rotated to disengage it from the lens, and then lifted a 
 little to see if the lens is inclined to rise with it ; if not, the 
 operation is finished, and the needle may be withdrawn. But 
 if the lens should rise, it must be more completely separated 
 from the zonula, or, if the operator piefers, he may rupture the 
 posterior capsule with the needle, after which the lens should be 
 again depressed. 
 
 Reclination — This is a modification of depression, in which 
 the lens, instead of being pushed downwards in a straight direc- 
 tion, is turned on its axis, so as to lie horizontally in the vitre- 
 ous humor, below the pupil. As it possesses no material advan- 
 tages over the operation just described, it is unnecessary to 
 dwell upon it. 
 
 The after-treatment for depression is the same as for flap 
 extraction (which see). 
 
356 
 
 PRACTICE OF MEDICINE. 
 
 3 -LINEAR EXTRACTION. 
 
 This operation, which is indicated in both congenital and 
 traumatic forms of cataract, when the lens substance is fluid or 
 pulpy, is now employed for the immediate removal of the 
 latter through a small linear incision. It may also be per- 
 formed a few days after the ordinary operation of discission, 
 when the lens has become softened and swollen, instead of 
 leaving it, or its fragments, to be slowly absorbed by the 
 aqueous humor. It is also suited for the removal of siliculose 
 and other forms of regressive and secondary cataracts, 
 in which the capsule is greatly shrunken, and contains but a 
 small portion of degenerated lens substance. 
 
 If the capsule is entire, the operation is performed by first 
 dividing the anterior capsule and lens by a very fine curved 
 needle, (PL I , Figs. 8, 9), passed through the temporal side 
 of the cornea, near its margin, without evacuating the aqueous 
 humor. This puncture is then enlarged in a perpendicular 
 direction, to the extent of about two lines, by a lance-shaped 
 knife, or one similar to Fig. 13. The cataract, if fluid, will 
 now escape from the opening ; but if pulpy it will have to be 
 assisted by the curette, or Daviel's spoon. (PL I., Fig. 31.) 
 The operator first presses the spoon against the posterior lip 
 
 of the incision, so as to cause 
 it to gap, at the same time 
 gently pressing the opposite 
 part of the globe with his 
 finger ; and if this does not 
 succeed in causing the lens 
 matter to escape, he endeav- 
 ors to effect its dislodgement 
 by a circular motion of the 
 ends of his fingers upon the 
 lids ; but if this also fails, he 
 
 Fig. 15. 
 
 LINEAR EXTRACTION. 
 
SUCTION OPERATION. 357 
 
 carefully introduces the spoon into the wound, and scoops out 
 any remaining portion of the lens substance. (See Fig. 15.) 
 If any portions of opaque capsule still remain, they may be 
 removed by means of the canula forceps, (PI. I, Fig. 3), or by 
 one of the iris hooks, (Figs. 4, 5). Siliculose and other 
 forms of secondary cataracts may also be removed in the same 
 manner ; but as it is very apt to set up severe and even 
 dangerous inflammation, in consequence of coexisting synechias, 
 or other complications, most operators now prefer to leave the 
 membrane in situ, and to make a small clear aperture in it by 
 means of the round stop-needle, as this is found to give 
 excellent sight, and is attended with far less risk of exciting 
 inflammation. The needle opening may be enlarged, if 
 necessary, by means of a pair of canula iris scissors, (PI. I, 
 Figs. 1, 2, 18, 19), passed through a linear incision. After 
 the operation, the pupil should be kept well dilated with 
 Atropine, and a light bandage should be applied to the eyes. 
 If inflammation supervenes, it should be subdued by ice-water 
 compresses, or other appropriate treatment. 
 
 4.-SUCTI0N OPERATION. 
 
 This is an ancient mode of extracting soft cataract, 
 recently revived by Mr. Pridgin Teale. The instruments 
 required are a broad needle for puncturing the cornea and 
 dividing the anterior capsule, and a suction tube, (PI. II, Fig. 39), 
 consisting of a glass stem, (B), five or six inches in length, 
 with a silver tubular curette (A) at one end, five-eighths of an 
 inch in length, and of the size of an ordinary curette, and an 
 exhausting tube, (C), about twelve inches in length, with a 
 mouth-piece at the other end. The tubular curette is 
 passed through the incision made by the needle, as described 
 under the head of linear extraction, and carried through 
 
358 PRACTICE OF MEDICINE. 
 
 the pupil, previously dilated by Atropine, to the centre 
 of the lens substance. Gentle suction is then made upon 
 the mouth-piece, and the lens matter is drawn into the 
 glass tube, which allows the operator to watch its progress, 
 and thus regulate the aspirative efforts. These should be 
 continued as long as any opaque matter appears in the pupil, 
 the end of the curette being slightly moved about within the 
 capsule, so as to take up any portions of the crystalline 
 substance which may be observed to remain. If any 
 portions of the crystalline are too glutinous or tenacious to 
 be readily drawn into the curette, they may be left to dissolve 
 in the aqueous humor, as after an ordinary operation for dis- 
 cission ; or they may be removed by a subsequent suction 
 operation, after having become sufficiently softened, provided 
 there has been no rupture of the posterior capsule, nor too 
 much irritability of the eye, nor any iritis ; conditions which 
 in the opinion of Mr. Teale generally render the operation 
 unsuitable. 
 
 5. -FLAP EXTRACTION. 
 
 This operation is most suitable for senile cataracts, but 
 may also be employed for the cortical variety, in cases where 
 the cortical substance has softened, and the nucleus is large 
 and of more than normal consistence. The instruments 
 required are : an ordinary cataract knife, such as Beer's (PL I, 
 Figs. 28, 29) or White's, (Fig. 23) ; a pair of fixing forceps, 
 (PL II, Fig. 36); a cystotome, (Fig. 12), for dividing the capsule ; 
 a curette, (Fig. 31), which, for the sake oi convenience, is 
 generally attached to the other end of the cystotome ; and a 
 blunt-pointed secondary knife, or pair of scissors, for enlarging 
 the corneal incision, or what is better, an instrument expressly 
 devised for the purpose, represented in PL I, Fig. 20. 
 
FLAP EXTRACTION. 359 
 
 The patient being in a recumbent position, and the lids 
 separated by an experienced assistant, the operator, placing 
 himself in a convenient and unrestrained position behind the 
 patient, fixes the globe by pinching up a fold of the conjunctiva 
 with the forceps, and then enters the cornea with the cataract 
 knife about a quarter of a line from its outer edge, and in the 
 line of its transverse diameter, taking care that the point of 
 the knife enters the anterior chamber, instead of between the 
 laminae of the cornea ; he then carries it steadily forward, with 
 the blade parallel to the surface of the iris, until its apex 
 emerges from the cornea at a point diametrically opposite to 
 where it entered, when the forceps are to be laid aside, as the 
 globe is now fully under the control of the operator. The 
 blade is now carried steadily forward until it cuts its own way 
 out ; or, when the section is nearly finished, the operator, 
 following the advice of Von Graefe, instead of carrying it 
 straight on, may complete the section by drawing it back from 
 heel to point, thus diminishing the straining by causing a relax- 
 ation in the tension of the muscles of the eye, at a time when 
 it would otherwise be at its maximum. The lids are now care- 
 fully closed, so as not to cause an eversion of the flap. After 
 resting a moment, the eye is again opened, the cystotome care- 
 fully introduced, and the capsule freely lacerated, the operator 
 being careful, in doing it, not to displace the lens into the vitre- 
 ous humor. We have now reached the third and most delicate 
 part of the operation, namely, the removal of the lens. This 
 will require to be managed with particular care, in order to 
 prevent the escape of any considerable quantity of the vitreous, 
 an accident that may not only give rise to an insidious form of 
 irido-choroiditis, but is likely to be followed by detachment of 
 the retina. After the eye is again opened, the operator places 
 the points of his index and middle fingers, or the end of the 
 curette, against the lid, on the side opposite the incision, and 
 the point of the other index finger on the other side of the 
 
36o 
 
 PRACTICE OF MEDICINE. 
 
 FLAP EXTRACTION. 
 
 globe, so as to exercise a steady but gentle pressure upon it. 
 
 This generally causes the 
 lens to advance through the 
 pupil into the anteriorcham- 
 ber, and to make its exit 
 through the incision (see 
 Fig. 16) ; if not, we must 
 aid it with the curette, un- 
 less the hindrance is behind 
 the pupil, when we must 
 lacerate the capsule again, 
 and proceed as before. Af- 
 ter resting the eye a few 
 seconds, the vision may be 
 tested by trying if the patient can count fingers ; and if he 
 cannot, we should examine the pupil to see whether any por- 
 tions of the lens substance have been stripped off and 
 left behind, in which case they should be removed with 
 the curette, or with the canula forceps (PL I., Fig. 3). 
 
 After-Treatment. — After the operation the patient 
 should be placed in bed in a darkened room, and the bed cover 
 fastened above his arms, so as to prevent his touching his eyes 
 during sleep. A binocular bandage should be lightly applied, 
 and changed whenever it becomes very uncomfortable to the 
 patient, The edges of the lids should be kept from sticking 
 together, by sponging with luke-warm milk and water, after 
 which they should be anointed with a little cosmoline, or cold 
 cream, care being taken not to disturb the flap by opening the 
 lids unnecessarily, or without due caution. After union of the 
 flap occurs, which generally takes place within forty-eight 
 hours, or less, after the operation, Atropine should be instilled 
 between the lids, without widely separating them, in order to 
 dilate the pupil and lessen the danger of secondary cataract. 
 If no untoward symptoms occur, the eye should not be opened 
 
PERIPHERAL LINEAR EXTRACTION. 361 
 
 for several days, as an early or frequent movement is apt to 
 induce iritis. But if the eye becomes very hot and painful, it 
 should be examined, and if there is no protrusion of the iris, 
 nor any marked suppuration of the cornea, cold water com- 
 presses should be applied ; but if the iris is prolapsed, a firm 
 compress should be at once applied, which will not only pre- 
 vent its increase, but will even cause it to shrink. Methodical 
 compression is also the best treatment for suppuration of the 
 cornea, tending, as Wells truly observes, more than any other 
 remedy, to diminish the swelling of the lids and the discharge, 
 and to limit the suppuration of the cornea. 
 
 In this country, patients are seldom confined to the bed 
 more than two or three days after an operation for extraction. 
 In favorable cases a shade is generally substituted for the band- 
 age in the course of a week or so, in order that the eye may 
 gradually become accustomed to the light. In the case of 
 children the bandage is frequently omitted altogether, the pa- 
 tient being simply confined to a dark room. 
 
 6.-PERIPHERAL LINEAR EXTRACTION. 
 
 VON GRiEFE'S MODIFIED LINEAR OPERATION. 
 
 The indications are the same as for the ordinary flap ex- 
 traction ; and it, or some modification of it, is now very gener- 
 ally substituted for that operation. The instruments employed 
 are : A Graefe's cataract knife (PI. II., Fig. 34) ; a sharp and a 
 blunt hook (Figs. 35 a: ond 35 £); a delicate, sickle-shaped nee- 
 dle (PI. I., Fig. 8) ; iris scissors (Figs. 1, 2, 18, 19) ; iris forceps, 
 (Fig. 3) ; toothed forceps (PI. II., Fig. 36), and a stop-speculum 
 
 (Fig. 33). 
 
 Very few operators now adhere closely to Von Graefe's 
 method of operating. We are in the habit of performing per- 
 ipheral extraction in the following manner . The patient hav- 
 ing been brought under the influence of an anaesthetic (we 
 46 
 
362 
 
 PRACTICE OF MEDICINE. 
 
 FIG. 17. 
 
 generally prefer a mixture of equal parts of chloroform and 
 sulphuric ether), the eyelids separated with the speculum, and 
 the eye fixed and somewhat depressed with a pair of fixing 
 forceps, as represented in the cut, the point of the knife, with 
 its cutting edge upwards, is entered in the sclera, about one- 
 third of a line behind the upper and outer edge of the cornea, 
 and cautiously pushed downwards and inwards until it pene- 
 trates about three lines into the anterior chamber, when the 
 point is raised, carried horizontally across the chamber, and 
 made to emerge at a point exactly opposite to that of entrance 
 (see Fig. 17). 
 
 The edge of the blade is 
 now turned somewhat ob- 
 liquely forwards, so as to 
 complete the section at the 
 upper margin of the cornea, 
 by pushing the knife for- 
 ward until its length is near- 
 ly exhausted, and then 
 drawing it gently backwards 
 toward the point. After 
 completing the section of 
 the cornea, but before sev- 
 ering the conjunctiva, the 
 peripheral extraction. edge of the knife is turned 
 
 forwards and somewhat downwards, so as to divide the 
 conjunctiva in such a manner as to form a conjunctival 
 flap of about a line in breadth. The prolapsed 
 iris is then exposed by laying back the little con- 
 junctival flap over the cornea, seized with the forceps, 
 drawn out to the required extent, and excised close up to its 
 ciliary attachment. This requires extreme care, in order to 
 prevent any portion of the iris remaining in the wound, which 
 would not only excite iritis, but retard cicatrization. We 
 
PERIPHERAL LINEAR EXTRACTION. 363 
 
 now come to the laceration of the capsule, which should be as 
 free as possible. The sickle-shaped needle is passed flat- 
 wise through the incision to the opposite side of the pupil, and 
 commencing as near as possible to the lower margin of the 
 capsule, the incision is carried beneath the iris, as recommended 
 by Wells, to the upper border of the capsule ; another incision 
 is made in a similar manner through the proximal side of the 
 capsule ; and then the upper border is freely lacerated in the 
 line of the corneal incision, so as to unite the two former 
 incisions. This forms a sort of flap in the anterior capsule, 
 which greatly facilitates the escape of the lens. The stop- 
 speculum should now be removed, and gentle pressure made 
 upon the lower margin of the cornea with the needle or 
 curette, when the upper edge of the lens will probably present 
 at the section ; if it should not readily escape therefrom, its 
 exit may be aided by introducing the two hooks, (PL II, Fig. 35), 
 one on each side of the lens, and scooping it out. After the 
 lens engages in the section, its removal will be facilitated by 
 gentle pressure with the curette upon the lower portion of the 
 cornea. If it fails to engage readily, by showing a tendency 
 to pass behind the upper lip of the incision, it should be tilted 
 forward by making slight pressure above the wound, the edge 
 of which should also be pressed backward, so as to cause the 
 lens to enter the incision. If portions of the cortical matter 
 should remain behind after the nucleus is extracted, they 
 should be coaxed forward by gently rubbing the lids in a cir- 
 cular manner with the ends of the fingers. 
 
 After Treatment. — This is the same as that for flap 
 extraction, except that after the first two or three days, if no 
 unfavorable symptoms occur, the patient may be allowed much 
 greater freedom. Atropine should be instilled as early as 
 the second day after the operation. If inflammatory compli- 
 cations occur, the case should be managed as directed under 
 flap extraction, (which see). 
 
364 PRACTICE OF MLDICINE. 
 
 DIV. V.— OPTICAL AIDS AND TESTS. 
 
 Before enterning upon the description of the anomalies of 
 refraction, accommodation, and other functional disturbances 
 of the eye, it will be best to devote a few paragraphs to the 
 consideration of some of the more important of the optical 
 aids and tests relating to their discovery and correction. 
 
 l.-THE OPHTHALMOSCOPE. 
 
 The reason that the pupil of a healthy eye usually appears 
 black, is not because all the rays of light that enter it are 
 absorbed, for some of them are always reflected, but because 
 the reflected rays, instead of returning to the eye of the 
 observer, are, in consequence of the refractive power 
 of the dioptric media, reflected back to exactly the 
 point from whence they came ; that is, the incident and 
 reflected rays exactly coincide. In order, therefore, that the 
 eye of the observer should catch the returning rays, it must be 
 placed between the source of light and the eye under examina- 
 tion, and this, in consequence of the interposition of the observer, 
 cannot be done without intercepting the illuminating rays. 
 Moreover, it must be remembered that the examiner will be 
 unable to perceive light emanating from the eye of another 
 person, when the latter is exactly accommodated for the eye of 
 the observer, since only a dark image will be formed on the 
 retina of the eye under examination, and hence only a reflection 
 of this dark portion of the retina can be returned to the eye 
 of the observer. 
 
 In order, therefore, that the interior of the eye may be 
 distinctly seen, it is necessary (1) that it be sufficiently illumin- 
 ated ; (2) that the eye of the observer be situated in the 
 direction of .the reflected or emergent rays ; and (3) that these 
 rays, which are convergent, be rendered divergent or parallel. 
 
THE OPHTHALMOSCOPE. 365 
 
 Now, Prof. Helmholtz found that all this could be accomplished 
 by simply allowing the light of a lamp to fall. on a polished 
 plate of glass, in such a manner as to reflect the rays into the 
 eye to be examined, and then, after having made the con- 
 vergent rays divergent by means of a concave lens, placing 
 himself on the other side of the glass plate, so as to catch the 
 emergent rays as they passed through it. But this, the first 
 and simplest form of the ophthalmoscope, is now seldom 
 employed ; highly polished mirrors, which possess much 
 greater illuminating power, having been substituted for the 
 glass plate. These mirrors are provided with a small aperture 
 in the centre through which the returning rays reach the eye of 
 the observer. 
 
 As our object is merely to illustrate the principle of its 
 action, and not to describe with particularity the various forms 
 of the instrument, we will simply add, that ophthalmoscopes, 
 as now constructed, may be divided into four different classes. 
 I. The portable or hand opthalmoscope, of which we have 
 three distinct forms, namely, (a) Liebreich's, which consists of 
 a slightly concave metallic mirror, attached to a convenient 
 handle, and provided with a small bracket or clip for holding 
 a convex or concave lens; (b) the ophthalmoscope of Coccius, 
 which consists of a plane mirror combined with a double 
 convex collecting lens ; and (c) the ophthalmoscope of 
 Zehender, which differs from that of Coccius in being provided 
 with a slightly convex mirror, instead of a plane one. 2. The 
 fixed ophthalmoscopes, which are especially suited for class 
 demonstrations, as their successful use does not depend on the 
 dexterity of the observer. 3. The binocular ophthalmoscopes, 
 by which we are enabled to use both eyes at once, and thus, 
 by obtaining a stereoscopic view of the fundus, readily distin- 
 guish any change of surface on the retina and optic disc. 
 4. The aut-ophthalmoscope, by which the observer is enabled 
 to examine the interior of his own eye. Of these, the most 
 
366 PRACTICE OF MEDICINE. 
 
 useful for the general practitioner is the ophthalmoscope of 
 Coccius, which possesses the following advantages over that of 
 Liebreich, which is the one in most common use : — first, we 
 can more fully concentrate the light upon any given part of 
 the fundus ; secondly, we can readily increase or diminish the 
 focal distance and illuminating power of the mirror ; thirdly, 
 we can generally obtain a much better view of the fundus 
 through a contracted or natural sized pupil, in consequence of 
 the corneal reflex being considerably less ; and, fourthly, it is 
 far better adapted for the direct method of examination. 
 
 MANNER OF USING THE OPHTHALMOSCOPE. 
 
 I. Indirect Method. — The examination of the inverted 
 image, or the indirect method, as it is called, is conducted by 
 seating the patient in a darkened room, with a lamp placed by 
 the side of and a little behind the eye to be examined. The 
 surgeon then seats himself in front of the patient, and holding 
 the ophthalmoscope in his right hand, places the aperture of 
 the mirror close to his eye, directing the instrument in such a 
 manner as to cast the reflection of the flame directly into the 
 pupil. To be able to do this with facility, and at the same 
 time keep the eye well illuminated while conducting the exam- 
 ination, requires considerable care and experience, as the slight- 
 est movement of the mirror is liable to throw the reflection far 
 away from the pupil. Having illuminated the eye, the surgeon 
 takes the rim of the object lens between the forefinger and 
 thumb of his left hand, and holding the lens from two to three 
 inches from the patient's eye, according to its focal length, at 
 the same time steadying the hand by placing one of his fingers 
 upon the edge of the orbit, he endeavors to obtain an ophthal- 
 moscopic view of the fundus. This is somewhat difficult for 
 the beginner, who is apt while adjusting the lens to displace 
 the mirror ; and it is not until he learns to use the hands inde- 
 pendently of each other that he can make a proper examina- 
 
MANNER OF USING THE OPHTHALMOSCOPE. 367 
 
 tion of the eye. He then finds that the rays of light reflected 
 from the fundus, after passing thrnugh the lens, form an in- 
 verted image. If the eye of the observer is presbyopic or 
 hypermetropic, the image is rendered more distinct by using a 
 convex glass in the clip behind the mirror. The same is true 
 if the eye of the patient is hypermetropic. If the observer 
 wishes to gain a view of the optic disc, he should direct the 
 patient to look toward his (the surgeon's) right ear, if the right 
 eye is under examination, and vice versa, in order that the axis 
 of vision may be turned slightly inwards, so as to bring the 
 optic nerve entrance directly behind the pupil. If the patient 
 looks straight forwards, the surgeon will see the region of the 
 macula lutea, which is distinguished by being of a slightly 
 darker color than the rest of the fundus, and without any ap- 
 pearance of blood-vessels passing over it. The ophthal- 
 moscopic appearance of the optic papilla has already been 
 given (see Fig. 10). The color of the fundus of the normal 
 eye differs according to the complexion of the individual. In 
 light-complexioned persons it is light or yellowish-red, while in 
 persons of dark complexion it is dark red. 
 
 2. Direct Method. — If the examination be made without 
 the lens in the left hand, the image will be erect and much 
 larger than when made by the indirect method As perfect 
 relaxation of the accommodation is required in order to render 
 the emergent rays parallel, and as this is difficult to obtain 
 without the use of Atropine, in consequence of the close ap- 
 proximation of the patient to the observer leading him, not- 
 withstanding he is directed to look at some distant object, to 
 accommodate for a much nearer point, it is advisable to dilate 
 the pupil with Atropine, as this secures at once the needed re- 
 laxation, and at the same time increases the size of the field 
 of vision, and also facilitates the illumination of the fundus. 
 The lamp should be placed on the side and a little behind the 
 plane of the eye under examination, the surgeon seating him- 
 self on the same side and examining with the corresponding 
 
368 PRACTICE OF MEDICINE. 
 
 eye — that is, using the right eye for the right eye of the pa- 
 tient, and vice versa. If the image is indistinct, either in con- 
 sequence of the surgeon being unable to fully relax his own 
 accommodation, or in consequence of his eye or that of the 
 patient being myopic, he will find it necessary to use a concave 
 lens in order to render the rays parallel. But, if the eye of 
 one is myopic, while that of the other is hypermetropic, the 
 difference in the refractive power of the two eyes may be so 
 far neutralized as to enable the surgeon, by using his accom- 
 modation, to examine without the aid of a concave lens. As 
 every ophthalmoscope is supplied with a series of these lenses, 
 of different focal lengths, fitting into the bracket or clip behind 
 the mirror, the surgeon will have no difficulty in selecting one 
 to suit the condition of his own and the patient's eyes, whether 
 emmetropic, myopic or hypermetropic. 
 
 The advantages afforded by the direct method of examina- 
 tion are (i) that we are enabled to ascertain the optical condition 
 of the eye independent of its visual power, or of the statements 
 of the patient ; and (2) that we are enabled to measure defi- 
 nitely the amount of elevation or depression of any portion of 
 the fundus ; such, for example, as the amount of excavation of 
 the optic disc, the height of tumors, the amount of swelling in 
 the retina, etc. On the other hand, the field of vision is more 
 limited, and the examination more difficult, than by the indi- 
 rect method, the employment of which renders all nice dis- 
 tinctions as to myopia, hypermetropia, and the state of the 
 accommodation unnecessary — conditions which must always be 
 taken into the account in searching for the retinal image by the 
 direct method. 
 
 2.-LATEEAL OR OBLiaUE ILLUMINATION. 
 
 This method of exploring the anterior and central por- 
 tions of the globe is best conducted in a darkened room. The 
 light is placed in the same position with respect to the patient's 
 
SPECTACLES. 369 
 
 head as in the ophthalmoscopic examination. A double con- 
 vex lens is then. held between the lamp and the eye to be ex- 
 amined, in such a manner as to concentrate the light upon any 
 portion of the cornea, iris, crystalline lens, or vitreous, that the 
 surgeon desires to illuminate. We may obtain a magnified 
 image of these parts, and thus give greater clearness to the de- 
 tails, by holding a second bi-convex lens immediately in front 
 of the eye — that is, directly between the patient's eye and our 
 own. In this manner we may detect slight opacities or irregu- 
 larities in the cornea which would otherwise escape notice, ex- 
 amine minutely the texture and condition of the iris, discover 
 the faintest traces of cataract, or the presence of foreign bodies 
 in the anterior chamber, observe various morbid changes in the 
 vitreous, hemorrhagic effusions, floating opacities, etc., and, in 
 some cases, the projecting folds of a detached retina. It 
 will thus be seen that lateral illumination is oftentimes no mean 
 substitute for the ophthalmoscope, while the ease and rapidity 
 with which it may be employed renders it doubly valuable as 
 a means of detecting many diseased conditions. A good rule, 
 therefore, and one that is generally observed in practice, is to 
 begin the examination with oblique illumination, and, if there 
 is any remaining obscurity about the case, to clear up the diag- 
 nosis with the ophthalmoscope. 
 
 3-SPECTACLES. 
 
 These are generally employed for the purpose of correct- 
 ing such optical defects as cannot otherwise be rectified. They 
 consist of convex spherical lenses for the correction of hyper- 
 metropia, concave spherical for myopia, cylindrical for astigma- 
 tism, and a combination of both spherical and cylindrical for 
 complicated forms of ametropia. Besides these we have the 
 following special forms and combinations : 
 
 Pantoscopic Spectacles \ termed by the French verres a double 
 47 
 
370 Practice of medicine. 
 
 foyer, consist of lenses the upper and lower half of which have 
 different foci. They are especially useful where the presbyopia 
 is combined with myopia or hypermetropia. In the former 
 case the upper half should be concave to neutralize the myopia, 
 and the lower half convex to neutralize the presbyopia. 
 
 Periscopic Spectacles, consisting of concavo-convex glasses, 
 are constructed for the purpose of reducing the spherical aber- 
 ration to a minimum. When the concave surface is towards 
 the eye, the image is less distorted, on account of there being 
 less irregular refraction at the periphery of the lenses ; conse- 
 quently, the observer is enabled to look more obliquely through 
 them. 
 
 Prismatic Spectacles, the glasses of which are ground either 
 in the form of prisms, or of prisms and lenses combined, are 
 used for relieving or strengthening certain muscles of the globe. 
 The bases of the prisms are generally turned inwards, for the 
 purpose of relieving the internal recti muscles. (See Muscular 
 Asthenopia). The same object may be accomplished by what 
 are called decentered lenses. These are so constructed as to 
 throw the centre a little to the inner side of the visual axis in 
 convex lenses, and to the outer side in concave glasses, thus 
 producing a slight prismatic effect. 
 
 Cataract Spectacles consist of convex lenses of great 
 refractive power. The eye having lost the power of accom- 
 modation, two sets will be required, one for near objects, of 
 about two and a half inches focal length, and the other of 
 about four and a half inch focus for distant objects. The 
 glasses should be small, as large ones, by admitting too much 
 light, generally cause more or less dazzling. They are, of 
 course, adapted to every form of aphakia. 
 
 Stenopaic Spectacles are constructed for the purpose ot 
 excluding the peripheral, and permitting only the central rays 
 of light to enter the eye. For this purpose, metallic plates 
 with small central apertures are used in place of glasses. 
 They increase the sharpness of vision for near objects, and are 
 
TEST TYPES. 37 1 
 
 also useful in opacity of the cornea, but as they contract the 
 field of vision, they are not adapted for distant objects. 
 
 Protective Spectacles, or eye protectors, are composed of 
 variously colored glasses, amber, brown, grey, blue, green, etc. 
 The majority of ophthalmologists recommend blue glasses, as 
 these exclude the orange rays, which are the most irritating to 
 the retina ; but Dr. Dobrowolski, of St. Petersburg, gives the 
 preference to grey or smoke-colored glasses. He argues that 
 in attempting to shield the eyes from too bright a light, we 
 should employ glasses which will diminish equally all the rays 
 which constitute sun-light, and not confine the patient to blue 
 glasses, which only exclude the yellow rays, nor to green ones, 
 which only protect the eye from the red rays, but should use 
 the grey or smoked glasses, which not only diminish the 
 passage of all the rays, but also enable the eye to readily 
 accommodate itself again to ordinary sunlight, a matter of 
 some difficulty after wearing the blue spectacles.* 
 
 The most convenient instrument for ascertaining the focal 
 strength of lenses, is formed on the model of the ordinary 
 measuring stick used by shoemakers. The stationary upright, 
 or toe piece, is fitted to receive the lens, and the movable 
 upright, or heel piece, has attached to it a card on which are 
 small printed letters. Placing the card at the focal distance 
 required, the power of glasses is readily ascertained by chang- 
 ing the lenses until a suitable one is found, or by selecting 
 another lens which, placed before the first, will render the 
 letters distinct, and then adding or subtracting its power. 
 
 4.-TEST TYPES. 
 
 In order to have some generally accepted standard by 
 which the range and acuteness of vision may be readily ascer- 
 tained, and referred to in published cases, Prof. Jaeger, Dr. 
 
 Am. Horn. Obs., vol. xi, p. 555. 
 
372 PRACTICE OF MEDICINE. 
 
 Snellen, and others, have published different series of test 
 letters. Those of Jaeger begin with the smallest type used 
 in printing, and gradually increase to letters of a size to be 
 easily distinguished by a normal eye at a distance of twenty 
 feet. Dr. Snellen's test types extend the scale, by means of 
 letters made up of squares, to two hundred Paris feet. These 
 two scales, which are the ones in general use, do not exactly 
 correspond, that is to say, No. 20 Jaeger does not represent 
 precisely the same point in the scale as Snellen, XX, and 
 hence it is best to specify the particular scale employed in the 
 test when the lower Nos. are used. 
 
 Figures are placed above each series of letters, indicating 
 the distance, in feet, at which they may be read by a normal 
 eye. Thus, No. 10 should be read with ease at a distance of 
 ten feet ; but if it can be read only at a distance of five feet, 
 we say V, which expresses the acuteness of vision, 
 
 _5_ 1 
 
 10 2. 
 If No. 18, which should be read by an emmetropic eye at 
 eighteen feet, can be read only at a distance of twelve feet, 
 we say 
 
 V = — = - 
 12 3. 
 
 The numerical values found in thif manner do not always 
 
 accurately represent the acuteness of vision, although sufficiently 
 
 precise for all practical purposes. For example, a sharpness of 
 
 6 4 3 
 
 — — or - 
 
 18, 12 9. 
 
 js not necessarily the same as -J- ; for eyes that see No. 18 at 
 six feet, may not see No. 9 distinctly at three feet, or No. 3 at 
 one foot. Hence, as Stellwag points out, if we would represent 
 accurately the state of vision, we must avoid all reduction of 
 the fraction. 
 
DISEASES OF THE EYE. 373 
 
 DIV. VL— FUNCTIONAL DISEASES. 
 
 The diseases which we propose to consider in this section, 
 are those functional disorders immediately influencing the 
 accommodation, more especially asthenopia, and paralysis and 
 spasm of the ciliary muscle ; those of refraction, namely 
 myopia, hypermetropia and astigmatism ; those affecting the 
 optic nerve and retina, particularly hyperaesthesia, anaesthesia, 
 amblyopia, hemeralopia, and amaurosis ; and those involving 
 the ocular muscles, especially nystagmus and strabismus. 
 Assuming that the reader is already sufficiently acquainted 
 with the refractive properties of the different kinds of lenses, 
 we shall proceed at once to consider 
 
 l.-THE THEORY OP ACCOMMODATION. 
 
 It is assumed, in the first place, that all rays emanating 
 from distant objects, by which is meant all objects at or 
 beyond twenty feet from the observer, are parallel ; that is, 
 the divergence being too slight to be taken into account, the 
 objects are considered as if they were placed at an infinite 
 distance. Such rays the refractive media of an emmetropic 
 eye, when in a state of rest, are adapted to bring to a focus 
 upon its retina, and thus to produce distinct images of the 
 objects from which they emanate. The eye is then said to be 
 accommodated for its far point, (punclnm remotissimuni), 
 denoted by the letter r. Being thus adjusted for parallel 
 rays, the normal eye perceives distant objects without any 
 effort of the accommodation. And since the more distant 
 the object the more nearly are the rays from it rendered 
 parallel, it follows that the furthest point of distinct vision 
 must be at an infinite distance. 
 
 But if the rays, instead of being parallel, are very diver- 
 gent, as in the case of very near objects, the state of refraction 
 of the normal eye is such that they can only be brought to a 
 
374 PRACTICE OF MEDICINE. 
 
 focus behind the retina, unless it can increase the amount of 
 refraction sufficiently to focus them upon the retina. Now the 
 normal eye is provided with an apparatus by which it is 
 enabled, intuitively and unconsciously, to increase or diminish 
 at pleasure the amount of its refraction, and thus to adjust 
 itself for near vision. When thus adjusted, the eye is said to 
 be accommodated for its near point, (punctum proxirnum), 
 denoted by the letter/. 
 
 The distance between these two points is called the range 
 of accommodation, and is expressed by the letter A. In the 
 youthful emmetropic eye, it extends from about three and a 
 half or four inches, the nearest point of distinct vision, to the 
 furthest point, which, as we have seen, lies at an infinite 
 distance. Anywhere between these points objects may be 
 distinctly seen ; but beyond the point for which the eye is 
 accommodated, circles of dispersion are formed upon the 
 retina, and the images appear blurred. 
 
 If, as proposed by Prof. Donders, the range of accommo- 
 dation be expressed by i, the distance of the near point (p) 
 from the eye, measured from the nodal point, by h and that of 
 the far point (r) by £, its value in any particular case may 
 
 be readily determined by the formula 
 
 i 1 i 
 
 A P R. 
 
 Thus, in an emmetropic eye, if the nearest point at which 
 
 vision is distinct is 5", and the furthest point is an infinite 
 
 distance, qq, we have by the above formula 
 
 1 1 1 1 
 
 A 5 00 5. 
 
 Here the range of accommodation is represented by what 
 is called a 5 inch lens ; that is, it would require a convex lens 
 of five inches focus to be placed before the eye, to render the 
 rays coming from an object placed at the near point (5") 
 parallel, or what is the same thing, give them the direction 
 they would have if the object were situated at an infinite 
 distance. 
 
 The theory of accommodation upon which these con- 
 
THE THEORY OF ACCOMMODATION. 375 
 
 elusions are based, and which is now generally accepted as the 
 true one, though ably advocated by Thomas Young as early 
 as the beginning of the present century, did not receive a full 
 and satisfactory demonstration until Cramer and Helmholtz, 
 working independently of each other, furnished, by means of 
 ingeniously devised instruments, incontestable proof of the 
 alterations of curvature in the crystalline lens, when the eye is 
 accommodated for near and distant objects, and at the same 
 time proved that no change occurs in the curvature of the 
 cornea. 
 
 The changes in question may be readily demonstrated, 
 ocularly, by placing a lighted candle at a certain distance to 
 the right of a given fixed point, P, towards which the observed 
 eye is steadily directed, while the eye of the observer is 
 situated at an equal distance to the left of the same point. 
 Fig. 18, representing the pupil of an eye 
 thus observed in a state of rest, (r), 
 shows the three images formed by reflec- 
 tion from the cornea, (a), anterior capsule, 
 (b), and posterior capsule, (c). Fig. 19 
 shows the same eye in a state of accom- 
 modation for the near point, (/); the 
 pupil is somewhat contracted, as shown by the circular white 
 line, and the image forms by the anterior capsule, (b), is found 
 to be changed both in size and position. The image is 
 ^^^ rendered smaller in consequence of the 
 
 increased curvature of the anterior 
 surface of the lens, which forms a convex 
 reflector of less radius. The change of 
 position is due to the projection forward 
 of the reflecting surface, in consequence 
 of the lens being increased in thickness 
 during accommodation. The other images have undergone 
 
37^ PRACTICE OF MEDICINE. 
 
 no perceptible change, showing that neither the curvature of 
 the cornea, nor the curvature or position of the posterior 
 surface of the lens, undergo any perceptible change during 
 accommodation. 
 
 Fig. 20. 
 
 In full accom. Eye at rest. 
 
 Fig. 20 illustrates the changes which occur during accom- 
 modation. The right half of the figure represents the eye in 
 a state of rest, i, e., when accommodated for distance ; the left 
 half shows it when fully accommodated for near vision. The 
 relative difference in curvature of the anterior surface of the 
 lens, on the two sides, corresponds very closely with the 
 measurements of Cramer and Helmholtz. According to the 
 latter, the changes that occur during accommodation for near 
 objects are, (1) contraction of the pupil; (2) the pupillary 
 margin of the iris is pushed forward ; (3) the peripheral 
 portion of the iris moves backwards. (4) the anterior surface of 
 the lens becomes more convex, and is arched forward, so as to 
 render the lens considerably thicker in the antero -posterior 
 diameter, and give it much greater refractive power ; (5) the 
 posterior surface of the lens is also rendered more convex, but 
 not to such a degree as to cause any perceptable change in its 
 position. 
 
 It was formerly supposed that whilst the chief influence 
 concerned in the function of accommodation is exerted through 
 the action of the ciliary muscle, the iris also materially assists 
 
THE THEORY OF ACCOMMODATION. 377 
 
 in the process ; but as the accommodation has since been 
 found to remain unimpaired, in a case in which the entire iris 
 was removed after an accident, there can no longer be any 
 room for doubt that the change in the form of the lens is 
 wholly due to the action of the ciliary muscle. But the 
 manner in which the muscle causes the change in question has 
 not yet been satisfactorily answered. The most probable 
 explanation is, that, so long as the ciliary mucles continues 
 passive, the lens remains in its usual condition ; but as soon 
 as the muscle contracts the suspensory ligament becomes 
 relaxed, and the lens then increases its convexity by virtue of 
 its own elasticity. 
 
 Another factor in the procees of accommodation was, 
 until recently, supposed to exist in the action of the internal 
 recti muscles, in causing the necessary convergence of the 
 optic axes for binocular vision ; but a case of Von Graefe's, 
 in which all the external muscles of both eyes were completely 
 paralyzed, and yet the power of accommodation remained 
 unimpaired, clearly proves the contrary. 
 
 It is thus seen that refraction and accommodation are 
 two entirely different processes. The former is a passive 
 condition, depending wholly upon the focusing power of the 
 dioptric apparatus, which is chiefly due to the form of the eye 
 and of its different refracting media. In these respects the 
 eye does not essentially differ from any other optical instru- 
 ment, the images being formed agreeably to the well-known 
 laws of optics. Accommodation, on the other hand, is a 
 purely physiological process, being the result of muscular or 
 vital action, and is none the less real in consequence of being, 
 for the most part, unconsciously and involuntarily performed. 
 
 That the focusing power of the crystalline lens is 
 
 controlled by the action of the ciliary muscle, is clearly 
 
 proven by the suspension of the function whenever paralysis 
 
 of the muscle occurs from disease, or whenever it is artificially 
 
 induced by the action of Atropine. 
 48 
 
378 PRACTICE OF MEDICINE. 
 
 2.-AN0MALIES OF ACCOMMODATION. 
 
 Having shown that the function of accommodation is 
 dependent upon the action of the ciliary muscle, it remains to 
 consider the principal causes which are known to limit or 
 disturb the process. These are, (i), presbyopia, which is a 
 limitation of the function due to advancing age ; (2), paralysis 
 of the ciliary muscle, which is occasionally met with after 
 severe illness ; and, (3), spasm of the ciliary muscle, which is 
 frequently the result of over-working the muscle in accommo- 
 dation. 
 
 A.— Presbyopia. 
 
 This affection, which was formally supposed to arise from 
 deficient refractive power, is now known to have very little 
 effect upon distant vision, the actual change consisting in the 
 recession of the near point, and consequently in a limitation 
 of the range of accommodation. This removal of the near 
 point from the eye, is caused by senile changes in the crystalline 
 lens, whereby its hardness is increased, so that its form becomes 
 less and less susceptible of alteration from the action of the 
 ciliary muscle, and hence the function of accommodation 
 correspondently impaired. As this increase in the density of 
 the crystalline is a purely physiological process, it may 
 commence at any age, and may affect both emmetropic and 
 ametropic eyes. In point of fact, it is found to begin very 
 early, gradually increasing with advancing years, until, at the 
 age of forty or forty-five, the near point is at eight inches from 
 the eye, the distance which, for the sake of definiteness, has 
 been selected as the limit from which to reckon the commence- 
 ment of presbyopia. As age advances the refractive power 
 of the lens also suffers, so that the eye not only becomes 
 presbyopic, but hypermetropic. 
 
PRESBYOPIA. 379 
 
 As presbyopia diminishes the range of accommodation, 
 it cannot be of benefit, as is frequently supposed, to the 
 myopic eye. It is true, the senile changes in the refractive 
 power of the lens will have a slight tendency to diminish the 
 myopia, and if moderate may serve to correct it ; but as the 
 far point remains pretty much the same, the only effect will be 
 to shorten the range of adaptation, which is already greatly 
 reduced by the approximation of the far point. Presbyopia 
 supervening upon hypermetropia is, of course, still more 
 serious, loss of accommodation being added to diminished 
 refraction. 
 
 Since no effort of the ciliary muscle will render the lens 
 sufficiently convex for near vision, it should be aided by suit- 
 able glasses. The patient should be advised to commence 
 their use as soon as the presbyopia begins to be noticed, and 
 not postpone wearing them under the mistaken notion that he 
 may thereby be enabled to dispense with them altogether, for 
 this will necessarily fatigue and strain the accommodative 
 apparatus, and may possibly result in even more serious 
 disability. 
 
 The strength of the required glasses may be easily found 
 from the formula 
 
 Pr = i-± 
 
 8 P' 
 
 where Pr donotes the degree of presbyopia, 8" the presbyopic 
 near point, and p' the observed power of the presbyopic eye. 
 For example, if we find the nearest point of distinct vision to 
 be twenty-four inches, then the value of Pr will be 
 
 8 24 12 > 
 
 that is, it will take a convex lens of twelve inches focal length 
 to neutralize the presbyopia, and enable the patient to see 
 clearly at the distance of eight inches. 
 
 If the presbyopia is complicated with myopia or hyper-^ 
 metropia, it may become necessary to supply the patient with 
 two sets of glasses, the myope with convex glasses for small 
 
380 PRACTICE OF MEDICINE. 
 
 objects, to remedy the loss of accommodation, and concave 
 
 glasses for distance, to neutralize the increased refraction ; 
 
 while the hypermetrope will require two pair of convex glasses, 
 
 one for near vision, to compensate for deficient refractive power 
 
 and the loss of accommodation, and the other far distant 
 
 vision, to neutralize the hypermetropia. 
 
 To ascertain the range of accommodation for presbyopic 
 
 eyes, we may make use of the formula already given, namely, 
 
 i i i 
 
 A P R. 
 
 Thus, if the near point (p) be at fifteen inches, and the 
 
 far point (r) at infinite distance (oo ), we have 
 i _i i j_ 
 
 A 15 oo 15. 
 
 In choosing glasses it is well not to be governed too 
 rigidly by Donder's near point (8"); but to be influenced to 
 some extent by the distance at which the patient has been 
 accustomed to read or sew. If this has been at a considerable 
 distance, it will be more convenient not to have the near point 
 brought within ten or twelve inches. We should also be 
 guided in this matter by the range of accommodation. If this 
 is large, we may, if the patient prefers, bring the near point to 
 eight inches, or even less if the sharpness of vision is dimin- 
 ished ; but if the range of accommodation is greatly lessened, 
 weaker glasses should be selected, as these will be less fatiguing 
 to the eye ; such, for example, as will enable the patient to 
 read No. I of the test types at about twelve inches. 
 
 B.— Paralysis of the Ciliary Muscle. 
 
 This affection, which is not of very frequent occurrence, 
 sometimes follows exhausting diseases, especially diphtheria. 
 Paresis, or partial paralysis, is occasionally associated with 
 general atony of the muscular system, and is then apt to be 
 mistaken for amblyopia depending upon general debility. 
 
 As the paralysis lessens or destroys the power of accom- 
 
SPASM OF THE CILIARY MUSCLE. 38 1 
 
 modation, emmetropic eyes are unable to accurately distinguish 
 near objects, though their ability to see distinctly at a distance 
 is not impaired. But its effect upon vision is most marked 
 in hypermetropic eyes, as these are obliged to exercise the 
 function of accommodation even at a distance, and consequently 
 lose the power of seeing any object with distinctness, whether 
 near or remote. The myope, on the contrary, only becomes 
 aware of the defect when looking at very near objects. If 
 the paralysis is incomplete, these effects will, of course, be less 
 considerable. In the latter case the symptoms may be 
 mistaken for those of asthenopia, unless the range of accom- 
 modation is also examined. This is all the more necessary 
 in these cases, because, in simple paresis, the contractility of 
 the pupil and the various movements of the globe generally 
 remain unimpaired ; whereas in complete paralysis of the 
 accommodation there is almost always dilatation of the pupil 
 and divergent strabismus. 
 
 TREATMENT. — This consists chiefly in perfect rest of the 
 eyes, and the employment of such hygienic measures as are 
 best calculated to invigorate the general system. If the 
 patient is obliged to exercise his accommodation, he should be 
 supplied with such convex glasses as will enable him to see 
 distinctly without exertion, being careful to gradually diminish 
 the strength of the lenses, in proportion as the accommodative 
 faculty improves. 
 
 The remedies which have hitherto proven most beneficial 
 in this affection are : Caust., Physostig. ven. (used externally), 
 and electricity ; good results have also been obtained in some 
 cases from the internal administration of Arg. nit., Arn., Cup. 
 acet., Euph., Gels., Kali iod., Opium, Paris q., and Rhus tox. 
 
 C— Spasm of the Ciliary Muscle. 
 
 This is not, as was formerly supposed, a very rare affection, 
 being sometimes associated with both myopia and hypermetro- 
 pia. It is most frequently met with in young subjects who 
 
382 PRACTICE OF MEDICINE. 
 
 have strained their eyes in reading or fine work, the spasm 
 being the result of over-tasking the ciliary muscle, in accom- 
 modating the eye for near objects. This causes an apparent 
 myopia, so that the patient sees better through concave glasses ; 
 but if we paralyze the ciliary muscle by means of Atropine, we 
 shall generally find that the eye is really hypermetropic. 
 Such persons perceive distant objects very indistinctly ; and 
 although near objects may be seen clearly for a short time, 
 the effort at accommodation soon fatigues the eye. The pupil 
 is generally contracted ; and the iris is bulged forward by the 
 increased curvature of the lens. If we examine with the 
 ophthalmoscope, we shall find that the refraction is highly 
 hypermetropic, and that the optic disc and retina are more or 
 less hyperaemic ; there is also, not unfrequently, a co-existing 
 posterior staphyloma. 
 
 Treatment. — The most speedy and effective treatment 
 consists in completely paralyzing the ciliary muscle with 
 Atropine. For this purpose we require a strong solution, say 
 four or five grains to the ounce, which should be used three or 
 four times daily, until the spasm is entirely overcome. If it 
 returns we should enjoin complete rest of the eye, and endeavor 
 to improve the general health by regular out-door exercise, 
 and other hygienic means. If necessary, we should prescribe 
 strong convex glasses for near objects, and weak ones for 
 distance, the regular use of which will diminish the spasm by 
 producing complete rest of the accommodation. Internally, 
 we obtain the best result from the Physostigma ven. 
 
 3 -ANOMALIES OF REFEACTION. 
 
 An emmetropic eye is one whose dioptric media possess a 
 refractive power just sufficient, when the accommodation is at 
 rest, to form well-defined images of distant objects upon the 
 retina ; it also possesses the power of increasing or diminishing 
 
MYOPIA, 383 
 
 the refraction at pleasure, thus adapting itself to distinct 
 vision at any distance. But there are eyes which do not 
 possess these optically normal powers, namely, those in which 
 the optic axis is too long, constituting myopia; those in which 
 it is too short, producing hypermetropic/, ; and those in which 
 the cornea or lens have an unequal curvature in different 
 meridians, giving rise to astigmatism. 
 
 A.— Myopia, 
 
 NEAR -SIGHTEDNESS. 
 
 We have already remarked, that in the myopic eye 
 parallel rays are brought to a focus before reaching the retina. 
 This optical defect is due to the refractive power of the eye 
 being relatively in excess ; that is, although the refractive 
 power may not be too high for a normally constructed eye, it 
 is so in relation to the myopic eye, the antero-posterior axis of 
 which is too long. It was formerly supposed that in myopia the 
 cornea or lens was too convex, or that the latter was misplaced ; 
 but exact measurements have shown this not to be the case, 
 and that the lengthening of the optic axis is due to a bulging 
 of the posterior portion of the globe, in consequence of which 
 the retina is situated too far back of the lens and cornea. 
 The consequence of this displacement is, that while divergent 
 rays, or those coming from near objects, may be brought to a 
 focus upon the retina, and thus afford distinct vision when the 
 accommodation is at rest, parallel rays, or those coming from 
 distant objects, form upon that membrane greater or less 
 circles of dispersion, which render the images indistinct. It 
 does not necessarily follow, however, that because a patient 
 holds small objects very near to his eyes, or because he cannot 
 see well at a distance, he is myopic, as similar symptoms may 
 occur in hypermetropia. But if, in proportion as the object is 
 removed from the eye, the vision becomes rapidly indistinct, 
 
384 PRACTICE OF MEDICINE. 
 
 and there is no other apparent cause, we may strongly suspect 
 the existence of myopia ; and if the vision is greatly improved 
 by the use of weak concave lenses — say of thirty or forty 
 inches focus — the myopic condition is rendered almost certain. 
 But, as slight changes in refraction may be overcome by the 
 accommodative power, and also by extreme degrees of myo- 
 pia, it is better to ascertain at once the far point, and then, by 
 placing concave glasses of the corresponding number before 
 the patient's eyes, he will, if myopic, be able to see clearly at 
 a distance, and there will no longer be any doubt. 
 
 We may also determine the existence of myopia with the 
 ophthalmoscope. If we make use of the direct method of ex- 
 amination, we may be able to perceive the details of the fundus 
 at some distance from the eye, and if we move our head to 
 either side, we shall find that the retinal image moves exactly 
 in the contrary direction. But in order to obtain a distinct 
 image of the fundus, we shall, if the eye is strongly myopic, 
 require a concave correcting lens behind the mirror. We shall 
 now probably discover that the malformed eye is also a dis- 
 eased one, there being, in the majority of cases, a greater or 
 less degree of posterior staphyloma. This condition, which 
 exists chiefly in progressive myopia, is generally associated 
 with a sclero-choroiditis posterior. If the myopia is stationary, 
 or but slowly progressive, it causes but little inconvenience in 
 reading, sewing, etc ; but if rapidly progressive, it is apt, in 
 consequence of the choroiditis, to be accompanied with symp- 
 toms of high irritation and inflammation, and may even prove 
 a source of great danger to the eye. (See Sclero-choroiditis 
 Posterior) 
 
 Myopia is frequently congenital, and sometimes heredita- 
 ry, but the researches of Dr. Cohn and others show that, in all 
 probability, it is very often acquired. Dr. Cohn found that, of 
 one hundred and thirty-two compositors, more than half (51,5 
 per cent.) were myopic ; and of the sixty-eight myopes, not 
 
MYOPIA. 385 
 
 less than fifty-one (y$ per cent.) were possessed of normal 
 vision in early life. It is almost certain that the continuous 
 use of the eyes for near objects, especially by the young, is a 
 fruitful cause, if not of the origin of myopia, at least of its de- 
 velopment. Out of ten thousand and sixty school children 
 examined, this investigator found one thousand and four my- 
 opes, the proportion increasing in the higher departments, ac- 
 cording to the increased demand for study. Thus, of the four 
 hundred and ten students in the University of Breslau nearly 
 two-thirds were affected with a greater or less degree of myo- 
 pia. 
 
 Treatment. — This will vary according as the myopia is 
 stationary or progressive. The latter, if marked, and especially 
 if occurring in youthful subjects, will require similar treatment 
 to that recommended for Sclero-choroiditis Posterior (which 
 see). But if stationary, or if the progress is too slow to be 
 perceptible, and especially if it does not give rise to any mark- 
 ed inflammatory symptoms, no preliminary medical treatment 
 will be called for, and we may immediately proceed to select 
 the requisite glasses. 
 
 It is very important that the strength of the glasses re- 
 quired for correcting the refraction should be determined with 
 the greatest accuracy. As the degree of myopia (M.) is meas- 
 ured by the far point (r.) for distinct vision, we first determine, 
 by means of the test types, the furthest point at which the 
 patient can clearly distinguish the letters. For example, if 
 he reads No. 1 with facility at one foot, but is unable to distin- 
 guish No. 2 clearly at two feet, or No. 3 at three feet, and so 
 on, and yet is able to read No. 2 easily, say at twenty inches, 
 we represent the degree of myopia by the formula, 
 
 M = — > 
 
 20 
 
 twenty inches being the furthest point at which vision is dis- 
 tinct ; it will, therefore, require a concave lens of twenty inches 
 
 focus to neutralize the myopia. But, although No. 20 is theo- 
 49 
 
386 PRACTICE OF MEDICINE. 
 
 retically the proper glass, it is rarely the case that the strength 
 can be accurately determined in this manner; as a general 
 rule the glass will be found somewhat too strong, and will re- 
 quire to be corrected by subtracting the power of the weak 
 convex lens necessary to correct it. On the other hand, if the 
 original glass is too weak, we should add the power of the weak 
 concave lens required to give it the appropriate strength. The 
 correction is made according to the following formula : 
 
 a±b 
 
 x= , 
 
 ab 
 
 that is, the power of the required lens (x) is equal to the sum 
 or difference of the powers of the two lenses divided by their 
 product. Take, for example, the case above cited. We first 
 try the patient with a pair of 20-inch concave glasses, and di- 
 rect him to read, say No. XX. Snellen at twenty feet. He will 
 no doubt notice at once a marked improvement in his vision. 
 We now place in front of the former glasses a very weak pair, 
 say No. 60 concave, and, if his vision is still further improved, 
 the original pair are too weak. Suppose that upon repeated 
 trial this No. 60 concave is found to be the best corrective of 
 the first pair of glasses, then, according to the formula 
 
 a±zb 20-J-60 
 x= = 
 
 — — T5"J 
 
 ab 20X60 
 
 which gives concave 15 as the proper glass. But suppose, in- 
 stead of a No. 60 concave, it takes a No. 60 convex to render 
 distant vision distinct through the original glasses. This proves 
 that the latter are too strong, and we have 
 
 a±b 60 — 20 
 
 x= === — tct > 
 
 ab 60X20 
 
 Showing that only a concave 30 would be required to correct 
 the myopia.* 
 
 *Convex lenses are generally designated by the positive or + sign, and concave lenses 
 by the negative or — sign. If two or more are used in conjunction, the power of the com- 
 pound lens will be represented by their sum, if the signs are alike, and by their difference, 
 if unlike. 
 
MYOPIA. 387 
 
 If the patient wishes to procure glasses for some special 
 purpose, such as reading music, he will need a pair of less 
 power than those required for distant vision. For example, if 
 his myopia =J-, and he wishes to read at twenty-four inches, 
 the formula will be 
 
 ~~ 6 "•" TZ J; 
 
 Hence a concave 8 will be required. 
 
 In order to decide the question as to whether or not it will 
 be proper to allow the use of glasses for near objects, it will be 
 necessary to determine the range of accommodation. For this 
 purpose, we may make use of the method already given ; that 
 is, we first find the nearest and furthest point at which No. I 
 of the test types can be clearly distinguished, and then deduct 
 one from the other, according to the formula 
 
 For example, suppose the far point is at eight and the near 
 point at two inches ; then we have 
 
 A 2 8 2-| 
 
 But this method is less certain than that of Prof. Donders, 
 which only requires the patient to accommodate for his far 
 point. Having first neutralized the myopia, which is done by 
 using such concave glasses as render distant objects distinct 
 (No. 20 at twenty feet), the near point is ascertained by requir- 
 ing the patient to read No. 1 of the test types. Suppose this 
 point is found to be at three inches ; then, as r=oo , and p=3 /r , 
 
 we have 
 
 1 1 1 1 
 
 a 3 <» 3. 
 
 If only one pair of glasses is used, it is safest to wear 
 
 those which do not quite neutralize the myopia. If of full 
 
 strength they will be too strong for near vision, and will be 
 
 likely to overtask the accommodation. To prevent this, the 
 
 confirmed myope generally employs only one eye for near ob- 
 
388 PRACTICE OF MEDICINE. 
 
 jects, and thus avoids the convergence of the optic axes re- 
 quired in binocular vision. But this leads insensibly to a still 
 greater evil, namely, divergent strabismus, which is found to be 
 of very frequent occurrence in myopia. We should be careful, 
 therefore, to follow the advice of Prof. Donders, and prescribe 
 only "spectacles so weak as to avoid these results." 
 
 B. — Hypermetropia. 
 
 This affection, the opposite of myopia, was formerly con- 
 founded with presbyopia ; or, rather, the condition now called 
 hypermetropia was regarded as a particular form of presbyo- 
 pia. This opinion, however, was erroneous, the refractive 
 power for distant objects being normal in presbyopia, whereas 
 in hypermetropia it is deficient, in consequence of the shorten- 
 ing of the optic axis ; hence parallel rays are brought to a focus 
 behind the retina, and only convergent rays come to a focus 
 upon it. And since in this affection even parallel rays require 
 an effort of accommodation to concentrate them upon the re- 
 tina, it follows that, although hypermetropic eyes may be able 
 to accommodate themselves to distinct vision for a short period, 
 the constant use of them must soon become fatiguing and pain- 
 ful, especially for near objects. In fact, this is often the most 
 obvious symptom in hypermetropic eyes ; for while there may 
 be no apparent disease existing, the vision being pt^fectly good, 
 the eyes are incapable of continued use, especially upon small 
 objects, without causing so much fatigue and confusion of sight 
 as to compel the patient to desist from his employment, (as- 
 thenopia). 
 
 Prof. Donders divides hypermetropia into three forms, 
 namely, the faculative y the relative, and the absolute. The fac- 
 ulative form is that in which the eye readily accommodates 
 itself for all distances, and the patient experiences no fatigue 
 while at work ; but presbyopia sets in early, accompanied by 
 
HYPERMETROPIA. 389 
 
 symptoms of asthenopia. In the relative form of hyperme- 
 tropia, the eye is also enabled to accommodate itself for any 
 distance, but only by great effort, and by a too strong con- 
 vergence of the optic axes. This form, which generally oc- 
 curs soon after puberty, is always attended with more or less 
 asthenopia. Absolute hypermetropia, on the contrary, is a 
 form in which no effort of the accommodation will enable the 
 patient to see distinctly, without glasses, at any distance. It 
 generally occurs at a later period in life than either of the pre- 
 ceding forms. 
 
 If we examine the hypermetropic eye with the ophthal- 
 moscope, by the direct method, we get an erect image, con- 
 trary to what occurs in the myopic eye ; for if we fix our at- 
 tention upon any of the details of the fundus, such as the optic 
 disc or retinal vessels, and move our head to either side, the 
 image is seen to move in the same direction. By the indirect 
 method, the image appears much larger than it does in the em- 
 metropic eye, in consequence of its being formed further from 
 the object lens. 
 
 As the asthenopic symptoms depending upon hyperme- 
 tropia may be cured by the use of spectacles, it is important, 
 in order to select the proper glasses, to ascertain the actual de- 
 gree of hypermetropia. This is often considerably greater 
 than the manifest hypermetropia, (Hm,) in consequence of a 
 certain amount being rendered latent by the accommodative 
 power, (HI,) which, as we have seen, is exercised to some ex- 
 tent at all distances. Hence it becomes necessary to paralyze 
 the ciliary muscle by Atropine, before we can estimate correct- 
 ly the amount of absolute hypermetropia, (Ha). If we then 
 test the vision for distance, we shall find that the patient re- 
 quires the aid of a convex lens, or if presbyopic, he will require 
 much stronger glasses than he did before the accommodative 
 function was suspended. The power of these glasses being 
 the measure of the absolute hypermetropia, the latter may be 
 expressed by the formula, Ha = --- etc. 
 
 r J 10. 16. 20, 
 
390 PRACTICE OF MEDICINE. 
 
 Having neutralized the hypermetropia by the proper 
 glasses, we may readily ascertain the range of accommodation 
 hy measuring the nearest point at which the patient can dis- 
 tinctly read No. I of the test types with these glasses. In 
 young individuals, in whom the accommodative power is gen- 
 erally very strong, it often amounts to - or even - 
 
 Hypermetropia is of frequent occurrence in childhood, 
 and is often hereditary. It is generally caused, however, by 
 senile degeneration of the lens, the latter becoming more and 
 more flattened and less susceptible of a change of form by the 
 accommodative power. It may also be caused artificially, by 
 removing the lens from the optic axis, as in operations for cat- 
 aract. In these cases, the power of accommodation is entire- 
 ly lost, and the hypermetropia is always absolute. 
 
 According to Dr. Cohn, nearly two-thirds of the cases oc- 
 curring in childhood lead to convergent squint. Later in life 
 it causes accommodative asthenopia. As age increases, the 
 range of accommodation diminishes, and the patient can only 
 see large and remote objects. 
 
 TREATMENT. — We have already pointed out the principles 
 to be observed in the selection of the proper convex glasses, 
 the use of which constitutes the only scientific treatment of 
 this affection. They should be prescribed upon the first ap- 
 pearance of asthenopic symptoms. It is important that they 
 should not be too strong. De Wecker recommends the neu- 
 tralization of the manifest, and about one-fourth of the latent 
 hypermetropia, for near vision ; but even these glasses are 
 sometimes found to be too strong for the patient. The only 
 safe rule is, to prescribe glasses which may be used for a length 
 of time without causing any sense of fitigue or pain to the eye. 
 They will generally be found to be glasses of about thirty 
 inches focus. 
 
 In order to cure the asthenopia, it will often become nec- 
 essary, after a few weeks, to change the first pair of glasses for 
 
ASTIGMATISM. 39 r 
 
 stronger ones. If the hypermetropia is faculative, the cure is 
 generally soon accomplished, and the glasses may then be dis- 
 pensed with ; but if the hypermetropia is relative or absolute, 
 their use, even for distant vision, will require to be continued. 
 The main point in treatment is, to relieve, and at the same 
 time strengthen, the power of accommodation. Hence the 
 patient should never attempt to read or work without the aid 
 of glasses, and should always rest the eyes whenever they be- 
 come weary. He will find it beneficial, also, to follow the 
 advice of Dr. Dyer, and exercise the eyes for a few minutes 
 every day, at stated hours, in reading with proper glasses, grad- 
 ually increasing the time as the eyes improve, observing at the 
 same time not to overtask the accommodative power. 
 
 C— Astigmatism. 
 
 We have hitherto regarded the dioptric apparatus as being 
 perfectly symmetrical, and its different planes as having one 
 and the same focus. But this is not the case even with the 
 normally constructed eye, as it is found that rays entering it 
 in the vertical meridian are generally brought to a focus sooner 
 than those which enter it in the horizontal direction. This 
 variation in the refraction of the eye in different planes, which 
 exists in nearly all eyes, is too slight to exercise any percepti- 
 ble effect upon vision. But abnormal astigmatism, which 
 generally results from a marked want of symmetry in the curv- 
 ature of the cornea, makes the refractive power of the eye so 
 unequal, in one or another of its meridians, as to confuse the 
 retinal image and render it more or less indistinct. Similar 
 effects may also be produced by a similar irregularity in the 
 curvature of the lens, but such cases are comparatively rare. 
 Nor is it every case of irregular corneal refraction that is in- 
 cluded in our inquiry ; for such symptoms as occasionally re- 
 
392 PRACTICE OF MEDICINE. 
 
 • 
 suit from the cicatrization of corneal ulcers have already been 
 
 considered. (See Keratitis, etc.) 
 
 Regular astigmatism may be either simple, compound or 
 mixed. It is called simple when one meridian of the cornea is 
 normal, or emmetropic, and the other myopic or hypermetropic. 
 It is compound when both meridians are myopic or hyperme- 
 tropic, but in different degrees. It is termed mixed astigma- 
 tism when one meridian is myopic and the other hyperme- 
 tropic. 
 
 One of the most convenient tests of astigmatism is, to have 
 the patient look at the cross-bars of a window, and if he sees 
 either the perpendicular or the horizontal bars more clearly 
 than the others, he is astigmatic. Or he may be examined 
 in a similar manner at different distances with Snellen's large 
 test types, say No. LXX or C, and if a point can be found at 
 which one portion of the letters appear clear and the other por- 
 tions indistinct, the defect in vision is due to astigmatism ; 
 otherwise it must be referred to some other cause. 
 
 The readiest method of determining the exact direction of 
 astigmatism, is, to require the patient to look through a steno- 
 paic disc, which consists of a metal plate perforated with a 
 narrow slit. When this slit is held in a proper direction, that 
 is, in a line with the emmetropic meridian of the cornea, the 
 confusion of vision disappears, and the patient can see clearly. 
 The degree of astigmatism may be ascertained by simply plac- 
 ing convex or concave glasses before the slit until we find the 
 number which renders vision most distinct. 
 
 Treatment. — Stenopaic spectacles will suffice to correct 
 simple astigmatism ; but the compound and mixed forms will 
 require convex or concave cylindrical glasses, according as the 
 astigmatism is hypermetropic or myopic. Cylindrical glasses 
 cause no refraction in the plane of their axes, whilst those rays 
 which pass through them at right angles to their axes are re- 
 fracted most. Hence this line of the lens should be so placed 
 
} AMBLYOPIA. 393 
 
 as to correspond with the line of the greatest astigmatism. 
 Sphero-cylindrical glasses are required for compound astigma- 
 tism, one surface being convex- or concave-spherical, to correct 
 the hypermetropia or myopia, and the opposite surface cylin- 
 drical to correct the astigmatism. Mixed astigmatism requires 
 bi-cylindrical glasses for its rectification, one side of which is 
 concave, to suit the myopic meridian of the eye, and the other 
 convex, to suit the hypermetropic meridian. 
 
 The selection is best made by trial. We first ascertain 
 how much vision can be improved by means of the ordinary 
 convex or concave glasses. We then select a convex- or con- 
 cave-cylindrical glass of corresponding strength, and rotate it 
 before the eye until its axis is brought into the right direction 
 to correct the astigmatism. If it is found too weak or too 
 strong we try others. 
 
 Having ascertained by trial the exact angles which the 
 transverse diameter of the glasses makes with that of the eye, 
 the greatest care should be taken to have them set in precisely 
 the same position in the frames, as the least deviation from 
 the proper plane will lessen or destroy their beneficial effect. 
 For the same reason, spectacles are to be preferred to eye- 
 glasses, the latter being less nicely and less securely adjusted 
 to the eye. 
 
 ^.-AMBLYOPIA. 
 
 Amblyopia is a general name, used to denote any form of 
 blindness not due to optical defect. Hence it embraces hy- 
 peresthesia and anaesthesia of the retina, hemeralopia, or night- 
 blindness, and even amaurosis ; though the latter term is some- 
 times confined to cases of complete or absolute blindness, while 
 the various degrees of impaired vision, except such as arise 
 
 from anomalous refraction, are included under the term ambly- 
 50 
 
394 PRACTICE OF MEDICINE. 
 
 opia. In addition to the amblyopic affections above mention- 
 ed, which will be separately considered, we note two distinct 
 forms, namely, such as are due to functional disturbances of 
 the circulation, and those which seem to depend upon a de- 
 praved state of the blood, such as occurs in scarlet or typhus 
 fever. Thus we have what is called ancemic amblyopia, from a 
 deficiency of blood. This may originate in any of the causes 
 which give rise to general anaemia, such as excessive haemor- 
 rhage, hyper-lactation, etc. Congestive amblyopia, on the other 
 hand, generally results from a suppression of some customary 
 discharge, and is due to over-fullness of the vessels of the eye 
 or brain. It is most apt to occur during gestation, amenorr- 
 hcea, etc. Toxcemic amblyopia is commonly due to the pois- 
 onous influence of such agents as tobacco, {amblyopia nicotiana), 
 alcohol, {amblyopia potatorum), quinine, lead, etc. Urcemic 
 amblyopia has ^already been referred to under the head of ne- 
 phrite ietinitis, (which see). Transitory amblyopia sometimes 
 occup»4n;tj^course of low diseases, such as diphtheria, scarla- 
 tina, typhus fever, etc.; and it may also occur in connection 
 with derangement of the stomach from indigestion, disease of 
 the liver, etc. Finally, we have traumatic amblyopia, resulting 
 from concussion, shock, lightning-stroke, etc. 
 
 The ophthalmoscope reveals at first no abnormal appear- 
 ance, unless a slightly hypersemic condition of the retina and 
 optic nerve is regarded as such ; but even this is frequently 
 wanting. Besides, the appearance in question is no greater 
 than is frequently met with in a normal state of vision, and 
 may therefore be regarded as physiological rather than patho^ 
 logical. Subsequently, symptoms of atrophy of the optic 
 nerve make their appearance, and then the disease assumes the 
 character of amaurosis, (which see). 
 
 PROGNOSIS. — This will depend chiefly on the nature of the 
 cause, the length of time the disease has existed, and the age, 
 habits, and constitutional condition of the patient. In most 
 
AMBLYOPIA. 395 
 
 cases progressive atrophy of the optic nerve sooner or later su- 
 pervenes, and then the vision, although it may not be entirely 
 lost, is seldom capable of being fully restored. Von Graefe 
 founds the prognosis upon the state of the pupil, especially in 
 the transitory form of the affection ; for if the pupil reacts un- 
 der the stimulus of light, he- regards the prognosis as favorable, 
 even though all perception of light may have been lost. Cases 
 have occurred, however, in which the pupils have retained their 
 activity, and yet the sight has never returned. This is espe- 
 cially the case with the blindness of pregnancy, many instances 
 of which have terminated unfavorably. 
 
 Treatment. — The treatment of amblyopia should be 
 chiefly directed to the removal of the cause. Thus, anaemic 
 amblyopia requires a liberal and nutritious diet, exercise in the 
 open air, and such internal remedies as Anac, Ars., Chin., Ferr., 
 Igna., Nux v., Phos. ac, etc. Congestive amblyopia, on the 
 other hand, is most frequently benefited by such remedies as 
 are specially suited to the characteristic symptoms, as, for ex- 
 ample, Aeon., Puis., and Sep., in menstrual suppression ; Bry. 
 and Cimicif., in rheumatic cases ; Cactus and Lycop. in heart 
 troubles ; Bell, Cact., Gels., Glon., Phos., and Zinc, in hyperae- 
 mia of the optic nerve ; Nux v., Sec. c. and Zinc, in paralysis 
 of the retina ; Bell., Glon., Phos. and Sang., in cerebral conges- 
 tion, etc. Amblyopia potatorum et nicotiana require the im- 
 mediate and complete abandonment of the use of spirituous 
 liquors and tobacco, and the internal administration of such 
 remedies as are best calculated to invigorate the general sys- 
 tem, especially Ars., Chin., Igna., and Nux v. Amblyopia 
 saturnina has been greatly benefited by Opium. Traumatic 
 cases, and such as result from fright or shock, are best treated 
 with Ars., Coff., Cyp., Hyos., Igna., Scut., etc. 
 
39^ PRACTICE OF* MEDICINE. 
 
 5 -HYPEEJESTHESIA RETINJE. 
 
 SYMPTOMS. — This affection, which is frequently mistaken 
 for inflammation of the retina, is characterized by symptoms 
 of extreme irritation, such as severe photophobia, lachryma- 
 tion and ciliary neuralgia, accompanied in some cases with 
 spasmodic twitchings of the lids. The irritability of the retina 
 is so intense as to give rise to painful photopsies, even in the 
 dark. These generally take the form of spontaneous flashes 
 of light, accompanied with sensations of dazzling before the 
 eyes ; and are greatly aggravated by the least exposure of the 
 eyes to light, or by motion, excitement, exertion, or pressure 
 upon the globe. The sensibility of the retina is so much ex- 
 alted, that former impressions are manifested for an abnormally 
 long period ; and even the power of seeing in the dark (nycta- 
 lopia), or with an insufficient amount of illumination for normal 
 vision, has in some rare instances been observed. The so- 
 called phosphenes, or luminous rings, such as appear when the 
 globe is firmly pressed, likewise occur, either with or without 
 the dazzling sensations and photophobia. Moreover, the for- 
 mer, like the latter, may appear even in complete darkness. 
 In some cases objects are seen as through a mist, or surround- 
 ed by circles of various colors (ckromopsia). 
 
 Examined with the ophthalmoscope, the eye is found to 
 be free from every appearance of disease. The sight is good 
 in a subdued light, but owing to an anaesthetic state of the pe- 
 ripheral portion of the retina, the field of vision is considerably 
 contracted. 
 
 Etiology. — Hyperesthesia of the retina is most frequent- 
 ly met with in patients of an excitable, nervous temperament, 
 especially young and delicate females. It sometimes arises 
 from irritation or congestion caused by exposure to very bright 
 lights ; but the most common cause is straining or over-work- 
 ing the eyes by strong artificial light. It may also result from 
 
ANESTHESIA RETINiE. 397 
 
 -a blow or other accident about the eye ; but in many cases it 
 can be traced to no apparent cause, unless it be an impaired 
 state of the general health, such as comes from a disturbance 
 of the menstrual function, etc. 
 
 Treatment. — Blue glasses, which diminish equally all the 
 rays of the spectrum, should be worn as long as the eyes are 
 sensitive and painful, especially in the open air, and when ex- 
 posed to bright lights. If the photophobia is very severe, it 
 may be necessary for a time to exclude all rays of light from 
 the eyes ; but as the irritation subsides we should gradually ac- 
 custom them to bear the light, which in a mild form is not in- 
 jurious to the retina. 
 
 Internally we should prescribe such remedies as will ben- 
 efit the general health, and at the same time ameliorate the 
 local symptoms. We have generally obtained the best results 
 from Bell., Cimicif., Con., Gels., Merc, Nux v. and Puis,; but 
 have also derived benefit, in suitable cases, from Chin., Hep;, 
 Igna., Nat. m., Sulph., and Tart. em. 
 
 6.-ANJESTHESIA BETING. 
 
 This condition, which consists in a diminished excitability 
 of the retina, is unattended by any objective symptoms. It 
 is chiefly characterized by the very feeble impression which 
 moderate degrees of illumination make upon the eye ; and 
 seems to arise from the blinding effect of intense light upon the 
 nerve elements of the retina, whereby the latter appears to lose, 
 to some extent, its power of responding to the stimulating effects 
 of ordinary degrees of light. One of the most common forms 
 of the affection, snow-blindness, is characterized by a dimness 
 of vision which lasts as long as the affected eyes remain expos- 
 ed to the dazzling reflection of the bright sunlight upon the 
 snow or ice. 
 
398 PRACTICE OF MEDICINE. 
 
 Partial anaesthesia generally results from direct or reflect- 
 ed sunlight, or other strong light, acting suddenly or continu- 
 ously upon the retina ; and usually takes the form of a dark 
 cloud in the centre of the field of vision. This cloud is often 
 temporary, lasting but a few hours ; but it may continue for 
 several weeks or months, and then, if circumstances favor, grad- 
 ually clear up and disappear. When confined to the periphe- 
 ry of the retina, the visual field is more or less contracted, 
 while the degree of central vision is generally but little, if at 
 all, diminished. 
 
 There is a monocular form of anaesthesia, usually called 
 amblyopia exanopsia, which results from disuse of the eye, as in 
 strabismus convergens, (which see). It is also frequently as- 
 sociated with paralysis of the accommodative function. It is 
 generally confined to the central portion of the visual field, and 
 this will commonly serve to distinguish it from other pathogen- 
 etic forms of anaesthesia, in which the periphery is mostly in- 
 volved. 
 
 Treatment. — This should consist in attention to the gen- 
 eral health, regular exercise in the open air, rest and protection 
 of the eyes, and the internal administration of Igna., Nux v., 
 Sec. c, and Zinc. 
 
 7-HEMERALOPIA. 
 
 NIGHT-BLINDNESS. 
 
 Symptoms. — Hemeralopia is characterized by a state of 
 vision in which the patient sees well during the early part of 
 the day, or when objects are brightly illuminated, but imper- 
 fectly towards night. In high grades of the affection, the pa- 
 tient is unable to distinguish even large objects towards the 
 close of the day. This is not simply owing to the time of 
 day, as was formerly supposed, but chiefly to the diminished 
 intensity of the light ; for it is observed that, cceteris paribus. 
 
HEMERALOPIA. 399 
 
 the degree of amblyopia corresponds with the amount of illu- 
 mination, the patient being able to see even at night, provided 
 the artificial light is sufficiently bright. It is true, however, 
 that the patient can always see best in the morning ; but this 
 may be accounted for, in part, by the reinforcement, so to 
 speak, of the retinal sensibility during the night. It appears, 
 therefore, that the dimness of vision is due to torpor of the re- 
 tina ; an abnormally great amount of light being required in 
 order to see distinctly. 
 
 In the morning, or when there is sufficient illumination to 
 see clearly, the pupil is generally of normal size and mobility ; 
 but as night approaches, and the illumination decreases, it usu- 
 ally becomes dilated and sluggish. In old and severe cases, 
 however, the pupil is always enlarged and torpid, and it requires 
 the stimulus of a very strong light to excite contraction. 
 
 Hemeralopia is not always equally developed in both eyes, 
 the patient being able sometimes to discern objects with one 
 eye and not with the other ; or perhaps some parts of the 
 visual field may be clouded over, while in the other eye it may 
 be clear, and admit of a certain degree of indirect vision. 
 
 ETIOLOGY. — The chief predisposing cause of this affection 
 is an impoverished state of the blood, in consequence of which 
 the nerve elements of the retina are insufficiently nourished. 
 This accounts for the fact that soldiers and sailors suffering 
 from scorbutic diseases, are especially prone to be affected with 
 the disease. We also find that by far the largest number of 
 hemeralopes are individuals whose constitutions have become 
 impaired by severe illness, or whose general condition is one 
 of debility. It is likewise owing to this cause, doubtless, that 
 the disease sometimes prevails epidemically in camps, jails, 
 poverty-stricken fever-districts, etc. 
 
 The principal exciting cause of night-blindness is pro- 
 longed exposure to intense and unaccustomed light. Hence 
 its frequent occurrence in the spring and summer, increasing 
 
400 PRACTICE OF MEDICINE. 
 
 in clear, and diminishing in cloudy weather. Hence, also, its 
 frequent appearance amongst harvest hands, soldiers who 
 exercise much in the sunlight, and sailors who are similarly- 
 exposed within the tropics. 
 
 Treatment. — The chief indications are, to restore the 
 general health, and protect the eyes from bright light. If the 
 case is very severe, or very chronic, the speediest way to effect 
 a cure is, to apply a binocular bandage, or else confine the 
 patient in a dark room, and feed him with the most nourishing 
 and easily-digestible food, soups, etc. In this way, protracted 
 cases have been cured in a very few days. 
 
 Internally, the following remedies, which have given great 
 relief in some cases, may be prescribed, the selection depending 
 mainly upon the general condition of the patient : — Arg. nit., 
 Chin., Hyos., Lyco., Ranun. bulb., Stram., and Sulph. 
 
 8.-AMAUR0SIS. 
 
 The term Amaurosis was formerly used to denote any 
 impairment or loss of vision depending upon congestive, 
 inflammatory, organic, or functional disease of the nervous 
 apparatus of the eye, whether seated in the retina, optic nerve, 
 or brain. At present its signification is more restricted, the 
 term being mostly confined to cases depending upon degenera- 
 tive atrophy of the optic nerve, while those arising from 
 irregularities in the circulation of the nervous system, are 
 included under the head of amblyopia, (which see). Amaurosis 
 therefore differs from other amblyopic affections in being both 
 functional and organic. 
 
 SYMPTOMS. — The only characteristic symptoms of amauro- 
 sis are ophthalmoscopic. Of these, the most marked are : 
 a faint, white or bluish-white appearance of the papilla ; an 
 absence, or diminution in the size of the nutritive 
 vessels of the disc ; a contraction and attenuation 
 
AMAUROSIS. 401 
 
 of the retinal vessels, especially the arteries ; and an 
 opaque, somewhat irregular but sharply defined optic 
 disc, which is often slightly excavated. The amaurotic 
 excavation is liable to be mistaken for the physiological 
 excavation, which is congenital and frequently seen in the 
 normal eye, unless we bear in mind that in the latter the other 
 symptoms of atrophy above-mentioned are absent, the optic 
 nerve being in its normal state. In the amaurotic excavation, 
 the retinal vessels are never displaced, as in glaucoma, the 
 cavity being so shallow, and its edges sloped so gradually, that 
 the vessels appear to pass over a nearly level surface. In 
 many cases of spinal amaurosis, a bluish, or bluish-green 
 discoloration of the papilla is especially marked, and is best 
 seen by the direct method of examination. In other cases the 
 disc appears pale and white, sometimes as white as paper. 
 This is particularly the case in the form of cerebral amaurosis 
 caused by the excessive use of tobacco. In the first stage of 
 the tobacco amaurosis, which is one of congestion and very 
 transitory, the disc is abnormally red ; this is followed by 
 pallor of the outer half, or the part nearest the macula lutea ; 
 finally, the whole disc becomes pale, white, and in an advanced 
 state of atrophy. These changes all occur within a few 
 months, during which the sight becomes progressively impaired, 
 and often extinct. 
 
 Etiology. - The most frequent cause of amaurosis is 
 basilar meningitis, especially the chronic form. It may also 
 be produced by chronic periostitis at the base of the brain, or 
 by tumors within the brain or cerebellum. Other causes are : 
 cerebral hemorrhages, epilepsy, and diseases of the spinal cord, 
 especially chronic myelitis and locomotor ataxy. 
 
 PROGNOSIS. — This will depend mainly upon the cause, 
 the mode of attack, the state of the field of vision, and the 
 condition of the optic nerve. All cases, of course, are serious, 
 and should be considered more or less doubtful ; hence the 
 
402 PRACTICE OF MEDICINE. 
 
 prognosis should always be guarded. Sudden attacks are gen- 
 erally less unfavorable than the more gradual, especially in the 
 case of children. Cases that remain stationary for a consider- 
 able period are also hopeful, as they usually depend upon 
 causes which are removable, or which are more or less amena- 
 ble to treatment, such as the too free use of alcohol or tobacco, 
 or some disorder of the stomach, liver, or uterine system, etc. 
 So, also, if the visual field remains uncontracted for a consid- 
 erable time after the disease sets in, or if the edges of the field 
 are regular and well-defined, the prognosis is not altogether 
 bad. On the other hand, irregular contractions, occurring rap- 
 idly in both eyes,are very unfavorable ; and so, also, are central 
 scotomata, especially if the peripheral portions of the field are 
 likewise affected. Although the appearance of the optic nerve 
 is not sufficient of itself to determine the result, yet atropic 
 changes in it are always of serious import, and, in most cases, 
 render the prognosis very unpromising. 
 
 Treatment. — These cases will generally tax the skill of 
 the practitioner to the utmost. To be successful even in a 
 small proportion of cases, he will need to pay particular atten- 
 tion to the cause, and to select his remedies with the greatest 
 care. The hints and indications given under the head of Am- 
 blyopia, are no less appropriate to the treatment of Amaurosis, 
 and will be suggestive. In addition to electricity and the hy- 
 podermic injection of Strychnia, both of which have been used 
 with benefit, the following remedies, which have proven suc- 
 cessful in some cases, should be carefully studied : -Aeon., 
 Ars., Bell., Calc. c, Cimicif., Crotal., Gels., Glon., Hep., Igna., 
 Lycop., Merc, Nat. m., Nux v., Phos., Puis., Ruta g., Sant, Sec. 
 c, Sep., Sulph., Zinc. 
 
DISEASES OF THE EYE. 403 
 
 9.-MYDRIASIS. 
 
 ABNORMAL DILATATION OF THE PUPIL. 
 
 SYMPTOMS.-^-This is a functional disease of the iris, char- 
 acterized by an abnormal dilatation and immobility of the 
 pupil. As slight degrees of dilatation seldom produce any 
 special inconvenience, they are not apt to attract attention ; 
 and hence the term is only applied to those cases in which the 
 dilatation is well marked. The pupil is not always regular, 
 the opening being sometimes greater in one direction than in 
 another. Whatever may be its shape and size, the pupil is 
 generally more or less fixed, varying but little, if at all 
 under the stimulus of light, or from use. It is also less black 
 than the normal pupil, in consequence of the increased illumi- 
 nation of the fundus. The affection is generally confined to 
 one eye. 
 
 Vision is commonly more or less impaired, especially for 
 near objects. This arises partly from glare or dazzling, in 
 consequence of the dilated state of the pupil, and partly from 
 the circles of dispersion formed upon the retina, in consequence 
 of the loss of accommodation. The latter, however, is not 
 always present, nor is there any fixed or necessary relation be- 
 tween it and the degree of dilatation ; for this may be extreme 
 and the ciliary muscle but little affected, and, on the other 
 hand, if the mydriasis is but slight, the power of accommoda- 
 tion may remain unimpaired. 
 
 Etiology. — The causes of mydriasis, though numerous, 
 may be reduced to a very few heads. When binocular, the 
 disorder is due to some deep-seated intra-ocular disease affect- 
 ing the sensibility of the retina, or to certain diseases of the 
 brain, such as basilar meningitis, apoplectic effusions at the 
 base of the brain, chronic hydrocephalus, and diseases of the 
 cerebellum. In the great majority of cases, however, the my- 
 
404 PRACTICE OF MEDICINE. 
 
 driasis is monocular, and is caused either by spasm of the dila- 
 tor pupillae and of the vessels of the iris, arising from irritation 
 of the oculo-pupillary branches of the sympathetic nerve — in 
 which case the ciliary muscle, and consequently the power of 
 accommodation, remains unaffected — or else it depends upon 
 paralysis of the constrictor pupillae, in consequence of injury to 
 the conducting power of the third nerve. In these cases there 
 is often more or less paralysis of the accommodation, and in 
 some instances the entire region supplied by this nerve is im- 
 plicated, and then it is generally considered to be of rheumatic 
 origin. In some cases, however, it is undoubtedly syphilitic. 
 When due to irritation of the sympathetic ganglia, it can some- 
 times be traced to helminthiasis, spinal irritation, derangement 
 of the digestive organs, etc. To the same class, also, belongs 
 the ephemeral mydriasis which has been observed only at cer- 
 tain hours of the day, and which, as pointed out by Von Grsefe, 
 is sometimes premonitory of insanity. 
 
 Treatment. — This should be especially directed to the 
 removal of the cause; foralthough Atropine, Bell, and other my- 
 driatic remedies are homoeopathic to the condition of the iris, 
 they cannot be expected to prove curative unless the cause it- 
 self be removed. Hence, rheumatic cases call for such rem- 
 edies as Bry., Cimicif., Colch;, Rhus., etc.; syphilitic cases for 
 Merc, Kali iod.; traumatic cases, Arnica ; helminthiasis, Sant; 
 paralysis, Nux v., Rhus., etc. When associated with paralysis, 
 the treatment should generally be similar to that recommended 
 for paralysis of the ocular muscles, (which see). 
 
 10.— MIOSIS, 
 
 ABNORMAL CONTRACTION OF THE PUPIL. 
 
 Symptoms. — This affection, the opposite of mydriasis, is 
 characterized by extreme contraction of the pupil, which is 
 sometimes reduced to the size of a pin's head, and even less. 
 
PARALYSIS OF THE OCULAR MUSCLES. 405 
 
 The pupil is regular in form, black, extremely limited and slug- 
 gish in its movements, and yields but slightly to the influence 
 of Atropine. 
 
 Vision is generally impaired in proportion to the degree 
 of contraction, the field of vision being greatly diminished and 
 but feebly illuminated. In some cases the patient can see 
 only during the middle hours of the day ; in other cases he 
 may be almost totally blind. 
 
 ETIOLOGY. — Myosis may be due to paralysis of the radi- 
 ating fibres of the iris, or to spasm of the constrictor pupillae. 
 The former is most frequently met with in disease or injury of 
 the cervical portion of the spinal cord ; the latter in iritis and 
 inflammations accompanied by great irritation of the ciliary 
 nerves. It may also be caused by too great and long contin- 
 ued use of the eyes in the examination of very small objects, 
 as in watch-making, engraving, etc. 
 
 Treatment. — As this disease is very rarely idiopathic, 
 the treatment, to be effective, should be especially directed to- 
 wards the removal of the cause. Simple idiopathic cases 
 would probably be benefited by such remedies as Opium, Physo- 
 stigma ven., etc. 
 
 1L-PABALYSIS OP THE OCULAR MUSCLES. 
 
 SYMPTOMS. — The symptoms vary according as the paraly- 
 sis is complete or partial ; that is, according as it affects all or 
 only a part of the muscles supplied by a particular nerve. 
 Most frequently the affection is limited to the muscles furnish- 
 ed by the third nerve, or motor oculi, namely, the rectus supe- 
 rior, inferior, and internus. If the paralysis is complete, we 
 have, in the first place, ptosis, or dropping of the upper lid, 
 while the motion of the globe is restricted in the upward, down- 
 ward, and inward directions ; but as the rectus externus still 
 retains its power, the eye is readily turned towards the temple, 
 
406 PRACTICE OF MEDICINE. 
 
 and may also be rolled somewhat downward and outward, 
 through the action of the superior oblique. Subsequently, the 
 sixth nerve generally becomes affected, and then the paralysis 
 extends to the rectus externus. In this case the eye can no 
 longer be turned towards the temple, but looks directly for- 
 ward. Occasionally the fourth nerve becomes implicated, and 
 gives rise to paralysis of the superior oblique. 
 
 Diplopia, or double vision, is a very annoying symptom in 
 these cases, and is sometimes the only one of which the patient 
 complains. This symptom is always experienced when the 
 patient endeavors to look in the direction opposite to that as- 
 sumed by the affected eye. Thus, in paralysis of the superior 
 rectus, the inferior oblique muscle will cause the eye to deviate 
 outward, and crossed double images will appear in the upper 
 half of the field of vision. On the other hand, if the paralysis 
 affect the superior oblique, the deviation of the visual line will 
 be but slight, the double images will be homonymous — that is, 
 on the same side — and will be confined to the lower half of the 
 visual field. 
 
 Etiology. — Paralysis of the ocular muscles is most fre- 
 quently found to be due to syphilis. Von Graefe refers nearly 
 one-third of all cases to this cause. Many cases, however, are 
 of rheumatic origin, or arise simply from exposure to damp and 
 cold. Others, again, may be produced by some centrally act- 
 ing cause, such as cerebral hyperaemia, effusion of blood, 
 softening of the brain, hydrocephalus, etc. Occasionally, also, 
 syphilitic nodes, tuberculous deposits, and tumors of various 
 kinds, are so situated at the base of the brain, or within the 
 orbit or cranium, as to press injuriously upon the affected 
 nerves, and thus cause paralysis of the muscles to which they 
 are respectively distributed. 
 
 Treatment. — Recent cases, especially those of a rheu- 
 matic or syphilitic nature, are found to be the most amenable 
 to treatment. Bry., Caust, Cimicif., Euphr., and Rhus, are 
 
PARALYSIS OF THE OCULAR MUSCLES. 407 
 
 generally indicated in the former, and Aurum, Kali iod., and 
 Merc, in the latter. Of these, Causticum is the one most fre- 
 quently and successfully employed, especially where the paral- 
 ysis is caused by exposure to cold. The following remedies 
 have also been recommended in particular cases : — Arnica for 
 paralysis resulting from a blow or other injury ; Cup. acet. for 
 paralysis of the nervus abducentis ; Senega for paresis of the 
 superior rectus or superior oblique, especially when the diplo- 
 pia is relieved by bending the head backwards ; and Spigelia 
 when accompanied with sharp, stabbing pains. Alum., Con., 
 Gels., Hyos., Igna., Nux v., Phos., and a few other remedies, 
 have also been employed with advantage, when indicated by 
 constitutional or other general symptoms, but not so frequent- 
 ly as those above mentioned. 
 
 Galvanic electricity has relieved a large number of cases, 
 and may often be advantageously associated with internal treat- 
 ment. According to Benedict, who cured no less than seven- 
 teen out of twenty-seven cases by galvanization, the curative 
 action takes place, not by the direct excitation of the paralysed 
 nerve, but by a reflex irritation through the fifth nerve. The 
 same authority states, that in most cases a curative action is 
 only observed when the galvanic current is relatively weak. 
 
 Prismatic glasses are sometimes used to neutralize the di- 
 plopia, by making the double images to coincide. They may 
 also be used therapeutically, by adapting them to the eye in 
 such a manner as merely to approximate the images, the para- 
 lyzed muscles being benefited by the efforts to unite them. 
 
 If all other means fail, and the affected muscle is not too 
 much disabled to be incapable of producing the requisite de- 
 gree of contraction, the abnormal direction of the eye may 
 sometimes be remedied by tenotomy of the opposing muscle, 
 as described under the head of Strabismus, (which see). 
 
408 PRACTICE OF MEDICINE. 
 
 12-NYSTAGMUS. 
 
 This affection consists in a tremulous or oscillatory move- 
 ment of the eye-balls. The oscillations, which are involunta- 
 ry and exceedingly rapid, vary in direction, being either hori- 
 zontal, oblique, or rotatory. In most cases the movements oc- 
 cur simultaneously in both eyes, and in the same direction ; 
 but sometimes they take place alternately, and in different di- 
 rections. The oscillations are not generally perceptible to the 
 patient, nor do they prevent his seeing objects in their true re- 
 lations ; but they always impair the sight, rendering the retinal 
 images more or less confused, in proportion to the severity and 
 extent of the movements. It is also observed that, although 
 the eyes appear to act in concert, and the movements take 
 place simultaneously, the condition of the sight is often very 
 different in the two eyes, and binocular vision is more or less 
 disturbed. It is especially difficult for the patient to obtain a 
 correct view of small objects, and even large ones, if numerous, 
 or in a state of motion, may produce confusion and uncertainty. 
 This is remedied to some extent by a habit which the patient 
 acquires of involuntarily and unconsciously moving his head in 
 a contrary direction to the movements of his eyes, by which he 
 is often enabled to keep the visual axes fixed upon the object 
 under examination. 
 
 Etiology. — The chief cause of nystagmus appears to be, 
 over exertion of the ocular muscles in maintaining the necessa- 
 ry convergence of the optic axes for very near vision. This 
 over-taxing of the external muscles is generally produced by 
 holding objects very near the eyes, in cases of myopia, central 
 and other partial cataracts, opacities of the cornea, strabismus, 
 functional diseases of the optic nerve and retina, etc. 
 
 Treatment. — As nystagmus usually sets in during in- 
 fancy, there is some chance for it to diminish or disappear in 
 
STRABISMUS. 409 
 
 after life ; but as a general rule it undergoes but little change 
 or improvement, even under the most suitable treatment. This 
 is due, no doubt, to the fact that a cure can only be effected by 
 restoring acuteness of vision to the diseased eyes, and this is 
 seldom possible in this class of cases. But good results are 
 sometimes obtained by diminishing or neutralizing the impair- 
 ment of vision, correcting errors of refraction, and employing 
 the eyes in such occupations as will avoid all straining of the 
 ocular muscles. We may also derive benefit in some cases 
 from the internal use of Agar., Calab., Hyos., Igna., Kali brom., 
 Nux v., Puis., and Sant. 
 
 12.-STRABISMUS. 
 
 Although the various forms of squint and their surgical 
 treatment have been long known to the profession, yet it has 
 been only within a comparatively recent period that our pres- 
 ent more accurate knowledge of the pathology of strabismus, 
 the result of a careful re-investigation of the whole subject, has 
 been obtained. To Prof. Donders, especially, the profession are 
 indebted for the first correct view of its nature, and of the inti- 
 mate relations which it sustains to the eye as an organ of vision. 
 He has clearly shown that, in the beginning, it is in most in- 
 stances only a symptom resulting from certain conditions of re- 
 fraction ; but that after it has once become established it fre- 
 quently proves highly injurious to vision, and may even lead to 
 its entire destruction. We are also indebted to his investigations 
 for our knowledge of the highly important fact, that one form 
 of strabismus frequently depends upon myopia, and the oppo- 
 site form upon hypermetropia. 
 
 By the term squint, or strabismus, (strabismus concomitans) 
 we understand an inability to direct both visual lines simulta- 
 neously upon the same point. If the eye squints inward it is 
 called convergent strabismus ; if outward, divergent strabis- 
 
4IO PRACTICE OF MEDICINE. 
 
 mus; if the deviation is upward, it is called strabismus sursum- 
 vergens ; if downwards, strabismus deorsumvergens. If con- 
 fined to one eye it is monocular or monolateral; if it alternates 
 between the two eyes it is alternating or bilateral. 
 
 Strabismus is also divided into real and apparent, periodic 
 and permanent. Apparent strabismus is a form in which, 
 though there is a well marked convergent or divergent devia- 
 tion of the optic axis, as in real squint, both eyes are neverthe- 
 less fixed upon the object, and neither of them undergo the 
 slightest movement when the other is closed. Periodic squint 
 is occasionally merely a reflex symptom, as in dentition, but 
 generally its pathology is the same as that of confirmed stra- 
 bismus, of which it is usually but the forerunner. 
 
 A.— Convergent Strabismus. 
 
 As already defined, convergent strabismus is characterized 
 by excessive convergence of the visual lines. The conver- 
 gence takes place only during binocular vision ; for if the more 
 healthy eye is screened, the squinting eye changes its position 
 and looks forward. This also proves that the squinting eye is 
 but little concerned in ordinary vision. In these cases, if the 
 squinting eye is covered, the more healthy one will be found to 
 squint. This is called the secondary squint, and is generally 
 equal to that of the eye chiefly affected ; but in confirmed stra- 
 bismus it is usually more difficult for the squinting eye to di- 
 rect its visual line towards a given point than it is for the other. 
 In paralytic squint, on the contrary, the secondary deviation is 
 the greater. This serves as a ready means of distinguishing 
 it from concomitant squint, in which, as we have seen, the pri- 
 mary and secondary movements are equal. 
 
 The extent of the squint may be determined with sufficient 
 exactness by first marking upon the lower lid the precise situa- 
 tion of the pupil or edge of the cornea, when the squinting eye 
 is turned strongly inward or outward, and then, having cover- 
 
CONVERGENT STRABISMUS. 41 1 
 
 ed the healthy eye and fixed the other upon some convenient 
 object, measuring the distance between their present and for- 
 mer position. 
 
 Convergent squint is generally due to hypermetropia. 
 The latter is found to be present in about eighty per cent, of 
 the cases of convergent strabismus. The reason it is so often 
 overlooked in these cases is, doubtless, because the majority of 
 the patients are too young to read. This will also account 
 for the fact that periodic squint generally first appears at about 
 the fourth or fifth year, or when the child is learning to read 
 and spell. The explanation is this : In the hypermetropic 
 eye the refractive power is too low, parallel rays reaching the 
 retina before being focused, thus creating circles of dispersion 
 upon that membrane, and thereby rendering the vision indis- 
 tinct. To remedy this defect, the hypermetropic eye is oblig- 
 ed to accommodate for distance, just as the normal or emme- 
 tropic eye does for near objects. And since near vision re- 
 quires a still greater strain of the accommodation, the accom- 
 modative faculty, which in hypermetropic eyes is never at rest, 
 is soon over-worked. In order to lessen the strain, and at the 
 same time increase the power of accommodation, one eye 
 squints inward. At first it is periodic, occurring only when 
 viewing near objects ; but as the habit becomes confirmed it 
 becomes more and more frequent, and finally it takes place at 
 all distances, and the strabismus becomes permanent. It is 
 not surprising, therefore, that hypermetropia should be a 
 frequent cause of convergent squint. The only wonder is that 
 it does not occur more frequently amongst hypermetropes than 
 it does. Prof. Donders thinks it arises from an effort to avoid 
 double vision ; for if one eye of a hypermetrope is screened, it 
 will soon turn inward when the other is fixed upon near objects. 
 On the other hand, if the degree of hypermetropia is greater 
 in one eye than in the other, or if, in consequence of opacity, 
 the defect of vision is greater, the tendency to squint is 
 
412 PRACTICE OF MEDICINE. 
 
 increased, the annoyance from diplopia being no longer 
 sufficient to prevent it. In fact, next to hypermetropia, no 
 more frequent cause of strabismus is known, than impaired 
 vision. It is often seen in cases of opacity of the cornea and 
 lens, or in some affection of the deeper structures of the eye in 
 which the retinal image is rendered indistinct. In order to 
 avoid the confusion resulting from the difference in the visual 
 power of the two eyes, the patient involuntarily squints with 
 the diseased or more defective eye. The strabismus soon 
 becomes confirmed, and finally amblyopia from non-use of the 
 eye is added to the defect of vision already existing. It 
 should not be forgotten, however, that in many of these cases 
 hypermetropia is also present, and may constitute the chief 
 cause of the complaint. 
 
 B.— Divergent Strabismus. 
 
 As convergent strabismus is generally associated with 
 hypermetropia, so divergent squint is most frequently met 
 with in connection with myopia. And as the latter is most 
 marked at a later period of life than the former, so divergent 
 strabismus generally occurs later, not manifesting itself in 
 some cases until after the formation of extensive posterior 
 staphyloma. In fact, this is the chief reason that myopes are 
 so frequently subject to divergent strabismus. For, as we have 
 seen, the elongation of the antero-posterior diameter of the 
 globe in myopic eyes, is due in a great measure to the yielding 
 of the posterior portion of the globe, which gives it more or 
 less of an ellipsoidal shape. In consequence of this extension, 
 the mobility of the globe is diminished, and the difficulty of 
 rotating it in the orbital cavity is correspondingly increased. 
 Now, as myopic vision requires a very great convergence of 
 the optic axes, and as this is rendered impossible by reason of 
 the ovoidal shape of the globe, it follows that binocular 
 
TREATMENT OF STRABISMUS. 413 
 
 vision for near objects cannot be maintained without extieme 
 exertion. The internal recti muscles soon become fatigued in 
 the attempt to maintain the necessary inclination of the optic 
 axes, and so to relieve the muscular weariness, and the asthen- 
 opic symptoms arising from the strong efforts at accommoda- 
 tion, one eye is allowed to diverge, giving rise to one of the 
 most common forms of divergent strabismus. But Prof. 
 Donders has shown that divergent squint may also be produced 
 whenever the degree of myopia becomes so excessive as to 
 require too great a convergence of the optic axes for distinct 
 vision, or in other words, whenever objects have to be brought 
 so close to the eyes that the requisite amount of convergence 
 for clear vision cannot be obtained. This is most likely to 
 happen if the internal recti muscles are relatively weak. 
 Divergent squint is also apt to occur if one eye is amblyopic, 
 or more myopic than the other, the diseased eye deviating 
 outward, in consequence of the patient relinquishing all effort 
 at binocular vision. This form of relative divergence may 
 therefore be denominated passive. 
 
 TREATMENT OF STRABISMUS. 
 
 This will differ according as the squint is either paralytic 
 or concomitant, convergent or divergent, periodic or permanent. 
 If dependent on nervous irritation, the removal of the 
 primary disease will be required. Thus, squint arising 
 from dentition is best treated by such remedies as Aeon., 
 Bell., Cham., Coff., etc. If dependent on verminous affec- 
 tions, we should give Cina, Cyclamen, Merc, Sant, Sep., 
 Spig., Sulph., etc. Pertussis calls for such remedies as Bell., 
 Cast., Cin., Cupr., Dros., Phos., Verat., etc. When produced by 
 spasm and convulsions, we may give Agar., Bell., Cic, Cycla., 
 Hyos., Stram., Tabac, etc. 
 
 Recent cases depending on hypermetropia or myopia may 
 be frequently corrected by using suitable convex or concave 
 
414 PRACTICE OF MEDICINE. 
 
 glasses, so as to neutralize the errors of refraction. If this is 
 not done, the squint will soon become permanent, and then 
 tenotomy of the affected muscle will be required. 
 
 As true concomitant squint, when confirmed, can only be 
 cured by an operation, the surgeon cannot insist too strongly 
 on its early performance, more especially as the neglect to 
 perform it has, in thousands of instances, resulted in the loss 
 of sight. The operation consists in dividing the tendon of 
 the muscle in whose direction the squint occurs, thus permitting 
 it to recede slightly, so that it may reattach itself somewhat 
 further back. As the pain is severe, nervous persons and 
 children will require to be anaesthetized. Then, having separ- 
 ated the lids by the stop-speculum, (PL II, Fig. 33), an assistant, 
 if the case is one of convergent strabismus, turns the globe 
 outwards with a pair of fixing forceps, (Figs. 36, 37); and the 
 surgeon, seizing a small fold of the conjunctiva with a pair of 
 delicate forceps near the lower margin of the insertion of the 
 internal rectus, snips it through with the scissors, being careful 
 to make the incision small, so as to obtain, as nearly as possible, 
 the advantages of a sub-conjunctival operation. Having 
 separated, to a limited extent, the sub-conjunctival tissue from 
 the muscle, the surgeon now inserts the strabismus hook 
 (PI. I, Fig. 17), beneath the tendon, to hold it and raise it from 
 the globe, and it is then carefully divided close to its insertion 
 in the sclerotic, unless we desire to increase the effect to be 
 produced, when the division may be made farther back ; but, 
 on the other hand, if we desire to limit the effect of the 
 operation, the edges of the external wound should be brought 
 together with a suture. It was formerly the practice in cases 
 requiring only a slight degree of correction, say of from one 
 to one and a half lines, to sever the tendon only partially, 
 leaving a few of the upper or lower fibres undivided ; but this 
 is not found to answer the purpose. 
 
 Owing to the great change in the form of the globe, and 
 
TREATMENT OF STRABISMUS. 415 
 
 the consequent difficulty experienced by the internal recti in 
 overcoming the deviation, after section of the external rectus 
 for divergent strabismus, it is frequently desirable to keep the 
 eye in a position of forced inversion, until the rectus externus 
 has acquired a new union with the globe at a point further back 
 than would be the case if left to itself. This may be accom- 
 plished by passing a suture through the conjunctiva near the 
 inner edge of the cornea, and then attaching it to the skin 
 near the inner canthus. The suture will cut itself out in the 
 course of two or three days, but if the patient is careful not to 
 make undue traction upon it, it will not do so until after the 
 muscle has formed the requisite attachment. 
 
 The question as to whether we should operate upon one or 
 both eyes does not depend upon whether or not both eyes are 
 affected with squint, but solely upon its extent. It is found by 
 experience that a deviation of from two and a half to three 
 lines is all that can be overcome by a single operation ; and 
 therefore if the deviation exceeds this amount, we should 
 divide it between the two eyes, assigning the greater amount of 
 correction to the squinting eye, in order to diminish as far as 
 possible the muscular effort. 
 
 After the strabismus has been rectified by division of the 
 muscle, if there is any coexisting hypermetropia or myopia, it 
 should be immediately neutralized by the proper convex or 
 concave glasses, as already explained under the head of anom- 
 alies of refraction. This is necessary in order to secure 
 binocular vision, to prevent a recurrence of the deformity, and 
 to overcome the amblyopia due to the long disuse of the eye. 
 The amblyopia is often greatly improved after the operation, 
 especially if the sight is exercised with strong and suitable 
 glasses. 
 
416 PRACTICE OF MEDICINE. 
 
 14 -EXOPHTHALMIC BRONCHOCELE. 
 
 MORBUS BASEDOWII, GRAVES' DISEASE, ETC. 
 
 Symptoms. — This disease, the pathology of which is not 
 well understood, is characterized by certain functional disturb- 
 ances of the circulation, which give rise to violent palpitations 
 of the heart, bronchocele, and exophthalmos. The palpitations, 
 and other cardiac symptoms, generally occur in paroxysms, 
 and are usually accompanied by more or less nervous excite- 
 ment and dyspnoea. At first the patient may complain only 
 of weariness and exhaustion; but the breathing is almost 
 always difficult ; the mucous membranes are pale and anaemic, 
 especially the conjunctivae ; digestion is apt to be more or less 
 disturbed ; and, if we notice particularly, we may observe a 
 peculiar staring expression about the eyes. As the disease 
 progresses, the hearts' action becomes strong and tumultuous, 
 and is accompanied by loud systolic murmurs ; the paroxysms 
 of dyspnoea increase in severity and frequency, during which 
 the vessels of the neck frequently beat with great violence ; 
 the pulse, which previously was large, full, and perhaps not 
 more than 80 or 100 per minute, now ranges from 120 to 150, and 
 is irritable and jerking ; the thyroid gland becomes enlarged ; 
 the exophthalmos increases, so that the lids no longer cover 
 the globes ; the stomach becomes still more disturbed, and the 
 debility more marked ; and, as the disease reaches its height, 
 the respiration becomes shorter, more accelerated, and frequently 
 orthopnceic. Some of these symptoms, however, are not always 
 present, especially those connected with derangement of the 
 stomach. On the other hand, the digestive troubles may 
 become still more pronounced, giving rise to dyspepsia, severe 
 
EXOPHTHALMIC BRONCHOCELE. 417 
 
 and even bloody vomiting, diarrhoea, hemorrhage from the 
 bowels, etc. 
 
 Bronchocele is generally, but not always present in Base- 
 dow's disease. An interesting case of this kind has been reported 
 by Dr. J. E. Morrison. The patient was a woman, aged 33, of 
 nervous temperament, inclined to hysteria; menses "interrupted" 
 since the third month after their first appearance. The cata- 
 menia usually appeared in the morning and flowed until noon, 
 then suddenly ceased, or they would last from half an hour to 
 six hours, intermitting in this manner for ten or twelve days. 
 During the menstrual period there was active congestion of the 
 genital organs, with puffiness of the parts on and around the 
 pubis and vulva, exophthalmos, and forcible and tumultuous 
 action of the heart, which could be heard several feet from the 
 bed. 
 
 The exophthalmos is generally binocular, but does not 
 usually become very manifest until some time after the 
 appearance of the cardiac symptoms and goitre. Like the 
 latter it often varies considerably, especially during the first 
 stage, sometimes almost disappearing, at others becoming so 
 considerable that the lids cannot be closed. The protrusion of 
 the globe, which, as well as the swelling of the thyroid gland, 
 has been found to depend upon a dilatation of the vessels, 
 particularly of the veins, — generally occurs in an oblique 
 direction, and most frequently towards the inner or nasal side. 
 In consequence of the long-continued exposure of the cornea 
 to atmospheric and other irritating influences, the epithelial 
 layers become dry and rough, the xerosis increasing with 
 the degree and duration of the exophthalmos. Sometimes, also, 
 ulcerations of the cornea occur, which if unchecked may even 
 lead to perforation, and, finally, to atrophy of the globe. At 
 the same time the lids and conjunctivae become more or less 
 swollen and inflamed, and in some cases there are disturbances 
 of vision ; but the latter are generally caused by the coexisting 
 
418 PRACTICE OF MEDICINE. 
 
 xerosis, dilatation of the pupil, etc., and very rarely by real 
 amblyopia or amaurosis. 
 
 PATHOLOGY. — As already stated, the exopthalmos is found 
 to be due, in the first place, to a hyperaemic swelling of the 
 adipose cellular tissue of the orbit, which afterwards becomes 
 more or less hypertrophied. This swelling, which may 
 generally be diminished by pressure, is said by Virchow to 
 rapidly disappear after death. But the true nature of the 
 disease, and the relation which the cardiac affection sustains to 
 the bronchocele and exopthalmos, are still involved in much 
 obscurity and doubt. Some have referred the disease to 
 anaemia ; but anaemia, even when it gives rise to palpitations 
 and cardiac murmurs, is not generally associated with goitre 
 and exophthalmos, nor do these affections produce anaemia. 
 Others, again, have attributed the protrusion of the eyes to the 
 pressure of the enlarged gland upon the cervical vessels ; but, 
 as we have seen, the disease may occur without any enlargement 
 of the thyroid, and on the other hand very large bronchoceles 
 exist without any exophthalmos. The most rational and 
 generally received theory is that which refers the disease to 
 functional disturbances of the central parts of the sympathetic 
 nerve. Not only do the general symptoms point to disturb- 
 ances of the vaso-motor centres, but the almost numberless 
 complications of the disease, many of which are of an extremely 
 variable and transient character, appear strongly to confirm 
 this view of its origin. 
 
 ETIOLOGY. — The disease is generally less severe, occurs at 
 an earlier period, and much more frequently, in women than 
 in men. It is often associated with disturbances of the uterine 
 functions, especially chlorosis, menstrual suppression, etc, or 
 with some cutaneous neurosis, such as urticaria. It has also 
 been caused by great mental depression, sudden fright, severe 
 bodily exercise, hemorrhages, and other debilitating influences. 
 
 Prognosis. — This should always be guarded, especially 
 
EXOPHTHALMIC BRONCHOCELE. 419 
 
 in the case of males, in whom the symptoms are usually more 
 severe and more permanent. The disease is generally slow 
 in its progress, especially during the first stage, or before the 
 appearance of the goitre and exophthalmos. The symptoms 
 frequently abate, or become less frequent ; but relapses often 
 occur, and lead sooner or later to faulty nutrition, and in some 
 cases to death. Complete recovery is unusual, occurring only 
 in about one third of the cases. As a general rule the function 
 of the retina remains unimpaired. 
 
 Treatment. — Dr. Morrison's case, above-mentioned, was 
 cured by the internal administration of Lycopus virg., a remedy 
 which would seem from its provings to be pre-eminently 
 adapted to the disorder. Cures, or beneficial results, are also 
 said to have followed the use of Amyl nit., Brom., Cact, Fer., 
 lod.,* Spong., Nat. m., and Bary. c ; the Amyl nit., being used 
 by olfaction alone. Other remedies which deserve attention 
 are : — Bell., Calc, China, Cimicif., Dig., Gels., Plat, Puis., Sep., 
 Sil., and Sulph. 
 
 Galvanic electricity, applied to the sympathetic nerve, has 
 been employed with good success in many cases, especially in 
 curing the goitre and exophthalmos, and also in improving the 
 general health. This agent is also highly useful in regulating 
 the menstrual function, upon the disturbance of which many of 
 these cases measurably depend. 
 
 Diet and Regimen. — Experience shows that whatever 
 tends to invigorate the general system and improve the health, 
 usually exerts a beneficial influence upon the disease. Hence, 
 the patient should abstain from the use of stimulants, take 
 regular but gentle exercise in the open air, make use of a plain, 
 but liberal, nutritious, and easily digestible diet, and, avoiding 
 all emotional or other excitement, enjoy as much quiet cheer- 
 fulness as circumstances will permit. 
 
 See Am. Horn. 05s., vol. xiii, p. 603. 
 
420 PRACTICE OF MEDICINE. 
 
 In closing the first volume of our work on the Homoeo- 
 pathic Practice of Medicine, we desire to add, that 
 notwithstanding it is confined almost exclusively to the 
 consideration of diseases of the brain and eye, the affections 
 described are amongst the most important that the general 
 practitioner is called upon to treat. And if we have appeared 
 to give undue prominence to those of the eye, it is because, in 
 our opinion, the subjects discussed are too important to be 
 dismissed in a few short sections. On the contrary, this 
 department of medicine, though somewhat extended, should 
 no longer be excluded from our therapeutic treatises. For not 
 only are many diseases of the eyes, as we have seen, intimately 
 related to those of other parts of the system, but their 
 investigation, by throwing new light upon the latter, is full of 
 instruction to the general practitioner. Besides, he is frequently 
 called upon to treat diseases of the eye under circumstances 
 that preclude their being referred to specialists, even if that 
 were the proper course to pursue. But as the majority of 
 ophthalmic diseases must necessarily be treated by the ordinary 
 medical attendant, the propriety of incorporating the requisite 
 information in a work of this character, will, we doubt not, be 
 generally conceded. 
 
 For reasons which will hereafter appear, we have post- 
 poned the consideration of the various organic and functional 
 diseases of the brain, until we shall have occasion to take up 
 the corresponding affections of the nervous system generally. 
 
INDEX 
 
 Abnormal astigmatism 
 
 contraction of pupil 
 
 dilatation of pupil 
 
 Abscess of cornea 
 
 globe 
 
 lids 
 
 lachrymal sac 
 
 orbit 
 
 Absolute glaucoma 
 
 Absorption, treatment of cataract 
 
 by 
 
 Accommodation, theory of 
 
 anomalies of 
 
 effect of atropine upon 
 
 paralysis of 
 
 range of 
 
 Acidum nit 130, 135, 143, 
 
 Aconitum 42, 50, 84, m, 117, 
 
 157, 189, 231, 
 
 Acute glaucoma 
 
 Acuteness of vision 372, 403, 
 
 Additional therapeutic indications, 
 
 Agaricus 
 
 Ailantus gland. 
 
 Albugo 
 
 Albuminuria 
 
 Alternation of Medicines 
 
 Alumina 
 
 Amaurosis 256, 
 
 spinal 
 
 Amblyopia 
 
 exanopsia 398, 
 
 Amotio retinae 
 
 Amyl nit 
 
 Anatomy of the eye 
 
 Ankyloblepharon 
 
 Anaemia of the brain 
 
 Anaesthesia retinae 
 
 Aneurism by anastomosis 
 
 Anomalies of refraction 
 
 Apoplexy cerebral 
 
 Anterior chamber of the eye 
 
 Antimonium tart 
 
 Annular staphyloma 
 
 Apis mel Ill, 143, 
 
 Aphakia 
 
 Apthous ophthalmia 
 
 Aqueous humor, hypersecretion of 
 181, 
 
 Arcus senilis of the lens 
 
 Argentum nit 
 
 Arnica 43, 79, 189, 
 
 Arsenicum 39, 72, 96, 112, 143, 
 
 157, 189, 220, 
 
 77 
 
 PAGE 
 
 391 
 404 
 403 
 159 
 231 
 152 
 277 
 270 
 213 
 
 352 
 
 373 
 378 
 377 
 380 
 
 374 
 158 
 
 236 
 216 
 
 4C5 
 281 
 281 
 281 
 116 
 
 257 
 18 
 281 
 400 
 401 
 
 393 
 412 
 
 3i6 
 282 
 103 
 293 
 
 38 
 397 
 328 
 382 
 
 74 
 107 
 
 84 
 3H 
 231 
 37o 
 145 
 
 196 
 
 34i 
 118 
 231 
 
 232 
 
 Arthritic foam 
 
 ophthalmia 
 
 Artificial pupil, operations for 
 
 Asafcetida 
 
 Asarum 
 
 Assalini, on Egyptian ophthalmia. 
 
 Asthenopia 
 
 Arlt.Prof., on catarrhal ophthalmia, 
 Astigmatism 
 
 forms of 
 
 treatment of, by lenses 
 
 Atresia pupillae 178, 183, 
 
 Atrophy of the choroid. ..233, 235, 
 
 249, 
 
 eyeball 215, 
 
 retina 249, 257, 
 
 optic nerve 216, 249, 263, 
 
 Atropine, effect of, on the accom- 
 modation 
 
 on the iris 
 
 purity of 161- 
 
 Aurum 
 
 Bandage, compress 
 
 in keratitis 161, 
 
 Baryta 79, 
 
 Becker, Dr., on leucaemic retinitis, 
 
 Belladonna, 43, 50, 79, 84, 96, 
 
 ill, 118, 143, 157, 189, 221, 232, 
 
 ointment 
 
 Blear eye 
 
 Blenorrhcea 
 
 of lachrymal sac 
 
 Blepharitis 
 
 ciliaris 
 
 Bowman, Mr., on corneal opacities, 
 
 excision of pupil 
 
 Boynton, Dr., on choroido-retinitis, 
 
 Bronchocele, exophthalmic 
 
 Bryonia 43, 50, 85, 118, 189, 
 
 Buphthaimos 
 
 Cactus grand 157, 
 
 Calabar bean, effect of, on iris 
 
 Calcarea carb 39, 51, 73, 112, 
 
 iod 
 
 Calomel, insufflation of 167, 
 
 Camphora 39, 
 
 Canaliculi, division of 
 
 Cannabis sat 135, 
 
 Cantharis 
 
 Canthoplasty 
 
 Cancer of the eye 
 
 Capsules of Bonnet and Tenon, in- 
 flammation of 
 
 PAGE 
 
 212 
 
 210 
 190 
 282 
 282 
 123 
 388 
 122 
 391 
 392 
 393 
 190 
 
 253 
 230 
 263 
 400 
 
 377 
 186 
 note 
 282 
 172 
 172 
 282 
 258 
 
 236 
 187 
 
 150 
 
 120 
 278 
 149 
 150 
 3C6 
 203 
 
 244 
 416 
 221 
 310 
 
 237 
 1 88 
 
 143 
 282 
 177 
 85 
 279 
 143 
 135 
 168 
 
 333 
 269 
 
422 
 
 INDEX. 
 
 PAGE 
 
 Capsular cataract 343 
 
 Carcinomatous tumors 333 
 
 Caries of the orbit 274 
 
 Cataract, classification of 337 
 
 adnata 346 
 
 anterior capsular 343 
 
 black 341 
 
 capsular 343 
 
 congenital 337, 346 
 
 cortical 338 
 
 diabetic 346 
 
 glaucomatous 214 
 
 hard 340 
 
 lamellar 337 
 
 mature 339 
 
 mixed 341 
 
 Morgagnian 340, 342 
 
 nuclear 340 
 
 operations for 349 
 
 posterior polar 239, 344 
 
 pyramidal 344 
 
 secondary 340, 342, 345 
 
 senile 340 
 
 siliculose 340 
 
 soft 337 
 
 spectacles for 370 
 
 traumatic 345 
 
 Cataract, treatment of. 347 
 
 by division 352 
 
 by flap extraction 358 
 
 by linear extraction 356 
 
 by peripheral linear extraction 361 
 
 by reclination or couching 354 
 
 by solution 352 
 
 by suction 357 
 
 by Von Graefe's method 361 
 
 Catarrhal ophthalmia...... 109 
 
 Cats-eye, amaurotic 332 
 
 Caustics, on the use of, in episcler- 
 itis 174 
 
 in granular ophthalmia 130 
 
 in keratitis 156, 159 
 
 Caustics, on the use of, in purulent 
 
 conjunctivitis 119 
 
 Caustic, special form of J30 
 
 Cedron 221, 283 
 
 Cerebral ancemia 38 
 
 apoplexy 74 
 
 hypercemia 41 
 
 Cellulitis of the orbit 270 
 
 Cephalalgia 49 
 
 Cerebritis 60 
 
 Charpie 172 
 
 Chalazion 321 
 
 Ch amomilla 51, 189 
 
 Chemosis 176 
 
 Chelidonium 283 
 
 China . 40, 51, 97 
 
 Cholesterine in vitreous humor 239 
 
 Choroid 104 
 
 Choroiditis 223 
 
 disseminated or exudative 225 
 
 serous, simple 224 
 
 Choroiditis, syphilitic 225 
 
 suppurative 227 
 
 Chromopsia 229, 396 
 
 Chronic glaucoma 213 
 
 Cicuta 283 
 
 Ciliary body 106 
 
 inflammation of 195 
 
 muscle, paralysis of. 380 
 
 spasm of 381 
 
 neuralgia, 177, 189, 190, 196, 
 
 197, 206, 211 
 
 processes ic6 
 
 Cimicifuga 51, 157, 189, 221 239 
 
 Cina 40 
 
 Cinnabaris 153 
 
 Clematis 153, 283 
 
 Coccius, Prof., ophthalmoscope of.. 365 
 
 Coculus 80 
 
 Coffea cr 43 
 
 Colocynthis 98 
 
 Concussion of the brain 86 
 
 Cohn, Dr., on hypermetropia 390 
 
 on myopia 384 
 
 Colchicum 175, 189 
 
 Collyria 113, 174 
 
 Comocladia 283 
 
 Confirmed glaucoma 211 
 
 Congestion of the brain 41 
 
 Conical cornea 307 
 
 Conium 143, 158, 221 
 
 Conjunctiva. 105 
 
 inflammation of, see Conjunctivitis 
 
 xerosis of 300 
 
 Conjunctival croup..... 136 
 
 discharge, contagiousness of, 
 
 "7, 123 
 
 Conjunctivitis blennorrhoica 114 
 
 catarrhal 109 
 
 exanthematous 147 
 
 diphtheritic 136 
 
 gonorrhceal 132 
 
 granular 126 
 
 neonatorum 114 
 
 phlyctenular 138, 145 
 
 purulent. : 114, 120 
 
 scrofulous 138 
 
 simplex 109 
 
 variolous 148 
 
 Contagious ophthalmia 120 
 
 Contraction of pupil, abnormal 404 
 
 Convergent strabismus 410 
 
 Coredialysis 194 
 
 Corelysis 194 
 
 Cornea 104 
 
 abscess of 159 
 
 conical 307 
 
 herpes of 169 
 
 inflammation of 153 
 
 neuro-paralytic affection of.... 160 
 
 opacities of 1 15, 305 
 
 pannus of 165 
 
 paracentesis of 162 
 
 perforation of 161 
 
INDEX. 
 
 423 
 
 Cornea, perforating ulcer of 140 
 
 staphyloma of 307 
 
 ulcers of 1 15, 140, 159, 169 
 
 Corneitis, see Keratitis 
 
 Couching 354 
 
 Coup de Soleil 81 
 
 Crocus 237, 284 
 
 Crotalus 284 
 
 Croton tig 284 
 
 Crystalline lens 106 
 
 Cupping of the optic disc, 216, 
 
 234, 235, 401 
 
 Cyclamen 285 
 
 Cyclitis 195 
 
 serous 196 
 
 purulent 197 
 
 Cylindrical lenses 393 
 
 Cyst, tarsal 325 
 
 in iris 325 
 
 in orbit 325 
 
 Cysticercus in the anterior chamber 326 
 
 in the lens 346 
 
 under the retina 326 
 
 Dacryo-adenitis 275 
 
 Dacryocystitis 277 
 
 Definitions and aphorisims 9 
 
 Dermoid tumors 322 
 
 Descemetitis , 181 
 
 Descemet, membrane of 105 
 
 Detachment of the retina 316 
 
 of the vitreous 234, 239 
 
 Digitalis 189 
 
 Dilatation of pupil, abnormal 403 
 
 Diphtheritic conjunctivitis 136 
 
 Diplopia 406 
 
 Direct method of ophthalmoscopic 
 
 examination 367 
 
 Disease, analysis of 22, 23 
 
 causes of 10 
 
 definition of. 9 
 
 suppression of 10 
 
 Dislocation of the lens 346 
 
 Distichiasis 298 
 
 Distoma oculi humani 346 
 
 Divergent strabismus 412 
 
 Division of cataract 352 
 
 Dixon on calcareous deposits in the 
 
 cornea 306 
 
 Dobrowelski, Dr., on protective 
 
 glasses 129, 371 
 
 Donders, Prof., glaucoma of 215 
 
 on hypermetropia 388 
 
 on myopia 238 
 
 on strabismus 409 
 
 Dose, homoeopathic 15 
 
 repitition of 17 
 
 Dropsy of the brain 70 
 
 Drowsiness, morbid 48 
 
 Duct, lachrymal 107 
 
 nasal, stricture of 279 
 
 Double sight 406 
 
 Duration of Medical action 20 
 
 Dyer, Dr., on hypermetropia 391 
 
 PAGE 
 
 Echinococcus, in orbit 325 
 
 Ectropium 296 
 
 Eczema of the lids 149 
 
 Egyptian ophthalmia 123 
 
 Electricity 381, 402, 407, 419 
 
 Electrolysis 329 
 
 Encephalitis 60 
 
 Encephalon, diseases of. 35 
 
 Emmetropia. 382 
 
 Engorged papilla 265 
 
 Entozoa in the lens. 346 
 
 in the orbit 325 
 
 Entropium. 294 
 
 Enucleation of globe 20S 
 
 Epiphora 177 
 
 Episcleritis 1 73 
 
 Epitheliel cancer 334 
 
 Erysipelatous conjunctivitis 147 
 
 Euphorbium m 
 
 Euphrasia in 
 
 Evacuation of the aqueous humor.. 162 
 
 Eversion of the lids 296 
 
 Exanthematous ophthalmia 147 
 
 Excavation of optic nerve, amau- 
 rotic 401 
 
 glaucomatous 216, 401 
 
 physiological 216, 401 
 
 Excision of globe 208 
 
 of pupil 203 
 
 Exhaustion, thermic 81 
 
 Exophthalmic goitre 416 
 
 External applications 28 
 
 Extirpation of globe 208 
 
 Extraction of cataract, by flap 
 
 operation 358 
 
 by linear incision 356 
 
 by peripheral linear incision... 361 
 
 by suction 357 
 
 by Van Graefe's method 361 
 
 Eye, enucleation of 102 
 
 diseases of. 208 
 
 general inflammation of. 227 
 
 Eyelashes, inversion of 298 
 
 Eyelids, abscess of 152 
 
 adhesion of 293 
 
 to globe 29T 
 
 erysipelas of 152 
 
 eversion of. ;.. 296 
 
 follicular inflammation of 150 
 
 .inflammation of edges of 150 
 
 Eyelids, inversion of 294 
 
 oedema of 152, 176 
 
 Eye protectors 371 
 
 Face-ache 92 
 
 Far point 373 
 
 Far sightedness 378 
 
 Fatty degeneration of retina, 247, 255 
 
 tumors 327 
 
 Fibroma of eyelid , 329 
 
 of orbit 330 
 
 Field of vision, state of in amauro- 
 sis 402 
 
 in choroiditis 225 
 
424 
 
 INDEX. 
 
 PAGE 
 
 Field of vision, in detachment of 
 
 retina 317 
 
 illustrations of 244, 245 
 
 in glaucoma 214 
 
 in hyalitis 239 
 
 in retinitis, 243, 248, 253, 256, 
 
 260, 262 
 
 Filaria oculi humani 346 
 
 Fistula of lachrymal gland 275 
 
 ofthe sac 278 
 
 Flap extraction of cataract 358 
 
 Fluoric acid 285 
 
 Fomentations in suppurative kera- 
 titis 162 
 
 Foreign bodies in the eye 206 
 
 Functional diseases of the eye 373 
 
 Fundus oculi, ophthalmoscopic ap- 
 pearances of 367 
 
 Fungus heematodes of eyeball 332 
 
 Galazowski,Dr., on vitreous humor, 238 
 
 Gelseminum 43, 98, 158, 222 
 
 in choroido-retinitis 244 
 
 General observations Q 
 
 Giddiness 47 
 
 Gland, lachrymal 107 
 
 inflammation of 275 
 
 Glaucoma 209 
 
 acute inflammatory 210 
 
 chronic inflammatory.. 213 
 
 non inflammatory 215 
 
 fulminans 213 
 
 hemorrhagic form 218 
 
 iridectomy in 219 
 
 myotomy in 219 
 
 nature of. 217 
 
 ophthalmoscopic symptoms of, 216 
 
 paracentesis in 219 
 
 premonitory stage of 210 
 
 prognosis of. 218 
 
 sclerotomy in 219 
 
 secondary 234 
 
 simplex 215 
 
 subacute 213 
 
 treatment of 219 
 
 Glioma retinae 33 1 
 
 Glonoine 51, 64, 85 
 
 Goitre, exophthalmic 416 
 
 Gonorrhceal ophthalmia 132 
 
 Graefe, Von, Prof., on bandages for 
 
 the eye 162 
 
 on ephemeral mydriasis 404 
 
 on fomentations 157 
 
 on hypopya 183 
 
 on irido-choroiditis 202 
 
 on operation for cataract 361 
 
 on optic neuritis 266 
 
 on transitory amaurosis 395 
 
 on trichiasis 299 
 
 on sclero-choroiditis posterior, 235 
 on structure of vitreous hu- 
 mor 224 
 
 on sympathetic ophthalmia 206 
 
 Granulations, chronic 129 
 
 Granulations, diaphanous 109 
 
 Granular ophthalmia 126 
 
 Graphites 130, 144 
 
 Graves' disease 416 
 
 Gummy tubercles of the iris 184 
 
 Hamamelis 222, 285 
 
 Hahnemann's law of cure II 
 
 Headache 49 
 
 Helleborus 73, 85 
 
 Hemorrhage after enucleation 209 
 
 Helmholtz, Prof., on acccommoda- 
 
 tion ofthe eye 376 
 
 his invention of ophthalmo- 
 scope 365 
 
 Hemeralopia 398 
 
 Hemiopia 285, 289 
 
 Hepar sulph c, 98, in, 118, 135, 
 
 H4, 158, 232 
 
 Herpes of the conjunctiva 145 
 
 ofthe cornea 169 
 
 Herpetic bridge 170 
 
 Heymann, on retinitis apoplectica, 260 
 Hirschberg, Dr., ou glioma retinae 332 
 
 Homoeopathic aggravation 14 
 
 dose 15 
 
 materia medica 14 
 
 regimen 29 
 
 Hordeolum 319 
 
 Horns 323 
 
 Hyalitis 237 
 
 simple 238 
 
 suppurative 240 
 
 Hydatids of orbit 325 
 
 Hydrastis can 112 
 
 Hydrocephalus, acute 65 
 
 chronic 70 
 
 Hydrophthalmia, anterior 217 
 
 Hypersemia of the brain 41 
 
 Hyoscyamus 85 
 
 Hypersesthesia of retina 396 
 
 Hypermetropia..., 388 
 
 diagnosis of 389 
 
 frequent cause of asthenopia... 388 
 
 of convergent squint 390, 411 
 
 varieties of 388, 389 
 
 Hypopyon 159, 182, 228 
 
 posterior 240 
 
 Ignatia 52 
 
 Illumination, lateral 368 
 
 Indirect method of ophthalmosco- 
 pic examinations 366 
 
 Infinite distance, what is meant by 373 
 Inflammation of orbital cellular 
 
 tissue. 270 
 
 of the brain and its mem- 
 branes 56 
 
 of the substance of the brain.. 60 
 Inflammation of capsule of Tenon.. 269 
 
 of choroid 223 
 
 of ciliary body 195 
 
 of conjunctiva 108 
 
 of cornea 153 
 
 of eyelids 150 
 
itfDEX. 
 
 42S 
 
 Inflammation of eyelids, edge of.... 150 
 
 of eye generally 227 
 
 of iris 175 
 
 of iris and choroid 198 
 
 of lachrymal gland 275 
 
 of lachrymal sac 277 
 
 of retina 241 
 
 of sclera 172 
 
 sympathetic 204 
 
 of vitreous humor 237 
 
 Insomnia 48 
 
 Induration of the brain 61 
 
 Insufflation 167 
 
 Interstitial keratitis 153 
 
 Intra-ocular tension, increase of, 
 
 in glaucoma 213 
 
 Inversion of lid 294 
 
 Iodium 65, 112, 130 
 
 Ipecacuanha 40, 52 
 
 Iridectomy 190 
 
 in glaucoma 192, 219 
 
 in irido-choroiditis 202 
 
 in iritis , 
 
 in keratitis 157, 
 
 when indicated , 
 
 Iridenkleisis , 
 
 Irido-choroiditis, simple 
 
 glaucomatous 
 
 pseudo-membranous , 
 
 Irido-cyclitis 
 
 Iiidodesis 
 
 Iridodialysis 
 
 Iridotomy 
 
 Iris 
 
 color of 
 
 inflammation ot 
 
 prolapse of 1 16, 
 
 versicolor 
 
 Iritis 
 
 parenchymatous 
 
 serous 
 
 simple 
 
 suppurative 
 
 syphilitic 
 
 traumatic 
 
 Ischaemia of the disc 
 
 Iwanoff on detachment of the vitre- 
 ous 234, 
 
 Jackson, Dr., on optic-neuritis 
 
 Jaeger, Prof., on posterior staphy- 
 loma 
 
 test-types of 
 
 Kali iod 131, 158, 189, 
 
 bich 
 
 Kalmia 99, 
 
 Keratitis, diffuse 
 
 pannosa 
 
 punctata 181, 
 
 phlyctenular 
 
 suppurative 
 
 syphilitic 
 
 vascular 
 
 Kerato-conus 
 
 192 
 
 163 
 192 
 
 193 
 198 
 209 
 200 
 196 
 
 193 
 
 194 
 194 
 
 105 
 179 
 
 175 
 140 
 
 99 
 
 175 
 182 
 181 
 
 175 
 182 
 
 179 
 265 
 
 239 
 
 267 
 
 235 
 
 372 
 222 
 
 285 
 285 
 
 153 
 165 
 
 224 
 169 
 159 
 155 
 165 
 308 
 
 Kerato-iritis 155, 177 
 
 Kerato-globus 310 
 
 Keratonyxis 353 
 
 Lachesis 80 
 
 Lachrymal apparatus 107 
 
 fistula of. 275, 278 
 
 inflammation of 275 
 
 Lagophthalmos 300 
 
 Lateral illumination 368 
 
 Laurocerasus 80 
 
 Leber, Dr., on leucsemic retinitis.. 258 
 Lens, crystalline , 106 
 
 dislocation of 224, 346 
 
 Lenses 278 
 
 instrument for ascertaining the 
 
 focal strength of. 279 
 
 Leucoma 116 
 
 Liebreich, Dr., ophthalmascope of 365 
 
 on leucsemic retinitis 258 
 
 Lippitudo 150 
 
 Linear extraction in cataract 356 
 
 peripheral 361 
 
 Long-sightedness 388 
 
 Lycopodium 131 
 
 Lycopus. 286 
 
 Macula lutea 106 
 
 ophthalmoscopic appearance of 367 
 Mackenzie, Dr., on post-febrile 
 
 ophthalmia 203 
 
 Manz, Dr., on optic-neuritis 265 
 
 Materia Medica, homoeopathic, 14 
 
 defects of 103 
 
 Measles, ophthalmia of 148 
 
 Medical nomenclature S3 
 
 Medullar)' cancer 335 
 
 Meningitis 56 
 
 granular 56 
 
 tuberculous 65 
 
 Meissner, on neuroparalytic oph- 
 thalmia 160 
 
 Mercurius 44, 52, 73, 80, 
 
 99, I", 131, »35» r 44, 158, 
 
 189, 232, 280 
 
 corrosivus 237 
 
 proto-iodatus 175 
 
 Mezereum 99 
 
 Micropsia., 249-note 
 
 Military ophthalmia 120 
 
 Milium 326 
 
 Moluscum 326 
 
 Monostoma lentis 346 
 
 Morbus Basedowii 416 
 
 Mucous ophthalmia 109 
 
 Muriate of hydrastia 118 
 
 Muscles of the eye, paralysis of... 405 
 
 spasm of 408 
 
 Mydriasis 403 
 
 Myopia 383 
 
 frequent cause of divergent 
 
 squint 412 
 
 Myosis 404 
 
 Myotomy in glaucoma 219 
 
 Nsevus maternus.. 327 
 
426 
 
 INDEX. 
 
 PAGB 
 
 Nasal duct, treatment of stricture 
 
 of 279 
 
 Near point 374 
 
 Near-sightedness 383 
 
 Nebulae of cornea : 154 
 
 Necrosis of orbit 274 
 
 Neonatorum, ophthalmia 1 14 
 
 Neuralgia trigemini 92 
 
 Nephritic retinitis 254 
 
 Neuritis, optic, ascending 265 
 
 descending 266 
 
 Nighr-blindness 398 
 
 Nomenclature medical 33 
 
 Nux vomica 40, 44, 52, 80, 99 
 
 Nyctalopia 396 
 
 Nystagmus 408 
 
 Oblique illumination 368 
 
 CEdema of conjunctiva 121, 132 
 
 of eyelids 152 
 
 of retina 242 
 
 Ointment, belladonna 187 
 
 Onyx 159 
 
 Opacities of cornea 305 
 
 of lens 337 
 
 of vitreous 234, 238, 315 
 
 Ophthalmia, arthritic 2IO 
 
 catarrhal . 109 
 
 diphtheritic 136 
 
 Egyptian 123 
 
 exanthematous 147 
 
 gonorrhoeal 132 
 
 granular 126 
 
 military 120 
 
 neanatorum 114 
 
 neuro-paralytic 160 
 
 phlyctenular 138, 145 
 
 post-febrile 203 
 
 purulent 1 14, 120 
 
 rheumatic 180 
 
 scrofulous 138 
 
 sympathetic 204 
 
 tarsi .♦. 150 
 
 venous 210 
 
 Ophthalmic symptoms, table of..... 288 
 
 Ophthalmoscope 364 
 
 direct method of examination 
 
 by 367 
 
 indirect method 366 
 
 various forms of... 365 
 
 Ophthalmoscopic appearances of 
 
 the fundus oculi 367 
 
 of the optic papilla, normal.... 216 
 
 Opium 44, 80 
 
 Optic nerve 106 
 
 Optic Nerve, atrophy of...257, 263 267 
 cupping or excavation of, 216, 
 
 234, 235, 401 
 disc, normal appearance of..... 216 
 
 dropsy of 265 
 
 inflammation of. 264 
 
 neuritis 264 
 
 ascending 264 
 
 descending 266 
 
 PAGB 
 
 Optical aids and tests... 364 
 
 Ora serrata 106 
 
 Orbit, abscess of 269 
 
 caries of. 274 
 
 cellulitis of 270 
 
 hydatids in 325 
 
 ' necrosis of 274 
 
 periostitis of. 273. 
 
 tumors, cystic 325 
 
 fatty 327 
 
 fibrous 330 
 
 sarcomatous 331 
 
 vascular 326 
 
 cancer of 334 
 
 epithelial 334 
 
 medullary 335 
 
 melanotic 336 
 
 Oscillation of eyeballs..... 408 
 
 Pagenstecher, Dr., on vitreous hu- 
 mor 237 
 
 Pannus 128, 165 
 
 Panophthalmitis 227 
 
 Pantoscopic spectacles 369 
 
 Paracentesis cornese 162; 188 
 
 Paralysis of ciliary muscle 380 
 
 of ocular muscles 405 
 
 Parenchymatous keratitis 153 
 
 Passavant, Dr., on corelysis 195 
 
 Perforation of cornea 161 
 
 Periostitis of orbit 273 
 
 Peripheral linear extraction of 
 
 cataract 361 
 
 Periscopic spectacles 370 
 
 Petroleum 253 
 
 Phlegmonous inflammation of eye- 
 lids 152 
 
 Phlyctenular ophthalmia 138, 145 
 
 Phosphenes 304 
 
 Phosphorus 112, 222, 237 
 
 Photophobia 177 
 
 scrofulosa 139 
 
 Photopsia 229 
 
 Physostigma ven 237 
 
 Phytolacca 222, 286 
 
 Pigment degeneration of retina 261 
 
 Platina....!. 100 
 
 Polypi, conjunctival 327 
 
 Plumbum 65, 73 
 
 Posterior chamber 107 
 
 Post-febrile ophthalmia 203 
 
 Posterior polar cataract 239, 344 
 
 Preliminary observations on the 
 
 eye 102 
 
 Presbyopia 378 
 
 Pressure bandage 172 
 
 Prisms 407 
 
 Prismatic spectacles 407 
 
 Prolapse of iris 116, 140 
 
 Prosopalgia 92 
 
 Prosopon, diseases of the 92 
 
 Protrusion of globe 270, 331, 
 
 333, 4i6 
 Prunus sp 286 
 
INDEX. 
 
 427 
 
 PAGE 
 
 Psora 10 
 
 Psorinum » 224 
 
 Psorophlhalmia 149 
 
 Pterygium 301 
 
 operations for 303 
 
 Ptosis 405 
 
 Pulsation of retinal vessels 217 
 
 Pulsatilla 44, 52, 8t, 144 
 
 Puncta lachrymalia, eversion of... 150 
 
 Punctum proximum 374 
 
 remotissimum 373 
 
 Pupil, artificial, operations for 190 
 
 adhesions of 178 
 
 contraction of. 178, 404 
 
 dilatation of 181, 186, 403 
 
 exclusion of. 199 
 
 occlusion of 200 
 
 Purulent cyclitis 197 
 
 ophthalmia 114, 120 
 
 of adults 120 
 
 of infants 114 
 
 chronic 126 
 
 Pustular ophthalmia 143 
 
 Range of accommodation 374 
 
 Reclination of cataract 355 
 
 Recklinghausen, on leucsemic re- 
 tinitis 258 
 
 Refraction, anomalies of 382 
 
 Regimen, homoeopathic 29 
 
 Results of ophthalmic inflammation 291 
 
 Reichert, membrane of 105 
 
 Retina 106 
 
 anaesthesia of. 397 
 
 atrophy of. 243, 249 
 
 detachment of 239, 316 
 
 fatty degeneration of ..247, 255 
 
 glioma of 331 
 
 hyperassthesia of 241, 396 
 
 inflammation of 241 
 
 cedema of 242 
 
 operation in detachment of.... 319 
 
 pigment degeneration of 261 
 
 sclerosis of 247, 256 
 
 Retinitis 241 
 
 albuminunca 254 
 
 apoplectic 259 
 
 exudative 247 
 
 leucsemic 258 
 
 Retinitis, nephritic 254 
 
 parenchymatous 247 
 
 pigmentosa 261 
 
 serous 242 
 
 syphilitic 251 
 
 traumatic 244 
 
 Rheumatic iritis 179 
 
 Rhododendron 222 
 
 Rhus tox...45, 100, 113, 118, 144, 232 
 
 Ruta 286 
 
 Sac, lachrymal, inflammation of.... 277 
 
 fistula of 278 
 
 Saemische, Dr., operation for ulcus 
 
 serpens cornese 163 
 
 Sanguinaria 53 
 
 PAGB 
 
 Santonine 287 
 
 Sarcoma 331 
 
 Scarlatina, ophthalmia of 148 
 
 Schlemm, canal of 105 
 
 Scirrhus 336 
 
 Sclerectasia posterior 233 
 
 Sclera, sclerotica.., 104 
 
 inflammation of 172 
 
 Sclerotomy in glaucoma 219 
 
 Sclero-choroiditis posterior 233 
 
 Scotomata 225 
 
 Scrofulous ophthalmia 138 
 
 inflam. ofbrain 66 
 
 . Sebaceous cysts 323 
 
 Secale cor 41 
 
 Secondary cataract 340 
 
 Selection of remedies ^ 24 
 
 Senega 287 
 
 Sepia 53, 100 
 
 .Shields, glass, in symblepharon 292 
 
 Short-sightedness 383 
 
 Silicea 73, 85, 144 
 
 Similia Similibus £urantur II 
 
 Sleeplessness 48 
 
 Small-pox, ophthalmia in 148 
 
 Snellen, Dr., test-types of 372 
 
 Snow-blindness 397 
 
 Softening oi the brain 60 
 
 Solio ictus 81 
 
 Solution of cataract 352 
 
 Spasm of ciliary muscle 381 
 
 Spectacles 369, 370, 371 
 
 Spier's lachrymal catheter 280 
 
 Spigelia 100, 158, 190, 222, 237 
 
 Squint see Strabismus 
 
 Staphyloma 307 
 
 of cornea and iris 311 
 
 operations for 313 
 
 annular 314 
 
 anterior 173, 314 
 
 posterior 233 
 
 racemosum 133 
 
 treatment of 309, 312 
 
 Staphysagria 112, 144, 287 
 
 Steilwag, on curability of cataract, 347 
 
 on post-febrile ophthalmia 204 
 
 on syphilitic retinitis 251, 252 
 
 Stenapaic spectacles 370 
 
 Sticta 287 
 
 Strabismus 409 
 
 apparent 410 
 
 Sti-abismus, concomitans 409 
 
 convergent 410 
 
 divergent 412 
 
 monolateral 410 
 
 passive 413 
 
 periodic 410, 41 1 
 
 treatment of.., 413 
 
 Stramonium 53> 81 
 
 Stupor 48 
 
 Stye 319 
 
 Substitution of medicines 25 
 
 Suction operation for cataract. .... 357 
 
428 
 
 INDEX. 
 
 Sulphur 53, 73, 112, 131, 144, 
 
 Sunstroke 
 
 Suppurative cyclitis 
 
 iritis 
 
 keratitis 
 
 Symblepharon 
 
 operations for 292, 
 
 Sympathetic ophthalmia 
 
 Symptomatology 
 
 Symptoms 
 
 totality of 
 
 Synchysis 
 
 Synechia, ann ular 178, 
 
 anterior 
 
 posterior 180, 
 
 Syphilitic iritis 
 
 keratitis 
 
 retinitis 
 
 Syringe, suction, for cataract 
 
 Table I. Analysis of Disease, 22, 
 
 II. Substitution 
 
 III. Cerebral regions 
 
 IV. Cerebral sensations.... 
 
 V. Cerebral congestion 
 
 VI. Cephalalgia, its causes, 
 &c 
 
 VII. Cephalalgia, its seat 
 and character 
 
 VIII. Meningitis 
 
 IX. Acute hyrocephalus — 
 symptoms 68, 
 
 XI. Concussion — synopsis 
 of treatment 
 
 XII. Cerebral diseases 
 
 XIII. Prosopalgia 
 
 XIV. A. Ophthalmic symp- 
 toms 
 
 XV. B. Ophthalmic Inflam- 
 mation 
 
 Table A. — Ophthalmic symptoms.. 
 B. — Ophthalmic inflammation 
 
 Tarsal cysts 
 
 ophthalmia 
 
 Tarsoraphia 
 
 Teale, Mr., on suction operation 
 
 for cataract 
 
 Telangiectasis 
 
 Tenon, inflammation of capsule of, 
 
 Tenotomy for strabismus 
 
 Tension, intra-ocular, in glaucoma, 
 
 Test-types 
 
 Therapeutic indications, 39, 42, 50, 
 
 72, 79, 84, 92, m, 118, 
 
 i35» '43, J 57. 189, 22o f 
 
 236, 
 
 Thuja 112, 118, 
 
 223 
 81 
 
 197 
 
 182 
 
 159 
 291 
 
 293 
 205 
 
 12 
 9 
 
 13 
 239 
 198 
 116 
 194 
 184 
 155 
 251 
 357 
 
 23 
 
 27 
 
 .36 
 
 37 
 46 
 
 54 
 
 55 
 58 
 
 69 
 
 90 
 101 
 
 288 
 
 290 
 288 
 290 
 321 
 149 
 297 
 
 357 
 327 
 269 
 414 
 213 
 37i 
 
 231, 
 281 
 
 131 
 
 Tic douleureux , 92 
 
 Tobacco amaurosis 401 
 
 Tracoma 126 
 
 ficosa 129 
 
 Traumatic cataract 345 
 
 Trichiasis 298 
 
 Tumors, ophthalmic 319 
 
 dermoid 322 
 
 carcinomatous 333 
 
 cystic 324 
 
 fatty 326 
 
 fibrous 329 
 
 sarcomatous 330 
 
 sebaceous 323 
 
 Ulcer, resorption 169 
 
 of the brain 61 
 
 of cornea 140, 159, 169 
 
 Uveal tract 196 
 
 Variolous ophthalmia 148 
 
 Venous circle 211 
 
 ophthalmia 210 
 
 pulsation of central vessels... 217 
 
 Veratrum album 41 
 
 (( viride 45, 85 
 
 Verbascum 100 
 
 Vertigo 47 
 
 Vesicular tumors 325 
 
 Virchow, Prof., on Bright's disease 257 
 
 on dermoid tumors 323 
 
 on glioma retinae.. 332 
 
 on vitreous humor 238 
 
 Vitreous humor..... 107 
 
 chloresterine crystals in 239 
 
 detachment of 234, 239 
 
 fluid 
 
 idition of. 
 
 239 
 
 inflammation of 237 
 
 opacities of 238,240, 315 
 
 Walton, Mr. Haynes, on symble- 
 pharon 292 
 
 Warts 323 
 
 Weakness of sight 388 
 
 Weber, Dr.. canaliculus knife of... 279 
 
 on vitreous humor 238 
 
 Wecker, De, Dr., on hypermetro 
 
 pia. 
 
 390 
 
 137 
 260 
 
 Wells, Dr 157, 161, 174, 
 
 Williams, Dr 
 
 207, 251, 
 Wordsworth's glass shields in sym- 
 blepharon 292 
 
 Xerophthalmia 300 
 
 Zehender, Prof., ophthalmoscope of 365 
 
 Zinc 73, 81 
 
 Zinc, chloride of, paste 336 
 
 phos 237, 287 
 
 Zonule of Zinn 106 
 
X 2345^789 *o n la i3 14 xs 16 17 
 
 PLATE I. OPHTHALMIC INSTRUMENTS. 
 All these Instruments, 0/ the best make, are furnished by J. H. Gemrig, jog South 8th St., Philadelphia. 
 
33 
 
 36 
 
 PLATE IT. OPHTHALMIC INSTRUMENTS. 
 All these Instruments, e/the best make, are furnished by J. H, Gemrig, log South %th St., Philadelphia 
 
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