GT
A 576418
DISEASES
OF THE
EYE
ANGELL

LIBRARY OF
Dr. M. DESCHERE.
Ro. 569 984
:
I
ARTES
1837
SCIENTIA
LIBRARY
VERITAS
OF THE
UNIVERSITY OF MICHIGAN
E-PLURIBUS UNUM
SQUAERIS PENINSULAM AMOENAM
CIRCUMSPICE
1
AL
(4)
A TREATISE
ON
DISEASES OF THE EYE;
FOR THE USE OF
1587
GENERAL PRACTITIONERS.
TO WHICH IS ADDED
A SERIES OF TEST TYPES FOR DETERMINING THE
EXACT STATE OF VISION.
BY
HENRY C. ANGELL, M.D.,
PROFESSOR OF OPHTHALMOLOGY IN THE BOSTON UNIVERSITY SCHOOL OF MEDICINE,
OPHTHALMIC SURGEON TO THE MASSACHUSETTS HOMEOPATHIC Hospital,
AND TO THE BOSTON HOMEOPATHIC MEDICAL DISPENSARY,
REVISED EDITION.
JAMES
BOSTON:
CAMPBELL,
18 Tremont Street, Museum Building.
1873.
Entered according to Act of Congress, in the year 1870, by
JAMES CAMPBELL,
In the Clerk's Office of the District Court of the District of Massachusetts.
CAMBRIDGE:
PRESS OF JOHN WILSON AND SON.
THIS BOOK IS DEDICATED
ΤΟ
ROBERT ELLIS DUDGEON,
M.D., L R.C.S. EDIN., ETC., ETC.,
Of London, England,
AS A TRIBUTE OF RESPECT FOR HIS WORTH AS AN AUTHOR AND
AS A PHYSICIAN.
PREFACE.
My readers are requested to bear in mind
that this work is written, not for specialists,
but for homoeopathic physicians in general
practice for those too busied with the
whole, to devote a great amount of time to
any one part of medicine and surgery. The
endeavor has been, to treat the subjects
embraced, clearly and concisely, in the hope
of presenting a volume attractive enough,
and small enough, to induce the busiest to
give it some attention. That there is need
of works of this kind in our school is, I
presume, unquestioned; and some of the
reasons why this need has been permitted to
exist so long, are given very frankly in the
large treatise of Bæhr, translated by Hem-
pel. The author remarks, in speaking of
our neglect of ophthalmic practice, that "we
vi
PREFACE.
are yet too much upon the defensive towards
our professional opponents to enjoy the
privilege of exclusively cultivating a depart-
ment that requires extraordinary manual
dexterity." He then relates the nature of
other obstacles, chiefly those arising from a
lack of hospitals and clinical teaching, and
finally remarks that, if they were removed,
"an oculist would still have a great many
difficulties to contend with, which are inher-
ent in our materia medica. We confess,
without hesitation," he adds, "that there is
no section of our materia medica less useful
and less adapted to homœopathic treatment,
than the symptoms referring to diseases of
the eye." All these obstacles are, however,
soon to be swept away. Hospitals are
established and being established all over
the country; these will give us an oppor-
tunity for instruction and improvement in
special branches, and with this increased
interest in special departments, will come, in
due time, its legitimate fruit - a separate
and distinct literature for each important
class of diseases.
PREFACE.
vii
In the preparation of this work, I have
had the advantage of copious notes taken
during a somewhat prolonged attendance
at the European clinics; and I have availed
myself without hesitation, also, of the privi-
lege of taking and appropriating whatever I
have found desirable in the standard or peri-
odical works devoted to ophthalmology.
16 BEACON STREET, BOSTON, March, 1870.
PREFACE TO THE REVISED EDITION.
AN attempt has been made in this edition to
bring the work up to date in ophthalmologic
science, without materially increasing its size.
Alterations or additions have been made in
nearly every chapter, and a Glossary of scien-
tific terms has been placed before the Table
of Contents, which may be of convenience to
students and others.
BOSTON, August, 1873.
GLOSSARY.
REFRACTION
ACCOMMODATION.
•
ASTIGMATISM
HYPERMETROPIA .
MYOPIA
PRESBYOPIA
OPTICAL DEFECT
AMETROPIA
EMMETROPIA
AMBLYOPIA
OPTIC DISC
Power of cornea and lens to focus rays
of light.
Power of the eye to adjust the vision
for different distances.
Irregular refraction, an optical defect.
Over-sight, an optical defect.
Near-sight, an optical defect.
Far-sight, an optical defect.
Defective power of accommodation or
refraction.
Optical defect of any kind.
Without optical defect.
Impaired sight not due to optical defect.
Optic nerve at its entrance of the eye
as seen with the ophthalmoscope.
STAPHYLOMA POSTICUM Bulging of the coats of the eye posteri-
FUNDUS
TENSION.
•
DIPLOPIA
PHOTOPHOBIA
ASTHENOPIA
THE MEDIA
•
orally around the optic disc.
Back part of the interior of the eye.
Abnormal hardness or softness of the
eyeball.
Double vision.
Intolerance of light.
Weakness of sight.
The transparent cornea, lens, aqueous
and vitreous humors.
!
CONTENTS.
CHAPTER I.
BRIEF SKETCH OF THE RISE AND PROGRESS OF OPHTHALMIC
PAGE
SURGERY
CHAPTER II.
EXAMINATION OF THE EYES.
OBJECTIVE AND SUBJECTIVE EXAMINATION. — IMPLEMENTS AND
INSTRUMENTS.
·BANDAGING THE EYE.
CHAPTER III.
THE OPHTHALMOSCOPE.
THE PRINCIPLE OF. - HOW TO USE IT. WHAT TO OBSERVE.
LATERAL ILLUMINATION. DIFFICULTIES OF DIAGNOSIS FOR-
MERLY. — IMPORTANCE OF THE OPHTHALMOSCOPE TO THE
GENERAL PRACTITIONER
•
CHAPTER IV.
REFRACTION, ACCOMMODATION, AND THEIR ANOMALIES.
MYOPIA. SCLEROTICO-CHOROIDITIS
A
POSTERIOR. MUSCULAR
ASTHENOPIA. HYPERMETROPIA. - ACCOMMODATIVE ASTHE-
NOPIA. - ASTIGMATISM. CYLINDRICAL GLASSES. -TEST TYPE
AND LINES FOR ASTIGMATISM. PRESBYOPIA
CHAPTER V.
THE CONJUNCTIVA.
HYPERÆMIA OF THE
CONJUNCTIVA.
SIMPLE, CATARRHAL,
PURULENT, EGYPTIAN, CONGENITAL OR INFANTILE, GONOR-
RHEAL, DIPHTHERITIC, AND GRANULAR CONJUNCTIVITIS. —
PANNUS. SCROFULOUS OPHTHALMIA. — PHLYCTENULAR AND
PTERYGIUM. · PINGUE-
EXANTHEMATOUS CONJUNCTIVITIS.
·
CULA. WARTS, CYSTS, AND DERMOID TUMORS OF THE CON-
JUNCTIVA.
1
18
33
73
X
CONTENTS.
CHAPTER VI.
THE CORNEA AND SCLEROTICA.
PHLYCTENULAR CORNEITIS. ULCERATION OF THE CORNEA.-DIF-
FUSE, SUPPURATIVE, AND NON-INFLAMMATORY CORNEITIS.-
STAPHYLOMA ANTERIOR.— CONICAL CORNEA.—ARCUS SENILIS.
- OPACITIES OF THE CORNEA. EPISCLERITIS. - STAPHYLOMA
OF THE SCLEROTIC.
CHAPTER VII.
-
THE IRIS.
HYPERÆMIA OF THE IRIS. SIMPLE, RHEUMATIC, SUPPURATIVE,
AND SEROUS IRITIS. — PROLAPSE OF THE IRIS. CY CLITIS.
- ARTIFICIAL PUPIL. MYDRIASIS. - MYOSIS. ·ACTION OF
ATROPINE. - ACTION OF CALABAR BEAN. — IRIDODONESIS.
- CYSTS OF THE IRIS
CHAPTER VIII.
THE CHOROID AND VITREOUS.
HYPERÆMIA OF CHUROID.
SIMPLE, DISSEMINATED, AND SUP-
PURATIVE CHOROIDITIS. HYALITIS, SIMPLE AND SUPPURA-
TIVE. OPACITIES OF THE VITREOUS. - MUSCA- VOLITANTES.
HEMORRHAGE INTO
SPARKLING SYNCHYSIS.
THE VITREOUS.
M
SYNCHYSIS.
CYSTICERCI OF THE EYE
CHAPTER IX.
GLAUCOMA.
ACUTE, SUBACUTE,
CHRONIC INFLAMMATORY, CHRONIC NON-
INFLAMMATORY, AND ABSOLUTE GLAUCOMA. GLAUCOMA
FULMINANS. — IRIDECTOMY. - OTHER OPERATIONS FOR GLAU-
COMA.
CHAPTER X.
THE RETINA AND OPTIC NERVE.
RETINAL HYPERÆMIA. — RETINITIS SEROSA, EXUDATIVA, ALBU-
MINURICA, SYPHILITICA, APOPLECTICA, AND PIGMENTOSA. —
DETACHMENT OF RETINA.
ISCHEMIA
PAGE
119
136
152
161
GLIOMA RETINE.
•
RETINE. · PARALYSIS OF RETINA.
TRAL ARTERY OF THE RETINA.
ROSIS
-
EMBOLISM OF THE CEN-
NEURO-RETINITIS.
AMAU-
178
CONTENTS.
CHAPTER XI.
AMBLYOPIA.
DIAGNOSIS OF AND VARIOUS CAUSES OF AMBLYOPIA.
SIMULA-
COLOR BLINDNESS.
TION OF BLINDNESS. HEMERALOPIA.
RETINAL ASTHENOPIA. · ANÆSTHESIA RETINÆ. · NEURALGIA
OCULI.
CHAPTER XII.
XI
PAGE
THE CRYSTALLINE LENS.
CATARACT. — COMPLICATIONS WITH OTHER AFFECTIONS. - HARD
AND SOFT CATARACTS. — NUCLEAR, STRIATED, BLACK, AND
SILIQUOSE CATARACT. THE INFANTILE, LAMELLAR, AND
CORTICAL
THE VARIOUS OPERATIONS BY EX-
SECONDARY
CATARACT. — CAPSULAR CATARACT. — DISLOCATION OF THE
VARIETIES.
TRACTION, ABSORPTION, AND DEPRESSION.
·
LENS.
-
TRAUMATIC CATARACT.
APHAKIA.
203
·
216
•
240
CHAPTER XIII.
SPECTACLES — ARTIFICIAL EYES.
CATARACT GLASSES.—PANTOSCOPIC, PRISMATIC, AND STENOPAIC
SPECTACLES.-EYE PROTECTORS. — ARTIFICIAL EYES
CHAPTER XIV.
THE MUSCLES OF THE EYE.
PARALYSIS OF ALL THE DIFFERENT MUSCLES OF THE EYEBALL,
AND OF THE CILIARY MUSCLE. — SPASM OF CILIARY MUSCLE.
· STRABISMUS, CONVERGENT AND DIVERGENT. — OPERATIONS
FOR THE DIVISION OF THE MUSCLES
CHAPTER XV.
THE EYELIDS.
BLEPHARITIS. — ACNE CILIARIS.
·HERPES ZOSTER FRONTALIS.
MEIBOMIAN CYST.
OTHER
· LAGOPHTHALMOS.
ECTROPIUM.
ENTROPIUM.
TUMORS. - HORDEOLUM.
- EPICANTHUS.
BLEPHAROSPASM.PTOSIS
CHAPTER XVI.
THE LACHRYMAL APPARATUS.
EPIPHORA AND STILLICIDIUM LACHRYMARUM. — INFLAMMATION
—
S
—
OF SAC. BLENNORRHOEA OF PASSAGE. STRICTURE. - DIL-
ATATION OF SAC. FISTULA. THE PROBE, THE STYLE.
STILLING'S OPERATION. THE LACHRYMAL GLAND
•
244
264
275
xii
CONTENTS.
CHAPTER XVII.
AFFECTIONS OF THE WHOLE EYE AND OF THE ORBIT.
HYDROPHTHALMIA.
MEDULLARY CANCER.
-AFFECTIONS OF THE ORBIT
THE LIDS.
PAGE
GRAVE'S DISEASE.
291
CHAPTER XVIII.
INJURIES OF THE EYE.
THE CONJUNCTIVA.
ANCHYLOBLEPHARON.
SYM-
BLEPHARON. FOREIGN BODIES WITHIN THE GLOBE. IN-
JURIES OF THE CORNEA, THE IRIS, THE LENS, THE SCLEROTIC.
HEMORRHAGE INTO THE ANTERIOR CHAMBER. SYM-
PATHETIC OPHTHALMIA. SYMPATHETIC IRRITATION. — RE-
MOVAL OF THE EYE
•
CHAPTER XIX.
LIST OF A FEW INTERNAL REMEDIES WITH THE OPHTHALMIC
AFFECTIONS, OR THE SUBJECTIVE AND OBJECTIVE SYMPTOMS
OF THE EYES, FOR WHICH THEY HAVE BEEN FOUND USEFUL
IN THE PRACTICE OF THE WRITER.
CHAPTER XX.
TEST TYPES.
FIRST SERIES. SECOND SERIES. INDEX TO THE BOOK
294
311
. 815
DISEASES OF THE EYE.
CHAPTER I.
BRIEF SKETCH OF THE RISE AND PROGRESS OF
OPHTHALMIC SURGERY.
It appears that the ancient Egyptians were the
first to divide the practice of medicine and surgery
into distinct departments, and that in those days
there were practitioners who devoted themselves es-
pecially to the study and treatment of diseases of the
eye and ear. That no progress of consequence was
made in medicine at that epoch is to be attributed to
the primitive condition of anatomy and pathology,
and to the circumstance that whatever knowledge of
this kind existed was regarded as the exclusive prop-
erty of its possessor, to be left like an heirloom to
his family or his successor.
The Arabians, Greeks, and Romans possessed
considerable information in regard to diseases of the
eye; and Celsus, in the first century, wrote accurately
on diseases of the eyelids, described pterygium, and
an operation for its removal not unlike that practised
at the present day.
1
2
OPHTHALMIC SURGERY.
After this we hear little of disease of the eye,
until the beginning of the eighteenth century; and
even as late as this, oculists were but itinerant quacks
and lecturers, who trumpeted their fame at fairs, in
front of the booths in which they practised. There
were female oculists also in those days. An author
of that time says, "About five years since, I saw a
woman in Holborn, by King's Gate, that had a dis-
solution of vitreous humor in the right eye, a nar
rowness of the inward chamber and immobility of the
pupil, and half was dilated. The crystalline was
opaque and shrunk in its bigness, pressed against the
pupil and was of whitish-gray, by reason of the
fibrous parts of its crooked and contracted segments,
so that she could not perceive any light with that
eye. She asked me if I could do her any good; I
told her there was no hope, for she could not see
the least glimmering because her cataract was accom-
panied with a gutta serena which was perfect. She
told me that Mrs. Jones, a famous woman for couch-
ing of cataracts, would have couched her some years
before." The same author writes of the " Cataplexia
of the eye which Hippocrates speaks of,” and goes on
in this remarkable way: "Some call this the con-
ick movement which is the parrexis or helcosis and
abruption precision, or ulceration and solution of the
continuity of the optic nerve, caused from a stroke
ITS RISE AND PROGRESS.
3
wound or fall of humors or apostimation." He says
further that the "Syntosis of Galen or the syntomo-
sis is a collaption, compression, flabbiness of said
nerve, which is affected by dryness," and so on.
Some of the remedies in use only one hundred and
fifty years ago are equally remarkable. A scarifica-
tor was made of beards of barley tied into a little
brush. Applications in common use were vipers'
fat, gall of the eel and pike, a mixture of ants and
honey, and applications of a less delicate nature.
As original and curious as any, was the insertion in
the eye of a living louse, of which it was affirmed,
probably with good reason, that "it tickleth and
pricketh and rendereth the eye moist and rheu-
matic."
Towards the middle of the last century the atten-
tion of the profession in Germany began to be direct-
ed particularly towards the study of ophthalmology,
and this awakened interest finally led, in 1773, to
the foundation at Vienna, in connection with the
University, of a department of ophthalmology. This
school became famous for its successful and distin-
guished teachers, and in this respect flourished with-
out a rival up to a very recent period. Scarpa's
excellent treatise on Diseases of the Eye was pub-
lished in 1801, that of Beer in 1815, Guthrie's, the
first complete work in English, and long a standard
4
OPHTHALMIC SURGERY.
in this country, in 1823. Then followed the stand-
ard works of Lawrence, Tyrrell, and McKenzie, and
in Germany those of Rozas, Juenken, and Arlt.
About the year 1840, Dieffenbach, of Berlin first
practised his operation for the cure of strabismus,
the success of which gave an impulse to the study of
the physiology and pathology of the muscles of the
eyeball, and has resulted in the exhaustive researches
on this subject of the two Graefes and others.
We come now to the year 1851, the date of the
discovery of the ophthalmoscope.
From the very
earliest times the luminosity of the eye, especially in
the cat and the dog, had been observed, and had
been regarded by the people with superstitious awe.
In the year 1704 Méry saw the retinal vessels in the
eye of a cat under water, but not until some years
later was the cause of this luminosity properly re-
ferred to light received into the eye from without.
Cumming, in 1846, came very near depriving Helm-
holtz of the honor of his great discovery, and Reute,
who improved the ophthalmoscope in 1852 and ren-
dered it practical, may be fairly said to divide the
honor of its invention with Helmholtz.
Since the discovery of this instrument the progress
of ophthalmology in all its branches has been not
only rapid beyond precedent, but more rapid than
the most sanguine could have hoped for. It is im-
ITS RISE AND PROGRESS.
5
possible here to more than allude to some of these
great advances and their results. Recognition and
accurate description of the different diseases of the
optic nerve and retina and their frequent connection
with affection of the brain, heart, and kidney; diag-
nosis of diseases of the choroid and vitreous; classi
fication of opacities of the lens giving rise to variety
and improvement in operations for cataract; the oper-
ation of iridectomy, rendering glaucoma a curable
disease; improved methods of making artificial
pupil; rational surgical treatment of disorders of
the lachrymal apparatus; demonstration of the laws
of refraction and accommodation of the eye, which
has been of incalculable value in the diagnosis and
treatment of a large class of cases where imperfect
vision is a prominent symptom; the diagnosis and
cure of astigmatism; the progress in entoptics; the
detection of cysticerci in the eye; the treatment of
conical cornea; the use of the compressive bandage;
the introduction of the use of atropine and the cala-
bar bean; the invention of the aut-ophthalmoscope
whereby we may examine at our leisure the fundus
of our own eyes and "see oursel's as others see us";
the more cautious and less indiscriminate use of
caustics, and the almost entire abolition of the so-
called heroic antiphlogistic measures in disease of
the eye, these and many other improvements in
6
OPHTHALMIC SURGERY.
diagnosis and treatment, which I do not mention even
by name, are the results of the marvellous impulse
given to the study of disease of the eye by the dis-
covery of the ophthalmoscope.
F
CHAPTER II.
EXAMINATION OF THE EYES.
OBJECTIVE EXAMINATION.
AFTER a glance at the exterior aspect of the lids,
their margin, the cilia, the general appearance of the
eyeball as to position or prominence, we may turn
our attention to the different tunics of the globe
which permit of examination from without. For
this purpose a good light is necessary, and the best,
generally speaking, is that which falls obliquely on
the eye of the patient from a very near window. A
still stronger light may be had, when necessary, by
lateral illumination; as explained in the chapter on
the Ophthalmoscope. If we suspect a foreign body,
if conjunctivitis with discharge be present, if the lids
seem thickened, if any sensation is complained of
beneath the upper lid, if there is enlargement of the
mucous papillæ of the lower lid, the upper lid should
be reversed. This proceeding requires but a mo-
ment, can never do harm, and may often give us at
once the key to the difficulty.
α
୪
EXAMINATION OF THE EYES.
1
To reverse the upper lid it is merely necessary to
raise it slightly with the thumb of the left hand, then
seizing firmly the central cilia and edge of the tarsus
between the forefinger and thumb of the right hand,
the lid is pulled slightly downward and away from
the eyeball, and while the patient is requested to
look downward, at this instant the lid is tilted over
the point of the left thumb, which is used as a ful-
If necessary, a probe may be used as a
fulcrum, placing it half an inch above the margin of
the lid and parallel with it. The signification of the
various kinds of redness of the eye is noticed under
simple conjunctivitis. The surface of the cornea
should be carefully scrutinized for delicate opacity,
ulceration, abrasion, or unevenness.
crum.
A few weeks since a young lady called for me to
aid her in the selection of suitable glasses. She did
not see well at a distance. I expected to find, upon
examination, that she was either myopic or hyper
metropic. To my surprise there was neither myopia,
hypermetropia, or astigmatism present. Nor could I
find any abnormal condition of the eye whatever. I
thought of old opacity of the cornea, but did not find
it. After learning, however, that in childhood she
had suffered from an affection which was undoubtedly
a purulent ophthalmia, I felt positive that the cornea
must be at fault. On taking her again into a dark-
110,
THE PUPIL.
9
ened room, and re-examining the surface of the cornea
by oblique illumination, and comparing her eyes
under the strong light with those of her companion,
I discovered a delicate cloudiness in both corneæ.
Without the aid of lateral illumination and the com-
parison with the perfect cornea of a normal eye, the
haziness would have escaped detection.
The size of the pupil, its form, its mobility, and
the color of the iris should be noted. The mobility
may be tested by permitting the eye to be closed and
then raising the upper lid gently with the thumb, ob-
serving the reduction in the size of the pupil as the
light strikes the eye, or, by shading the opened eye
with the hand, then removing the hand suddenly.
In either of these experiments the eye not under ex-
amination must be closed, to avoid sympathetic influ-
ence between the two. If the pupil is sluggish in
movement, or does not look exactly circular, or if
the iris is at all discolored, we should drop into the
eye a solution of atropine (one or two grains to the
ounce of water), in order to determine whether there
is adhesion between the posterior surface of the iris
and the anterior surface of the capsule of the lens.
If adhesions exist the enlarged pupil will be irregular
in form. It is sometimes necessary to use a solution
of atropine stronger than this, of four or six grains to
the ounce, when the iris is diseased, in order to affect
10
EXAMINATION OF THE EYES.
the size of the pupil sufficiently. See article on Myd-
riasis. The appearance of the surface of the iris
may be abnormal as to color, texture, plastic de-
posits, and condylomata. The significance of these
objective examinations and their details will be found
when we come to speak of the diseases of the various
structures of the eye.
Tension or hardness of the eyeball is to be noted
in order to determine the degree of intra-ocular
It is determined by gentle pressure
pressure.
through the closed lids upon the eyeball with the
forefinger. The two eyes may be compared, or a
sound eye with the diseased one, in order to fix the
degree of hardness or softness with more accuracy.
Signs to denote the amount of intra-ocular pressure
are sometimes used. Thus: T. 1, T. 2, T. 3: indi-
cate first degree or slight, second degree or con-
siderable, third degree or extreme tension (hardness)
of the ball; while Tn., T? indicate tension normal,
tension doubtful. The same letter and figures pre-
ceded by the sign minus mean reduced tension or
softness of the globe. Thus :-T. 1, first degree of
reduced tension.
The mobility of the eye is to be tested by request-
ing the patient to follow the finger, which is moved
in various directions, in order to detect paralysis of
any muscle, or the finger may be moved towards the
THE PAIN.
11
eyes as directed under muscular asthenopia, to deter-
mine the strength of the recti interni muscles.
SUBJECTIVE EXAMINATION.
THE PAIN.
The nature, seat, and severity of the pain com-
plained of by the patient is of importance as an aid
to diagnosis and a fortiori to the selection of appro-
priate remedies. A dull pain in and around the
eyeball, with a sensation of heat, the pain very much
increased by using the eye, points to asthenopia.
Smarting and burning, and a sensation as if sand
were in the eye, indicates a conjunctivitis. Severe
pain with photophobia and lachrymation denotes
sensitiveness of the ciliary nerves, as in deep-seated
conjunctivitis, corneitis, iritis, or any inflammation
affecting the ciliary region, at the junction of the
cornea and sclerotica. Deep-seated pain in the eye,
or just above it, recurring periodically, accompanied
by dimness of vision, is to be seriously regarded, and
is characteristic of beginning glaucoma.
The severity of the pain, however, is not alone a
safe criterion by which to judge the gravity or slight-
ness of an affection of the eye. When present, it
helps us to determine the nature of the disease, but
it may be absent sometimes in the most serious cases,
such for instance as glaucoma, amaurosis, or choroi-
ditis.
12
EXAMINATION OF THE EYES.
Photophobia, with no pain, or appearances of
inflammation externally, indicates hyperæthesia retinæ
- too great a sensibility of the retina. Retinitis, by
itself, is a rare disease, and would be characterized
by a want of sensibility and the necessity of a strong
light to see distinctly.
THE STATE OF THE VISION.
=
The visual power of a diseased eye is an important
diagnostic point to determine. This will be best
investigated by the use of the test types annexed to
this volume. If the patient reads No. 1 or 2 readily,
and also the letters of No. 12, 15, or 20, at twelve,
fifteen, or twenty feet respectively, with the naked
eye or by the help of suitable spectacles, his sight is
perfect. His visual power 1. Good sight for a few
moments followed by confusion of vision, suggests
asthenopia. Rapid diminution of vision as objects
recede from the eye, points to myopia. Lack of
clearness in regarding objects near and distant, indi-
cates hypermetropia. Defective sight for near objects
and normal vision for distance, is characteristic of
presbyopia. Cloudiness of sight, improved towards
night and in dull weather, suggests cataract. If
spectacles never did any good" we think of astig-
matism; then amblyopia, and serious internal disease
of the eye will be thought of if glasses have recently
९९
THE FIELD OF VISION.
13
ceased to be of use. If the patient cannot see the
largest sized letters, he may be able to count fingers held
quite near the eye Failing in this he may distinguish
between light and darkness. Seat him before a window,
and then interpose between his eyes and the light some
dark object of sufficient size; or, a still better test,
because it admits of measurement, is to take the pa-
tient into a room from which daylight is wholly ex-
cluded. He may be able to point in the direction of
the lamplight, even if it is quite dim; or he may be
able to discern it only when it is very brilliant, or he
may not be able to see it at all. If he cannot tell
with certainty, standing near the light whether we
shade it from him or whether it shines full in his
face, there is no vision to be improved, and no res-
toration of sight is possible. In these experiments, if
one eye alone is being tested, cover the other with
the folded handkerchief so as to exclude all sight from
it. A healthy eye will readily distinguish light from
darkness with the lids firmly closed.
THE FIELD OF VISION.
The extent of the field of vision may be determined
by directing the patient to look steadily at one finger
held before his eye at a distance of eighteen or twenty
inches. We then move our other hand about at a dis-
tance of two feet below, above, and on each side, from
1
·
14
EXAMINATION OF THE EYES.
the finger towards which the patient is steadily to look,
noting whether he sees the hand or can count the
fingers. The finger which we hold up is at the
centre of the visual field, and it may be necessary to
bring the other hand very near to this before it can
be seen.
A few weeks since I found the field of vis-
ion so much narrowed in a case of retinitis pigmentosa
that the patient could not distinguish an object mov-
ing until it came within an inch or an inch and a half
of the centre of the field; showing that only a part
even of the yellow spot itself retained its normal func-
tion. A normal eye will distinguish an object moving
at a distance of from two to three feet from the central
point of vision. The field of vision may be mapped
out when great accuracy is desirable. Put the patient
before a blackboard, at the distance of fifteen inches;
make a dot for him to fix the eye on; then approach
a piece of chalk in a long black handle from different
directions, recording always the point where the chalk
is first perceived by a dot; afterwards unite these
dots by a continuous line, and the boundaries of the
field of vision are sketched.
DIPLOPIA.
Double images occur in paralytic strabismus, and
frequently after an operation for the cure of con-
comitant strabismus. Monocular diplopia is a result
TRIAL GLASSES.
15
of irregular refraction from abnormal curvature of the
cornea or lens, of mal-position or dislocation of the
lens, of inequalities of the corneal surface from old
cicatrices, or of bands of membrane stretched across
the area of the pupil. We may readily produce
double images by holding a convex lens of medium
strength partly before one eye so that we may look
through it and not through it at the same time, at
objects across the room.
IMPLEMENTS AND INSTRUMENTS.
TRIAL GLASSES.
Complete sets of trial glasses, or spectacles, are
necessary for those who propose to prescribe suitable
glasses for the various optical defects. The selection
of proper glasses for patients is a very important
and responsible duty, and should not be undertaken
unless the practitioner is disposed to give sufficient
attention to it to do it in a scientific manner. Let the
reprehensible, hap-hazard selection of glasses be left
to the itinerant vender and optician. The proper
glass having been determined, its number and kind
are to be written out and presented by the patient to
a respectable optician. A complete outfit of trial
glasses comprising the convex and concave, spherical
and cylindrical, the prismatic and the colored, will
amount to some two hundred, or the equivalent of a
16
EXAMINATION OF THE EYES.
hundred pairs of spectacles. To such as do not pro-
pose a more or less complete equipment for the
above purpose, I would suggest a few glasses
merely as an aid in diagnosis.
Weak convex lenses, of 30, 40, and 50 inch focus,
will help to determine a hypermetropia, or a begin-
ning presbyopia. If the patient sees No. 20 at twenty
feet as well with as without, or better with than
without either of the glasses, he is hypermetropic.
In beginning presbyopia the same glasses should aid
in reading the No. 1 print. Ordinary concave
glasses will aid in the differential diagnosis of a slight
myopia and hypermetropia. Through concaves of
30, 40, or 50 inch focus, a myope should see distant
objects more clearly. The same spherical convex or
concave glasses will aid in determining an astigmatism,
in connection with the metallic plate and slit. A slip
of colored glass will be useful in testing double images,
and a few prisms are necessary to measure the strength
of the ocular muscles, and to aid in curing some forms.
of strabismus.
The ophthalmoscope is very useful, and perhaps
ought now to be considered indispensable to the general
practitioner. Very necessary also are a pair of silver
lid elevators for the purpose chiefly of elevating the
eyelids of unruly children; and for the extraction of
foreign bodies embedded in the cornea, a wire specu-
BANDAGING THE EYE.
17
lum self-adjusting, a fine needle and a delicate spatula,
spud or grooved needle, and a pair of delicate forceps
for steadying the eyeball are useful. The Snellen
eyelid tourniquet is an almost indispensable aid in
removing cysts of the lids.
BANDAGING THE EYE.
The ordinary bandage may consist of a piece of
linen about ten inches long by two and a quarter inches
in width, with a piece of broad tape at either end to
pass around the head, and tie. A third tape may pass
over the top of the head to assist in holding the
bandage in place when necessary. Before applying,
a bit of linen and a little charpie should be placed
over the closed eye.
The compress bandage should be one and three-
quarters yards in length and about one and a half
inches in width, and made of linen, or, still better,
fine elastic flannel. To apply it, commence above the
affected eye, pass it across the forehead to the oppo-
site side, above the ear, to the back of the head,
below the ear, then up across the bit of linen and
charpie upon the affected eye, and pin it securely to
the first portion upon the forehead.
2
i
CHAPTER III.
THE OPHTHALMOSCOPE.
In order to see into the interior of an eye, it is
necessary first of all that the interior should be
lighted up. The old notion that an eye under cer-
tain nervous conditions becomes luminous from within
is not correct. It can be illuminated only by light
from without. The second condition necessary is,
that, having thrown rays of light into the eye under
examination, we should place our own eye in such a
position relative to the one illuminated, as to catch
the reflection of the rays of light which we have
thrown in. These two conditions are absolutely ne-
cessary, and any further ones merely add to the con-
venience of examination or render our examination
more accurate. With a bit of common window-
glass we can fulfil these two conditions. Seat the
patient in a darkened room with a lighted lamp by
his side, the flame about on a level with the eye to be
examined. With this fragment of glass held in
PRINCIPLE OF THE OPHTHALMOSCOPE.
19
front of the pupil and quite near the eye under ex-
amination, throw the rays of light from the lamp
directly into his eye. This fulfils the first condition.
The eye is illuminated. Now put your own eye be-
hind the glass directly opposite that of the patient,
and it will catch the return rays passing from his eye
through the glass into yours, and you will see the
entrance of the optic nerve, or optic disc as it is
termed, and the vessels of the retina passing over
and away from it. The fragment of glass is in real-
ity an ophthalmoscope, and all ophthalmoscopes are
merely modifications of this, and do not differ from
it in principle. It has been found more convenient,
however, to substitute for the plane glass a concave
mirror * with a small hole at its centre for the eye
of the observer. A concave mirror reflects more
light into the eye, and hence renders the details of the
fundus more distinct. To the same end also it has
been found serviceable in practice to hold immedi-
ately before the observed eye with the left hand, a
convex glass of about two-inch focus. This convex
lens enlarges the field of vision; and, although we
get an inverted image, on the whole it facilitates an
examination so much as to render its use almost in-
dispensable in the examination of the deeper struc-
* Sometimes, a plane or even a slightly convex mirror is pre-
ferred.
20
THE OPHTHALMOSCOPE.
tures of the eye. There are some forty or fifty
different kinds of ophthalmoscopes in use.
The one
most common, and the one I generally use, is that of
Liebreich. It consists of a metallic mirror slightly
concave, about an inch and an eighth in diameter,
set in a metallic frame, with a handle which pushes
into itself so as to be no more than two inches in
length when not in use, and convenient for the
pocket. In the centre of the mirror is an aperture
one-eighth of an inch in diameter, and attached to
the frame of the mirror is a hinged bracket to hold a
small convex or concave lens, to assist the eye of the
observer if necessary. The object glass or convex
lens is rather larger than the mirror, of about two-
inch focus, and may be set also in a metallic frame
with a short handle. A very interesting form of in-
strument is the binocular ophthalmoscope, so con-
structed that by means of prisms we are enabled to
use both eyes at once in an examination. Through
this we obtain a stereoscopic view of the fundus, all
its parts being brought into relief. We can readily
determine any change of surface on the optic disc,
small excavations or a slight prominence. It is
easier with this instrument also to determine the rela-
tive positions of opacities in the vitreous humor or
extravasations in the retina or choroid. Attractive,
however, as the binocular ophthalmoscope seems to
HOW TO USE IT.
21
be, I find that in practice I seldom use it. It is large,
cumbersome, and heavy, and requires more time for
its proper use, and ordinarily, therefore, its advanta-
ges do not in practice appear to be of sufficient im-
portance to compel its employment.
For many
difficult cases it is, however, almost indispensable.
Another, the aut-ophthalmoscope, is so arranged
that, by an ingenious combination of mirrors, one
may look with his right eye directly into his left, or
vice versa. There are also fixed ophthalmoscopes,
large and heavy, but useful in the class-room, and
for sketching the appearance of the fundus.
HOW TO USE THE OPHTHALMOSCOPE.
In the beginning, in order to learn to use the oph-
thalmoscope, it is best to examine a number of heal-
thy eyes. It is advisable also to dilate the pupil
with a weak solution of atropine, one grain to ten
which will so enlarge
or twelve ounces of water,
the field of vision as to make the examination more
interesting and instructive.
The advantage of a
weak solution is that its effect on the pupil vanishes
within about twenty-four hours. A stronger solu-
tion will act more quickly, but will not pass off in
two or three days, or perhaps a week. The instil-
lation of atropine does no permanent harm, but while
the pupil is under its influence, being widely dilated,
22
THE OPHTHALMOSCOPE.
i
a strong light is somewhat dazzling and vision is
more or less impaired for near objects. It must be
remembered that if we use the convex object glass
we get an indirect or inverted picture of the fundus,
and without the interposition of the object glass we
get a direct or upright image. Having seated our
patient in a room from which daylight is completely
excluded with a good steady light at his left side, we
take up the mirror in the right hand, put it close to
our own eye and our eye to the aperture, and on a
line with the eye to be examined, and distant from it
perhaps eight to twelve inches. Turning the mirror
slightly towards the lamp, we readily illuminate the
eye of the patient. Already we have learned some-
thing, because all eyes cannot be illuminated,
opaque lens, for instance, prevents it. Now, hold
with the left hand the convex object glass before the
illuminated eye, at the distance of an inch and a
half or two inches, directing the patient to look in
the direction of our left ear when we are to examine
his left eye, and our right ear when we direct our at-
tention to his right eye, — in other words, directing
that the eye under examination shall be turned slight-
ly inwards so as to bring the optic nerve directly op-
posite or behind the pupil. To examine the region
of the macula lutea the patient should look straight
forward, directly at the eyes of the observer. It will
-
an
HOW TO USE IT.
23
be recognized as a spot slightly darker in color,
with no vessels running over it. Having illuminated
the fundus of the eye with the mirror in the right hand,
we must be careful not to change its position while
we are adjusting the convex glass held in the left
hand, otherwise we shall fail to see the interior of the
eye from lack of light. Until the beginner learns to
use the hands independently of each other, he may
expect to trace one or more failures to a well-inten-
tioned illumination of a button-hole of his patient's coat.
If the patient is myopic we gain a more distinct
view by approaching our own eye a little, and if he
is hypermetropic we see better by increasing, slight-
ly, the distance between our eye and his.
If our
own eye is presbyopic or hypermetropic we may also
find it advantageous to use in the hinged bracket be-
hind the mirror one of the little convex glasses of
eight or ten-inch focus which belongs to the ophthal-
moscope. The convex glasses will also be found
serviceable if the eye of the patient is hypermetropic.
In the direct examination without the object
glass in the left hand, if we desire to examine the
disc or fundus, we must approach our eye very near
to that of the patient; but to simply test the trans-
parency of the media, — the lens or humors,
place our own eye at a distance of fifteen or eighteen
inches from the eye under observation.
we
24
THE OPHTHALMOSCOPE.
The appearance of the fundus of the normal eye
differs considerably in different individuals. The
fundus of the eye of a light-complexioned person
is light-red, while that of a dark-complexioned one is
dark-red, owing to an abundance of pigment in the
choroid. In the former, the epithelial layer of the
choroid being less pigmented, we may see many of
the vessels of the choroid through it, which gives
the fundus a striated appearance. In very dark
eyes the choroidal vessels are invisible.
The disc or optic nerve entrance appears generally,
to me, of a slightly yellowish-grayish pink. In dark
eyes more white and glistening, in light eyes more
rosy in color. It is usually circular in form, but in
astigmatism often has the appearance of being oval
when it really is circular.* Its edge is sharply de-
* Suppose, for instance, a case of astigmatism where the cornea
is too convex in the vertical meridian. The optic disc appears
oval in a vertical direction if we make a direct examination. In
indirect examination it will appear oval in a horizontal direction. The
reason of this is plain. Our convex glass makes objects appear
larger if held near them, but if removed from the object beyond
its focus (about two inches) we have an image inverted and re-
duced in size. Now in a case like the above, the eye lends the
greater refracting power to the glass in a vertical direction, and the
inverted and reduced image will, of course, be reduced most in
the direction of the greatest refractive power. The convexity of
the glass and the cornea combined being greater in the vertical
line, the inverted image of the disc is reduced most in this direc-
tion. Hence it appears oval horizontally.
A
THE RETINAL VESSELS.
25
fined, and near it may be seen occasionally a slight
crescentic line of pigment. The face of the disc is
more pinkish at its inner half, and where the retinal
vessels emerge from it.
seen.
The retinal vessels run principally upward and
downward, an artery, known by its light color, and
two veins running in each direction. The retina it-
self, in a healthy state, is transparent, and cannot be
Exceptionally in very dark eyes, it may be
detected as a gray film, in the immediate vicinity of
the disc. The physiological excavation, not unfre-
quently noticed in the healthy nerve disc, is spoken
of in connection with pathological excavations in the
remarks on atrophy of the optic nerve or amaurosis.
Venous pulsation may sometimes be observed in the
healthy eye. It is to be looked for in that part of
the retinal vein between the centre of the nerve disc
and its edges. It may be produced by gentle pres-
sure on the ball of the eye with the finger. Similar
arterial pulsation indicates intraocular pressure, and
is not found in the healthy eye.
The ophthalmoscopic appearance of the diseased
eye is spoken of in connection with the various af-
fections, which demand its aid for their diagnosis and
intelligent treatment. I may remark here, however,
on the great importance of what is termed lateral or
oblique illumination in detecting diseases of the
26
THE OPHTHALMOSCOPE.
anterior part of the eye. A good rule to follow in
ophthalmoscopic examinations, one that will save
time, facilitate diagnosis, and prevent error,
always commence the examination by
is to
LATERAL ILLUMINATION.
Lateral Illumination of the eye is best conducted
in a darkened room, also. The patient sits relatively
to the light, as in the ophthalmoscopic examination.
The convex object glass is to be held between his eye
and the light, the patient facing the observer, so that
a strong light is thrown obliquely on to the front of
the eye illuminating the cornea and anterior chamber.
We may in this way detect opacities of the lens, ex-
amine with the greatest nicety the surface of the
cornea and the texture of the iris. A second con-
vex glass may also be used at the same time to look
through as a magnifying power, if desirable.
DIFFICULTIES OF DIAGNOSIS IN DISEASES OF THE EYE, FORMERLY.
Before the discovery of the opthalmoscope, by
Helmholz, in 1851, very little, comparatively speak-
ing, was known concerning the internal diseases of
the eye, and the little knowledge which we possessed
was very inexact. The history and progress of this
kind of disease it was of course impossible to de-
termine with any certainty. Diseased eyeballs were
FORMER DIFFICULTIES OF DIAGNOSIS.
27
rarely dissected after death; and when this was done,
it yielded but scanty return for the labor.
A com-
parison of the pathological anatomy in such an in-
stance, with the symptoms observed during life, in
an organ of which nothing objective, in regard to its
deeper structures, could be previously determined,
afforded little satisfaction, and still less serviceable
information. We may say, therefore, that previous
to the introduction of the opthalmoscope, our entire
knowledge, almost, of the diseases of those parts of
the eye posterior to the crystalline lens was conjec-
tural. When the cornea and the iris and the lens
presented no appearances of lesion, and yet the
patient's visual power was impaired, we were dis-
posed, and it might be said perhaps that we were
compelled, nolens volens, to attribute the visual dis-
turbance to some affection of the optic nerve. In
the words of another, when neither the patient nor
the doctor could see any thing, it was amaurosis ! *
Now we are enabled to determine not only the exist-
ence of an amaurosis, but what is sometimes of still
greater practical importance, to determine what i
not an amaurosis. All the less important disorders
in the fundus of the globe are exposed to our careful
inspection, and we are enabled to treat them under-
standingly.
•
*Amaurosis sei jener Zustand wo der Kranke nichts sieht und
auch der Arzt nichts. Walther.
28
THE OPHTHALMOSCOPE.
IMPORTANCE OF THE OPHTHALMOSCOPE TO THE GENERAL
PRACTITIONER.
It is within a short time only that, in the treat-
ment of general nervous disorders, the attention of
the profession has been called to the importance of
knowing the exact condition of what has been fitly
termed the outpost of the central nervous system,
the nervous structure of the posterior portion of the
eye, the condition of which gives, to a great extent,
a faithful picture of the condition of the brain itself.
The ophthalmoscope is, therefore, destined in the
future to be of great service to physicians in the
treatment of a large class of diseases of the brain
and nervous system. Among disorders of this kind
which the general practitioner is called upon to treat,
and in which the ophthalmoscope has already proved
serviceable as an aid to diagnosis, to their pathology,
and to a more complete understanding of their his-
tory, are the following: meningitis, encephalitis,
hydrocephalus, cerebral hemorrhage, tumors, epilepsy,
insanity, locomotor ataxy, nervous fevers, and mye-
litis. These are all known to be accompanied by
changes in the appearance of the optic nerve and
retina, which can be seen and recognized through the
ophthalmoscope.
In the optic nerve disc, for instance, we may see
congestion and effusion, inflammation of substance
ITS IMPORTANCE TO PHYSICIANS.
29
and sheath, anæmia, and atrophy. An optic neuritis
is connected with meningitis of the base of the brain,
with a tumor, with large hemorrhage. An atrophy
of the nerve, which may be recognized as either pro-
gressive or stationary, is accompanied by disease of
the brain, cerebellum, or spinal cord. In lead poison-
ing, a German physician has noticed a change of
color and transparency in the optic nerve disc. In
the retina, we detect inflammations, fatty or fibrous
exudations, and hemorrhages; in the choroid, loss or
disturbance of pigment, hemorrhages, and effusions;
and in the blood-vessels of the fundus generally are.
observed diminution in size, dilatation, obliteration,
tortuosities, pulsations, varicosities, blood stases, dis-
placement, effusion, and rupture. In albuminuria
or Bright's disease, one may see extravasations along
the course of the retinal vessels, which later become
effusions, forming white patches. Finally, there is
degeneration of the substance of the retina, and de-
fective nutrition of the optic nerve. In syphilis, we
find a retino-choroiditis, with white, red, and brown
patches.
In meningitis, Bouchut* has observed, in fifty-nine
cases, obvious changes in the eye of all but two. In
the first stage, there is dilatation of the veins of the
* Medico-Chir. Review, January, 1868
30
THE OPHTHALMOSCOPE.
retina, peri-papillary congestion, and often effusion.
In the second stage, there are "tortuous veins,
stasis, thrombosis, and even rupture of the vessels.”
Sometimes the first noticeable symptom of the disease
is found in the eye. To be able to diagnose an ob-
scure case of meningitis from a nervous fever, in an
early stage of the disease, is of great practical im-
portance. In hydrocephalus, the same observer has
noticed numerous and enlarged retinal vessels, and a
prominent and suffused optic disc. He remarks that
the ophthalmoscope is of the greatest service in di-
agnosing this affection; and that without its aid,
diagnosis of chronic cases may sometimes be impos-
sible.
Chronic headache, especially when the location
of the pain is unusual or seems permanently fixed,
and when accompanied by vomiting, should be re-
garded with suspicion, and every means taken to
determine the state of the brain. Severe headaches
and bilious vomiting, have been known to herald final
disease of the brain, and amaurosis. The ophthal-
moscope will often be of value in enabling the
practitioner to determine the significance of these
symptoms, whether they are to be regarded as of
cerebral or of gastric origin, -a most important
question and often difficult to decide.
In insanity, the ophthalmoscope bids fair to be
IN DISEASE OF THE BRAIN.
31
come an important agent in determining its course.
Of a large number of patients already submitted to
examination, two-thirds have been found to present
affections of the optic nerve. Dr. Allbutt, of the
Leeds Infirmary, found that in fifty-three cases of
that kind of insanity known as general paralysis,
forty-one had disease of the optic nerve. The affec-
tion begins as a pink suffusion of the disc, and ends
in white atrophy. It resembles in appearance the
"red and white" softening of the brain.
Of fifty-
one cases of mania, more than half showed symptoms
of disease of the optic nerve, a stasis followed by
consecutive atrophy, or white, or mixed atrophy.
After a paroxysm, there is a paralysis of the blood-
vessels, and about the disc, causing hyperæmia. In
dementia and in idiocy more than half; and in insan-
ity, from epilepsy, a large number of cases showed
disease of the optic nerve or retina.
The eye has also been observed after the admin-
istration of chloroform, when temporary congestion
of the vessels of the retina and capillary effusion,
rendering the optic disc indistinct, were found.
After large doses of opium and belladonna, nearly
the same effects were observed. Prof. Graefe has
published some interesting ophthalmoscopic observa-
tions upon the retina of cholera patients. He found
invariably stagnation of blood in the branches of the
32
THE OPHTHALMOSCOPE.
arteria centralis retina, and the retinal veins were
unusually dark. The optic disc was of pale lilac
color, faded towards its centre. Of course, investi-
gations of this nature are of little consequence, as
showing simply the state of the eye, regarded by
itself as an organ apart from the brain. In the
treatment of a case of cholera, or even in the diag-
nosis of a case of cholera, the ophthalmoscopic ap-
pearance of the eye is a matter of the least possible
import; but when we regard the vascular and ner-
vous structure of the fundus of the eye as a picture in
miniature of the condition of the brain itself, the
importance of researches of this kind can hardly be
overstated.
Thus investigations in regard to the diseases in-
volving the brain and nervous system are being pushed
rapidly forward, through ocular examination of the
nervous and vascular tissues of the eye with the oph-
thalmoscope. For the first time we see a diseased
nerve, and measure with our eye the progress of the
affection. It has been remarked with truth that
hereafter no record of a nervous affection can be con-
sidered complete unless it gives a faithful account of
the ophthalmoscopic appearance of the retina and
optic nerve.
CHAPTER IV.
REFRACTION, ACCOMMODATION, AND THEIR ANOM-
ALIES.
Refraction of the eye, or the refractive power of
the eye, is the phrase used to express the power of the
cornea and lens to bring rays of light entering the
pupil to a focus in the vicinity of the retina.
Accommodation expresses the ability of the eye to
increase or lessen its refractive power by means of
the ciliary muscle and iris. Thus, in a state of rest,
regarding a distant object, the emmetropic (normally
refractive) eye needs no exercise of its power of ac-
commodation, because the cornea and lens are pre-
cisely convex enough to bring parallel or distant rays
of light to a focus on the retina. The latter is sit-
uated at a distance of about one inch behind the
cornea, and the refractive power of the eye at rest
is about equivalent to a convex glass of one-inch
focus. But if we regard an object near the eye, the
rays fall no longer parallel upon the cornea, but
divergently, and of course a greater focussing power
is needed to bring them to a point at the proper
distance behind the lens. A refractive power, the
3
34
REFRACTION, ACCOMMODATION,
equivalent of a one-inch convex glass, is insufficient,
and the exercise of the power of accommodation
becomes necessary.
HOW ACCOMMODATION OF THE EYE IS EFFECTED. *
The accommodation is brought about by the action
of the ciliary muscle upon the crystalline lens, the
surface of which is rendered more convex anteriorally
and posteriorally, giving it in consequence a higher
refractive power. The anterior surface of the lens
is also pushed slightly forward. Associated with
this, there are also the movements of the iris, the
pupil being diminished in size and moved forward,
while the periphery of the iris is drawn slightly back-
ward, and in binocular vision the action of the recti
interni to produce the necessary convergence of the
optic axes.
DISTINCTION BETWEEN REFRACTION AND ACCOMMODATION.
It is to be remarked that the power of accommo-
dation in the eye may be entirely suspended (as for
instance by the instillation of a strong solution of
atropine), and still the refraction remain sufficient
for distant vision. In presbyopia, the accommoda-
tion is much lessened in power, so that the near
* A very able paper, criticising this theory of accommodation,
and embodying the results of experimental researches on the
refractive power of the eye, by Dr. Dudgeon of London, may be
found in the British Journal of Homœopathy for January, 1871.
AND THEIR ANOMALIES.
MYOPIA.
35
point for fine print may be as far as fifteen inches or
further from the eye, while the emmetropic eye is
able to see the same print distinctly at three inches.
The former, like the latter, has perfect refractive
power for distance. In myopia, the antero-posterior
diameter of the eyeball being lengthened, the refrac-
tive power is too great for distant objects,
power of accommodation may be unimpaired.
the hypermetropic eye the same diameter is too short;
there is a lack of refractive power, the rays of
light reaching the retina before being focussed,
while the accommodative power may be good.
REFRACTION AND ITS ANOMALIES.
the
In
Considering rays of light from distant objects as
parallel rays, we may say, in general terms, that in
the
Emmetropic eye, parallel rays are brought to a focus upon the retina
Myopic eye,
Hypermetropic eye,,,
Astigmatic eye,
""
""
""
before
behind
""
""
""
""
""
irregularly focussed.
""
MYOPIA (NEAR-SIGHTEDNESS).
The optical defect of the myopic eye is exactly the
reverse of that of the hypermetropic; that is, its re-
fractive power being in excess, parallel rays of light
are brought to a focus before reaching the retina. It
was supposed formerly that in myopia the cornea
36
REFRACTION, ACCOMMODATION,
was too convex and prominent, but exact measure-
ments have proved the cornea to be less rather than
more convex, and although the antero-posterior
diameter is lengthened, the bulging of the globe is
wholly posterior, at the entrance of the optic nerve.
The retina is thus pushed too far back from the
cornea and lens. This elongation of the posterior
pole of the eyeball can be seen by requesting the pa-
tient to look as far inward as possible; we then no-
tice also that the space in the orbit between the outer
canthus and the globe, observable in the emmetropic
(normally refractive), and especially in the hyper-
metropic eye, is completely filled up by the distended
globe. When the affection is of a high grade, a
dazzling sensation is present in a bright light, and
there is also more or less amblyopia; the cause of
these symptoms will become apparent when we come
to notice the condition of the interior of the eye.
Myopia is often congenital, and sometimes heredi-
tary, but it is in all probability still oftener acquired.
Possibly a predisposition to elongation of the globe,
or some malformation of the ball must be present to
favor the development of the affection in young per-
sons, but it is nevertheless a fact that certain circum-
stances produce the disease in apparently well eyes.
I speak of it as a disease, and it will be seen pres-
ently that a myopic eye is a diseased eye. I have
AND THEIR ANOMALIES.
MYOPIA.
37
known several students at different times in Vienna,
who informed me that when quite young they saw as
far as their fellows, but that after commencing their
studies, and pursuing them late at night in their
homes among the mountains, with no light but that
of a miserable tallow candle, and sometimes even.
less than that, a shred of cotton in a cup of oil,
a light so dim and flickering that the book must
approach within a few inches of the eye, or the head
be bent over so as nearly to touch the paper when
writing, after studying in this way for a few years.
they became myopic. We know that myopia is
more common among the educated than the illiterate.
Soldiers and sailors almost never acquire it, while in
schools and colleges it is very common. At one of
the colleges at Oxford, 32 in 127 students were my-
opic. We have even more conclusive proof than
this, of the probability that myopia is acquired, in a
recent observation of the indefatigable Dr. Hermann
Cohn. He found that of 132 compositors, 51.5 per
cent were myopic; of these 68 myopes, so large a
number as 51 had in early life normal eyes, with un-
impaired vision for distance.
Dr. Cohn's researches among school children, if
they do not prove the development of myopia in
emmetropic eyes, show a fearful controlling influence
of certain circumstances in its progress. Of 10,060
38
REFRACTION, ACCOMMODATION,
school children examined, 1004 were near-sighted:
the percentage of myopes increasing from the ele-
mentary school upwards, according to the increase
of demand for study. For instance, in five village
schools the myopia was about: that is, the con-
cave glasses required to render vision acute for dis-
tance were on the average of about 24-inch focus.
In 22 Elementary schools the myopia averaged about 2
In 2 Gymnasiums
In 2 Prima (highest school)
In the University (Breslau)
""
18
""
""
""
""
""
4
Of the 410 students in the University examined
without selection, nearly two-thirds were found near-
sighted. Such statistics show but too plainly the pro-
gressive nature of the affection. Another remarkable
fact brought to light by these researches is that of the
apparent infrequency, comparatively speaking, of a
hereditary cause; of all these 10,060 children, only
28 had near-sighted father or mother.
Diagnosis. The diagnosis of myopia is not
difficult. It must not be taken for granted, however,
that because a patient holds his book too near, or
because he does not see well at a distance, he is
therefore near-sighted. Astigmatism, and especially
hypermetropia, may equally produce defective vision,
characterized by such symptoms. Still, no opacities
of the cornea or lens being present, if the indistinct-
I
AND THEIR ANOMALIES.
MYOPIA.
39
ness of vision increases very rapidly, as large letters.
are removed from the eye, we may be tolerably cer-
tain of myopia. A better test is to hold before the
eyes weak concave glasses, say of 30 or 40 inch
focus. If the patient sees better, he is in a great
majority of instances near-sighted. Occasionally,
however, persons of good accommodative power see
more distinctly, for the moment, through weak con-
cave glasses, though not myopic, and sometimes
when a very high degree of myopia is present weak
concaves are of almost imperceptible benefit; there-
fore, to make our diagnosis certain, it is better to
ascertain beforehand about the number of the glass
required to correct the myopia. This may be done
by finding the farthest point at which the patient can
read the finest type, such as "Briliant," and if this be at
a distance of six, eight, or ten inches from the eye, we
may place before his eyes concave glasses of a corres-
ponding number; if his far point is eight inches, a con-
cave glass of eight-inch focus will enable him to see
well at a distance, and the existence of myopia is
demonstrated beyond a doubt. Another ready and
convenient proceeding for the diagnosis of either near
sight or oversight is mentioned under the head of
Hypermetropia at page 57.
Myopia is also readily diagnosed with the ophthal-
moscope. For this purpose we use the erect image
::
40
REFRACTION, ACCOMMODATION,
1
(simply the mirror, without the convex object glass),
and find that we can see the optic nerve disc and retinal
vessels, when the pupil is large, distinctly at a short
distance from the eye. On moving our head to either
side we find the image moves in the opposite direc-
tion; we obtain an inverted image of the fundus of
the globe exactly the reverse of that obtained in the
hypermetropic eye under a similar examination. For
detailed examination of the fundus, especially if the
pupil be small, the indirect mode of examination
with the object glass is better and more convenient.
We may then discover in a majority of cases where
the myopia is marked, a staphyloma posticum, which
is recognized as a brilliant white or yellowish-white
crescent around the edge of the optic nerve disc. It
is sometimes narrow, distinct, and regular in outline,
extending quite around the disc, but oftener seen
only on the side of the disc towards the macula lutea.
The crescent is also frequently irregular in shape,
broadest towards the yellow spot, its edge indistinct
and marked here and there at its margin by patches
of black pigment. This appearance is noticed chiefly
in progressive myopia, and is the result of a sclerot-
ico-choroiditis posterior, and as it progresses we
notice a hyperæmic condition and gradual enlarge-
ment of the crescent, small white patches appear at
the macula lutea, coalesce and form a union with the
AND THEIR ANOMALIES.
crescent about the nerve disc.
MYOPIA.
41
Vision becomes im-
paired as the region of the macula lutea is invaded.
Vitreous opacities are present as a result of the cho-
roiditis. The vision of the patient is troubled by
fixed scotoma, or floating films and shreds, and de-
tachment of the retina from the choroid, or even
glaucoma may supervene.
Pathology.
The pathological changes in myopia
and staphyloma posticum, and an accompanying
sclerotico-choroiditis, consist chiefly in an atrophy
of the choroid resulting from the inflammation.
This occurring principally around the nerve entrance,
permitting the white sclerotic to shine through,
we have, as a result, the characteristic crescent so
often observed with the ophthalmoscope. The irreg-
ular deposit of pigment is owing to the same cause
as are also the exudations into the vitreous, and the
final separation of the retina to a greater or less ex-
tent from the choroid. There is also a thinning
of the sclerotic coat, in the vicinity of the optic
nerve entrance, and particularly at the apex of the
staphyloma. With the choroid the retina suffers
also, and finally becomes atrophied in the region
of the optic nerve and macula lutea.
The characteristic ophthalmoscopic symptoms
spoken of may also be observed when no staphyloma
or bulging of the globe obtains, being the result
42
REFRACTION, ACCOMMODATION,
simply of a posterior choroiditis or sclerotico-choroid-
itis. In the greater number of cases of myopia of
the medium and severer grades, ranging from 1
1
12
15
or
up to 1, an inflammatory condition of the fundus
of the globe, with or without the bulging, exists ;
hence the inference, that a myopic eye is a diseased
eye. The same cannot, as a rule, be said of the
presbyopic, hypermetropic or astigmatic eye. These
names convey the idea simply of certain optical defects.
The popular notion, therefore, that a near-sighted eye
is par excellence a strong eye, is erroneous. No doubt
this error arises from the fact so generally noticeable
that myopes see fine objects near the eye in a very
dim light, and that presbyopia occurs rather later in
life. It is true also that the myope, if his eye con-
tinue tolerably healthy until advanced in life, finds
distant vision somewhat improved. This is due to a
diminution in the size of the pupil, and a senile
change in the convexity of the lens.
Treatment. For the purpose of treatment, it is
convenient to divide myopia into the stationary and
progressive. Strictly speaking, however, stationary
myopia is very rare. It may occur exceptionally,
and undoubtedly occurs oftenest in the least severe
cases, such as those of from to, and in persons
above the age of twenty-five or thirty. Wecker*
20
* Maladies des Yeux. Par L. Wecker. Paris, 1867. Tome
second, p. 707.
AND THEIR ANOMALIES.
MYOPIA.
43
has examined and recorded carefully the status of
2500 cases of myopia. Many of these have been
re-examined after the lapse of months or years, and
he is led to conclude, from results thus obtained, that
myopia is almost invariably more or less progressive.
If, however, we are satisfied that in a given case it is
non-progressive, we have only to prescribe for our
patient the proper concave spectacles, and we have
afforded him all the necessary treatment.
In youth, however, almost all myopia is progres-
sive, and progressive myopia threatens blindness.
It does not always lead to blindness by any means,
but it may lead to it. Staphyloma posticum being
present, there is no particular limit to the bulging of
the sclerotic, and the consequent or accompanying
inflammation and degeneration resulting. The prog-
ress of the disease may be exceedingly slow, but at
middle age or before, a myopia with staphyloma pos-
ticum sometimes reaches a fatal termination, so far
as sight is concerned.
Suppose this fatal termination escaped, amblyopia
is the invariable accompaniment of a high degree of
myopia. A myopic eye of,,, or, armed with
the proper glass, possesses an acuteness of vision,
calling normal vision I, frequently of only,, or
after middle life. There is a feeling of fulness
and tension of the globe, and, owing to its increased
44
REFRACTION, ACCOMMODATION,
:
length, the lateral movements of the ball are some-
what limited. There is frequently pain in and
around the globe, which is rapidly increased by use
of the eyes for reading, especially by artificial light,
and muscular asthenopia is often present. If there
is much atrophy of the choroid and loss of pigment,
the dazzling in a bright light becomes annoying. In
cases like these, where the amblyopia is considerable,
no glasses can safely be permitted the patient for
near objects, for concave lenses diminishing the size
of the object, the print for instance, is brought very
near the eye. This is injurious, as it overtaxes the
accommodative power, requires extreme convergence
of the visual axes, thereby causing pressure of the
external muscles upon the eyeball, tending to enlarge
the posterior staphyloma. It is especially this strong
convergence of the visual axes which favors the
progress of high degrees of myopia, for those who
accommodate for near and fine objects, using but
one eye for the purpose, such as watch-makers, are
comparatively exempt from the affection. Strong
convergence of the eyes for near objects is then to
be particularly avoided.
When the eye is irritable, the conjunctiva injected,
the ophthalmoscope showing a hyperemic condition of
the nerve disc with or without staphyloma posticum
and the patient complains of pain around and some-
AND THEIR ANOMALIES.
MYOPIA.
45
times in the eye, with feeling of tension and heaviness
in the eyeball, the prescription of glasses should be
temporarily delayed until, by complete rest of the
eyes and proper remedial measures, the irritable state
of the eye is removed. Gentle use of the eye douche
will be found grateful, also a lotion composed of a
drachm of sp. ether nit. to six or eight ounces of pure
water, to which may be added a few drops of aro-
matic vinegar, the wash to be sponged over the
closed lids and about the eye several times a day and
allowed to evaporate. At other times a weak collyr-
ium to be dropped into the eye will do better. Such
collyria may be made of ten or fifteen grs. of borax, two
or three grs, of alum, a grain of sulph. of zinc, each to
one or two ounces of water. Occasionally when the
congestion has been markedly venous I have applied
a lotion of ten to twenty drops of hamamelis to a cup
of water, at the same time administering ham.
internally. Frequently, however, a wash of simple
tepid milk and water is best, the slightest irritant
causing too great reaction. When the congestion
and heat are considerable, I give acon.
frequently, however, this is not demanded, and
macrot., spig., and bell. are more serviceable.
Cactus is admirable also, especially if the ophthal-
* Vide Hyperæmia of the Conjunctiva.
Far more
46
REFRACTION, ACCOMMODATION,
moscope show a hyperæmia of the optic nerve and
retina. Many other and perhaps an entirely different
class of remedies may be indicated from other general
disturbance in the patient's health, the general health
of the patient being of very great importance in
nearly all cases of disease of the eye. The treatment
of choroiditis is spoken of elsewhere.
Spectacles. Generally speaking, no preliminary
treatment is called for, and our first step is to select
the appropriate spectacles. When the irritability of
the eye is not too great, spectacles, instead of retard-
ing, are a potent auxiliary in hastening a cure.
They are to be selected with the greatest care. If
too weak, they are comparatively useless; if too
strong, a positive injury. The degree of myopia is
determined by the negative focus of the glass which
neutralizes it. If a patient reads No. 1 of the test.
type at six or eight inches, his myopia is or. A
concave glass of six or eight inches focus should, theo-
retically speaking, enable him to read No. 20 at
twenty feet, and to see well at a distance. Practically,
however, we find it necessary to prescribe concave
spectacles rather weaker than this. If the myopia is,
vision will be most perfect through glasses of or 1
which of the two numbers will prove best is to be
determined by trial. The reason of this non-corre-
spondence of the number of glass to the degree of
9
109
AND THEIR ANOMALIES. MYOPIA.
47
myopia is this: the patient's far point being eight
inches, the visual axes were converged for this dis-
tance, and with convergence of the eyes is associated
accommodation or an increased convexity of the
crystalline lens; in looking at a distance through
the prescribed glasses, the visual axes are of
course parallel, and there being no accommodative
power (increased convexity of the crystalline lens)
to overcome, the glasses must be proportionally
weaker. The proper glass to enable him to read
music or small print at twenty-four inches would
be of about twelve-inch focus. The formula is this:
-+4=-12. The patient's power of accommo-
dation will influence greatly the choice of spectacles.
When little or no accommodative power exists, as is
often the case in a high grade of myopia, spectacles
may be given which completely neutralize the myopia
and entirely supplant any little accommodative power
present. When only a tolerable power of accommo-
dation is found, it is advisable to prescribe glasses
which partially supplant it. Thus if our patient has
a myopia of, and finds glasses of best, if his power
of accommodation be, he will, through these
glasses, be obliged to use his whole power of accom-
modation for reading at a distance of twelve inches.
This is not safe, lest symptoms of fatigue supervene,
his eye become irritable and his myopia be increased.
48
REFRACTION, ACCOMMODATION,
He should, therefore, be provided with weaker spec-
tacles for reading; concave glasses for instance of
sixteen or eighteen inch focus, by diminishing but
little the convexity of his crystalline lens enable him
to see easily at ten or twelve inches, and tolerably at a
short distance beyond. IIe should therefore, like the
myope without accommodation, provide himself with
two pairs of glasses, one for reading and one for distance.
If perfect accommodation is present, as is sometimes
the case in the slighter forms of myopia in young
persons, a single pair of glasses which neutralize the
near-sightedness may be worn for both far and near
vision. Generally speaking, though, it is best to
prescribe concave spectacles for near objects which
only partially neutralize the myopia, and enable him.
to read comfortably at fourteen or sixteen inches.
Rules are often however of little practical service. The
myopia must be neutralized by suitable glasses whether
their strength correspond or not to the apparent degree
of near sight. Frequently very strong glasses will be
necessary for distant vision, and the patient will find
it convenient to carry eye-glasses to use temporarily
before his spectacles. These eye-glasses must, of
course, be concave and of just the power to supple-
ment the spectacles sufficiently to neutralize the
myopia for distant vision. When the myopia is
slighter than or, fine print being read easily
1
14
AND THEIR ANOMALIES. MYOPIA.
49
at fourteen inches, spectacles need not be pre-
scribed, but simply the proper eye-glasses for distant
vision.
Too great care cannot be exercised in the choice
of spectacles in progressive near sight, nor can spec-
tacles be provided too early for children after their
education has commenced. The chief danger in the
selection of spectacles is that of getting them too
strong and so overtaxing the eyes for near objects.
Wecker believes the great prevalence of myopia in
Germany to be due partly to wearing too strong
glasses. I believe it due principally to the peculiar
text in which their books are mostly printed. It
requires too sharp vision and too close attention to
distinguish the letters. I can never read it long
by artificial light without causing asthenopic symp-
toms, and I have no doubt that the change to the
Roman letter, now going on in Germany, will event-
ually prove of great advantage to its students.
Spectacles, therefore, should not be bought at
random of opticians or itinerant venders, but should
be prescribed by a competent physician or oculist.
The result of random spectacle-buying is seen in Dr.
Cohn's report. Of 1004 near-sighted children, only
* Wecker's rule is very good in doubtful cases: " Eviter de
donner dans l'hypermétropie des verres trop faibles, et d'en pre-
scrire de trops forts dans la myopie."
4
dy
50
REFRACTION, ACCOMMODATION,
107 wore glasses at all. Of this number, 11 only
wore glasses which were not injurious to the eye!
Of these children 99 had selected their own glasses.
Only 8 had glasses selected by a physician or oculist.
It is well to determine the amount of myopia for
each eye separately, as the refractive power of the
two eyes sometimes differs. The glasses should be
selected for the least myopic eye as a rule. When
one eye is myopic and the other hypermetropic, the
most serviceable eye should alone be provided for.
If we prescribe a concave for one and a convex glass
for the other, the former diminishing and the latter.
magnifying objects, it will be difficult to fuse the
different sized images on the retina. Actual trial,
however, is the best method of determining these
matters. The best rules have their exceptions. I
have a patient whose right eye is myopic and astig-
matic, and whose left eye is hypermetropic. For the
first he wears an 18-inch concave cylindrical, and for
the second a 16-inch convex spherical glass, and
with these reads more comfortably with both eyes
than with either eye alone.
The phosphenes, spectra, flashes of colored light,
and like phenomena, arise from over-sensibility of the
retina, and generally disappear under treatment of
the irritable condition of the eye. If they do not,
like muscæ volitantes and scotoma, they will be ren-
A
AND THEIR ANOMALIES.
MYOPIA.
51
dered less apparent and troublesome by the use of
blue glasses.
After prescribing with the greatest care the proper
glasses, it is necessary in progressive myopia to en-
force the strictest hygienic measures. Our patient
should not work continuously at near objects, but
should rest a short time at intervals of a quarter or
half hour, and always whenever the eyes feel in the
least fatigued. He should never work or read with
the head bent forward, as this promotes intraocular
congestion, choroiditis and increase of staphyloma
posticum. The light should fall upon his work from
behind, so that the eye may be protected from glare.
Children's school desks should, therefore, be made.
sufficiently high and sufficiently sloping, and be
placed, as regards light, to fulfil these conditions.
It is almost needless to add that in the modern school-
room this is not the case. I remember a humble
school-house in the country, where, thirty years or
more ago, these conditions were fulfilled. The desks
were high and very sloping, and running along the
sides and across the ends of the room, were all ex-
cellently lighted. I never saw a near-sighted boy in
those days. Dr. Cohn found all the school furniture
badly constructed. Low desks and bad light fre-
quently compelled the scholars to bend over so as to
bring the head within three or four inches of the
52
REFRACTION, ACCOMMODATION,
book. It is the duty of physicians everywhere to
enlighten parents and teachers in regard to this fatal
defect in school-room furniture.
1
In very high degrees of myopia, such as 4,, or½,
even if no amblyopia be present, we cannot expect
the patient to read large print through his glasses at
a point as distant as a normal eye would do it. The
powerful concave glasses diminish the size of the
image too much. Very strong concaves are also in-
convenient to the wearer, by compelling him to move
his head always in looking to the right or left. His
glasses are so deeply hollowed that he must always
look through their centre, or they produce the
effect of prisms or decentred glasses. If the glasses
produce dazzling, they may be slightly tinted with
blue.
MUSCULAR ASTHENOPIA,
Or insufficiency of the recti interni, is not unfre-
quent in the severer grades of myopia. It gives rise
to confusion of sight and fatigue of the eye, similar to
that described under the head of Accommodative As-
thenopia. It is caused by overtaxing the internal
recti in converging the eyes so as to bring both optic
axes to bear at once on near objects. Greater conver-
gence being necessary for myopes, this class suffer
oftenest from this affection. It may occur tempora-
AND THEIR ANOMALIES.
ASTHENOPIA. 53
rily after exhaustive diseases, such as diphtheria and
various kinds of fevers.
DIAGNOSIS.
Let the patient fix his eyes on our finger, and as
we approach it to within five or six inches of his eyes,
the weaker internus will suddenly relax, and one eye
will roll outwards. We may measure the weakness
of the muscle by means of prisms. A normal rectus
internus will successfully resist the tendency to the
production of diplopia of a prism of from 20° to 30%,
its base outward. If, therefore, we find double
images caused by a prism of 6° or 8°, we may judge
as to the degree of weakness of the internal muscles.
The action of prisms is further explained under Par-
alysis of the Ocular Muscles.
TREATMENT.
The treatment will consist, generally, in present-
ing the proper concave glasses so as to enable the
patient to read at a distance of twelve or fifteen
inches, in order to avoid great and prolonged conver-
gence of the visual axes. If this does not cure, the
general muscular system of the patient being in
good condition, we may divide the recti externi, one
at a sitting, or only one externus, if this is sufficient
to admit of the necessary convergence of the eyes
54
REFRACTION, ACCOMMODATION,
for near vision. The operation is described under
the head of Strabismus. Muscular asthenopia, due
to general debility after serious illness or other
causes, will be cured by such internal treatment and
hygienic measures as are necessary for the restoration
of the usual health and muscular energy. See Hy-
peræmia of the Conjunctiva.
HYPERMETROPIA AND ASTHENOPIA (ACCOMMODATIVE).
HYPERMETROPIA,
As we have already seen, is that condition of the
eye in which its antero-posterior diameter is too short
in comparison with the refractive power (convexity)
of the crystalline lens and cornea. The rays of light
consequently reach the retina before they are brought
to a focus, forming circles of diffusion, and vision is
indistinct. A convex glass, or spectacles, by sup-
plementing the refractive power of the natural lens,
enables the patient to focus the rays of light upon
the retina, precisely as in presbyopia. In presbyo-
pia, however, rays of light from a distance
is, what are termed parallel rays are brought to a
focus on the retina without the use of accommodating
power; while, in hypermetropia, the exercise of this
power is always necessary, even for distant vision :
and, in the higher grades of the affection, convex
glasses are also necessary for all distances. A
that
AND THEIR ANOMALIES.
HYPERMETROPIA. 55
hypermetropic eye is generally smaller in all its
dimensions than the emmetropic or normally refrac-
tive, and is probably of congenital and hereditary
source.
Hypermetropia is divided by Donders into facul-
tative, relative and absolute.
Facultative is the slightest form, where the
patient accommodates readily for all distances; pres-
byopia occurs rather early, and then asthenopic
symptoms are apt to occur; while, in
Relative hypermetropia, although the patient can
accommodate so as to see well at all distances, yet
this is only accomplished through great efforts of
accommodation, and by converging the optic axes
too much at the same time. Such persons are almost
certain to become asthenopic.
Absolute hypermetropia is a condition of the eye
in which the patient sees distinctly only by the aid of
convex glasses. Without spectacles no effort of
accommodation, however great, will suffice to pre-
vent rays of light reaching the retina before being
brought to a focus.
DIAGNOSIS.
Let the patient look at No. 20 of the test type at
twenty feet, and if his vision is improved by looking
through convex glasses of 30, 40, or 50 inch focus
56
REFRACTION, ACCOMMODATION,
he is hypermetropic. These glasses would not ren-
der the vision of an emmetropic eye more acute.
But it may happen that, although slightly hypermet-
ropic, he does not see as well through the convex
glasses, or he may even see as well, through concave
glasses of thirty or forty inch negative focus, as in
myopia. He is not myopic, however; but in look-
ing through the concave glasses he involuntarily
exerts all his power of accommodation; and when
this power is considerable he overcomes, for the time
being, his own as well as the additional hypermetro-
pia caused by the concave glasses. Ordinarily, how-
ever, we find that a weak convex glass improves
vision; if it does not, we may try the effect of para-
lyzing the accommodation by the instillation of atro-
pine. We can then determine the whole extent of
the hypermetropia, both latent and manifest. If after
an hour or two we try our convex glasses again, we
may find that whereas, previously he could only see
well through convex thirty, he now sees best through
convex twelve or fifteen. His manifest hypermetropia
was only one-thirtieth; but his latent, being added,
gives him really a hypermetropia of one-twelfth or
one-fifteenth. It is advisable, however, to avoid the
use of atropine on account of the inconvenience
which a solution sufficiently strong to paralyze the
accommodation causes the patient in the disturbance
AND THEIR ANOMALIES.
HYPERMETROPIA. 57
of vision for several days, and to this end the follow-
ing method will be serviceable.
It will be remembered that the retina is so near the
lens that rays of light reach the former before being
focussed; the eye is for ever accommodated for a
point beyond the object. It is over-sighted. Now, if
we place before an emmetropic eye a convex glass of
eight-inch focus, it will be able to read No. 1 test
type at a distance of eight inches, for the rays of
light coming to the eye through this lens are rendered
parallel, just as they would be if they came from a
distance or the far point of the eye. If we find,
however, on applying this test, that the type can be
distinctly seen through our No. 8 convex glass no
nearer than at nine, ten, or eleven inches, we are sure
that we have an oversighted or hypermetropic eye.
This test also proves an eye to be myopic if it sees
the type best at a distance less than eight inches from
the eye. Another, and very simple test, for anoma-
lous refraction, without the aid of glasses, is men-
tioned under Amblyopia.
We may diagnose the affection also by means of
the ophthalmoscope, using the direct image. With
this we see the details of the fundus at a little dis-
tance, as in myopia, only in this instance we get our
image uninverted. A movement to the right or left
will produce a similar movement in the image,
58
REFRACTION, ACCOMMODATION,
and not the reverse as in myopia. Approaching
nearer, we find the field of vision unusually large,
and the optic disc apparently small, but very distinct,
just the reverse of what we notice in myopia. If we
use the indirect mode of examination with the object
glass, we find the disc to appear larger than usual in
other refractive states of the eye.
In the higher grades of hypermetropia we often
find, especially in young children, a convergent stra-
bismus. The accommodative effort of the eye is
always accompanied by a slight convergence of the
optic axes.
These consentaneous movements in the
normal eye are necessary for acute visual power in
regarding near objects. For distance, no accommo-
dation being necessary, no convergence takes place.
With the relative or absolute hypermetropic eye all
this is different. It is obliged to accommodate for
all distances, and with accommodation comes con-
vergence, and in course of time a periodic strabismus
becomes fixed and permanent.
Spectacles for distance should not be prescribed
for hypermetropia, if the patient can see well and
without fatigue, as, after being used for distant vision,
they become indispensable for all time; but, for near
vision, they should be ordered the moment asthenopic
symptoms appear. In higher grades of the affection,
where vision for all distances is imperfect, glasses
AND THEIR ANOMALIES.
ASTHENOPIA.
59
which correct the manifest hypermetropia should first
be worn; and later, when the eyes become accus-
tomed to these, stronger ones should be prescribed,
if necessary, so as to correct more or less of the
latent defect also.
ASTHENOPIA
May be defined as a condition of the eye in which
it cannot be used continuously for near vision, even
in the best light, without pain and confusion of sight,
although for the first moment the patient sees with
ease and distinctness. The eyes are sound in appear-
ance, in movement, in visual form, in convergence
of visual axes, but they rebel against all use, how-
ever moderate. After the least service upon near
objects, they feel fatigued, full, hot, and sometimes
become quite painful; the pain extending to the
head, or following the branches of the fifth nerve.
It is not unusual for asthenopic eyes to show a
slight hyperemia of the conjunctiva, and sometimes
we notice an enlarged and rather sluggish pupil.
The dilated pupil is not due to any local disease, but
to reflex disturbance of the ciliary nerves from irri-
tation of the sympathetic. In these cases we find
spinal irritation or disturbance of the uterine or di-
gestive functions. The dilatation of the pupil is,
when it exists, an additional hindrance to distinct
60
REFRACTION, ACCOMMODATION,
vision for near objects, by admitting too much light
and too many lateral rays, and by increasing the
circles of diffusion. As the rays reach the retina
before being focussed the object is not pictured upon
the retina at a single point, but by a number of
conical pencils of rays in the form of circles which
overlapping each other, render the image blurred.
The ophthalmoscopic signs are usually negative.
The media are clear, and there are no striking anom-
alies of refraction. Sometimes, however, there is
to be observed a hyperemic condition of the optic
nerve disc, and retina similar to the hyperæmic state
of the conjunctiva. In rare instances, the optic
nerve itself appears to be the principal seat of the
pain. I can recall instances where the least exercise
of the eye produced deep-seated pain of the globe.
The cause of this affection is the characteristic for-
mation of the eye which renders it hypermetropic.
Formerly, asthenopia was looked upon as a grave
affection, and as a probable precursor of amaurosis,
or some other disease fatal to sight. More recently,
it has been regarded as a symptom of general de-
bility, arising from exanthematous or febrile affections,
from overwork, mental troubles, dissipations, abuse
of the eyes, and like causes. All these, however, only
express the occasional, or exciting, cause.
The pri-
mary cause is to be sought in a more or less faulty state
AND THEIR ANOMALIES.
ASTHENOPIA.
61
of the refractive power of the eye, and the faulty re-
fraction is a hypermetropia. We can now explain very
readily the mystery of some eyes giving out upon the
least abuse or overwork, or deterioration of the general
health; while others bear any amount of fine work
night or day, and, in failure of the general health, are
the last to be affected. The first are hypermetropic,
and have always required extra exertion of the ciliary
muscle in accommodating for near vision; while the
second are emmetropic, or as nearly this as possible,
and, the apparatus of accommodation having necessarily
been used with moderation, its integrity is preserved.
Some hypermetropic eyes escape asthenopia for a
longer time also, on account of having been originally
endowed with a wider power of accommodation. A
youthful normal eye is sometimes able to read the
finest type, No. 1, from three up to eighteen
inches, while another may be able to read it only
from four up to twelve inches: the first showing an
accommodative power of considerably greater range
than the second. Moreover, according to Graefe,
there is considerable difference exhibited by different
individuals in the impunity with which they may
exert a great part of the accommodative power at
their disposal. Some persons, for instance, are un-
able to use one-half of this power for any length of
time without injury, while others use more than
62
REFRACTION, ACCOMMODATION,
three-quarters without fatigue. In the first, there
appears to be a lack of energy in the ciliary muscle :
while, in the second, it is unusually vigorous. Hence
it may follow that the more or less perfect optical
construction shall in some instances give but an im-
perfect indication of the serviceableness of an eye
for fine work. This, however, is certain, that the
greatest amount of muscular energy, and the widest.
range of accommodation, cannot prevent a decid-
edly hypermetropic eye from becoming asthenopic.
TREATMENT OF ACCOMMODATIVE ASTHENOPIA AND HYPERME-
TROPIA.
The first and most important indication in the
treatment of asthenopia is to relieve the painful and
overworked ciliary muscle by supplementing the
refractive power of the crystalline lens with suitable
convex glasses. We have by no means finished our
treatment, however, when we have prescribed convex
spectacles for our patient. We must still keep him
under our control, to determine whether the glasses
are affording him the requisite relief; whether we
have perhaps prescribed a too weak or too strong
pair, and whether they are invariably worn for near
objects, as directed.
Sometimes, when the affection is of long standing,
and the whole eye seems to have been reduced to an
extremely irritable and sensitive condition, we may
AND THEIR ANOMALIES.
HYPERMETROPIA.
63
have considerable trouble in finding glasses that can
be worn with comfort; and yet, if the eyes are to be
used at all, the help of glasses is absolutely required.
It may be necessary in those cases to completely
paralyze the accommodation for some weeks by the
instillation of atropine, simply for the purpose of
resting the eye.
For the selection of glasses, I generally determine
the amount of manifest hypermetropia, by permitting
the patient to look at No. 20 print at a distance of
twenty feet, or where an emmetropic eye would see
it with distinctness. Then I find the lowest convex
glass through which he can read the print, and this
determines the degree of manifest hypermetropia.
In the great majority of cases of asthenopia, the con-
vex glass will be about thirty-six or forty inches.
Having determined this point, I prescribe, if the
hypermetropia is thirty-six, a convex glass of thirty-
inch focus; if it is fifty, glasses of about forty-inch
focus, and so on. Wecker advises that the manifest
and about one-fourth of the latent hypermetropia
should be corrected by the first glasses presented. I
notice, in looking over my records of quite a large
number of cases of asthenopia, glasses of thirty-inch
focus are prescribed oftener than any other; and the
cases occur almost invariably in persons from fifteen
to thirty years of age. I find nearly twice as many
64
REFRACTION, ACCOMMODATION,
cases in females as in males; but this is probably
not owing to a preponderance of hypermetropia in
females, but rather to the fact that their occupation
in general, and especially by artificial light in the
evening, requires greater exertion of the accommoda-
tive power of the eye than that of males. Collegians
and accountants, among the latter, are frequent suf-
ferers.
It will often be necessary to change the glasses,
after a few weeks, for those of greater refractive
power, in order to cure the asthenopia. Sometimes,
in asthenopia due to facultative hypermetropia, the
glasses, after having served to cure the asthenopic
symptoms, may be discarded. The patient should
be particularly enjoined to use invariably his specta-
cles for near vision, and, whenever in any occupation
his eyes seem fatigued, to rest a few minutes. In
looking at distant objects, although he is obliged to
accommodate, it is only momentarily as a rule, and
need not, if discretion is used, fatigue the eye much.
It is also advisable generally, according to my ex-
perience, that the patient should use the eyes daily
for near objects, always of course with moderation
and discretion, rather than persist in resting them
wholly.
If the asthenopia is clearly the result of general
debility, due to diminished energy of the muscular
AND THEIR ANOMALIES.
65
system generally, and the hypermetropia is very
slight, it is possible that the restoration of vigorous
health through internal medication, generous as well
as prudent dietetic regulations or change of air, may
cure the asthenopia without the necessity of a resort
to spectacles at all. The hyperemia of the conjunc-
tiva common in asthenopia is noticed elsewhere.
The irritability of the eye is best treated, according
to my experience by the internal use of macrot., nux v.
spig., and gelsem. when the general symptoms of the
patient do not forbid their use. When there is irri-
tability of the sympathetic nerve, nervous dyspepsia,
irritation of the uterus or kidneys and sensitiveness of
the brain and nervous system generally, these reme-
dies are indicated, aside from the symptoms of the
eye itself.
itself. Want of appetite also is successfully met
by macrot., nervous dyspepsia by nux v. and gelsem.,
and an appearance of congestion of the tunics of the
globe as well as of the nerve disc and retina points
to spigel., cactus, and bell. Retinal asthenopia is
noticed under Amblyopia.
ASTIGMATISM.
This is an anomaly of refraction dependent gener-
ally on a lack of symmetry in the different meridians
of the cornea. It was noticed by Young in 1793,
but first correctly explained by Donders, who pub
5
66
REFRACTION, ACCOMMODATION,
lished a work on the subject in 1862. Previous to
the researches of Donders, there had been recorded
less than a dozen cases, for seventy years; since hist
investigations, cases are recorded daily. Astigma-
tism is congenital, or may be acquired from wounds
- or ulceration of the cornea. It is divided into the
regular and the irregular.
REGULAR ASTIGMATISM
Is called simple when one meridian of the cornea is
emmetropic and the other myopic or hypermetropic.
It is compound when both meridians are myopic or
hypermetropic, but in different degrees, as if, for in-
stance, in the vertical meridian the cornea were suffi-
ciently convex to make a myopia of, while in the
horizontal line it might be only convex enough for a
myopia of. In rare instances there is mixed as-
1
16
tigmatism, one meridian being myopic, the other
hypermetropic.
IRREGULAR ASTIGMATISM
Is due to imperfections in the structure of, or to
partial dislocation of the lens, or to its partial opacity.
It is found also in conical cornea, and results from
ulcerations of the cornea, and occasionally from irreg-
ularity of its surface after cataract operations.
o
AND THEIR ANOMALIES. ASTIGMATISM. 67
DIAGNOSIS AND TREATMENT.
To determine whether a patient is astigmatic we
have only to place some rather thick vertical and
horizontal lines before him at considerable distance,
- perhaps thirty feet, and then gradually approach
them so as to find if, at any distance, one set of lines
appear clear and the other indistinct. If such a
point can be found he is astigmatic; if not, we are
obliged to refer his defective vision to some other cause.
We must bear in mind that no eye is perfectly
symmetrical in form, and so we may expect to find
that vertical and horizontal lines will not be seen
always with equal distinctness: but usually this
asymmetry is so slight that no annoyance in vision
is occasioned. Astigmatism is to be suspected when
the patient finds no glasses (spherical) which satis-
factorily improve his sight.
Having determined the existence of astigmatism,
if we permit the patient to hold a metallic disc before
the eye, in which there is a slit of about a line or
rather less in width, and rotate it until it comes op-
posite the emmetropic meridian of the cornea, so
that rays of light are received by the eye through this
meridian alone, he will see distinctly, reading No. 20
at twenty feet. This supposes a case of simple as-
tigmatism, one meridian of the cornea being nor-
68
REFRACTION, ACCOMMODATION,
mally refractive or emmetropic. To neutralize this
astigmatism and render vision acute, we have only
to prescribe weak concave or convex cylindrical
glasses.
CYLINDRICAL GLASSES
Are segments of a cylinder, whereas ordinary
glasses are segments of a sphere. A concave spheri-
cal glass, for instance, increases in thickness from the
centre in all directions. A concave cylindrical glass,
held with its axis in a horizontal direction, is equally
thin throughout in its horizontal plane, but in its
vertical plane increases in thickness from the centre
like a spherical concave. Those rays of light which
strike a cylindrical lens at right angles with the plane
of its axis are refracted most, and those which strike
in the plane of its axis are not refracted at all.
Cylindrical glasses are, therefore, unlike spherical,
to be rotated before the eye until the plane of their
highest refraction comes opposite that plane of the
cornea which requires it.
In compound astigmatism we proceed to deter-
mine first how much we can improve vision by the
ordinary glasses, convex or concave. Suppose it a
case of myopic astigmatism, and we find sight best
through a spherical concave glass of 20. We then
select a weak concave cylindrical glass, and placing
1
>
AND THEIR ANOMALIES.
ASTIGMATISM. 69
it before the other allow the patient to look through
both, rotating the last until its axis is in the right
direction. If it proves too weak we try others.
We may determine also, in advance, the number of
the cylindrical glass required with tolerable exact-
ness by noting the different strength of two glasses,
through one of which horizontal lines are best seen,
and through the other of which vertical ones are
plainest. Take the two letters on the next page made
up of horizontal and vertical lines. A. sees N black-
est, but with convex No. 15 sees Z blackest. With
cylindrical convex No. 15 axis vertical, his astigmatism
will be corrected. B. sees Z blackest through No. 60
concave, and N blackest through No. 20 concave.
1
1
1
Then *---. A cylindrical —30 glass
20 60
30
with the axis horizontal would neutralize his astig-
matism.
A color test is recommended by Green, of St. Louis.
Bright red and blue, or other shades of these colors,
rendered brilliant by transmitted light, as when hung
at a window, are most practical. The colors are
arranged in radiating lines. For the details of the
color test and others, consult the proceedings of the
American Ophthalogical Society for the year 1869.
I have mentioned also a simple test for astigmatism
under Amblyopia.
* A concave glass is designated by the sign and a convex by
the sign +.
70
REFRACTION, ACCOMMODATION,
5
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MIXED ASTIGMATISM. PRESBYOPIA.
71
MIXED ASTIGMATISM.
This form requires by-cylindrical glasses for its
correction. A plano-cylin. convex glass for the hy-
permetropic meridian, and a plano-cylin. concave
glass for the myopic meridian of the cornea are to be
selected and put together, their axes at right angles,
then rotated before the eye until their best position is
found.
Astigmatism may also be diagnosed with the oph-
thalmoscope, as mentioned in the chapter preceding,
the disc appearing oval instead of circular. Mixed
astigmatism has also been diagnosed with the oph-
thalmoscope by noticing both the erect and inverted
image by direct examination of the different meridi-
ans of the same eye.
PRESBYOPIA.
Far sight is a symptom of advancing years, and
is due to diminished power of accommodation. Dis-
tant vision remains good, but no effort of the ciliary
muscle is sufficient to render the lens convex enough
to bring rays of light from near objects to a focus
on the retina. Hence the necessity for convex
glasses. It is not advisable to postpone the use of
glasses as long as possible at the expense of discom-
fort and fatigue of the eye. The proper glasses for
72
REFRACTION, ACCOMMODATION, ETC.
a presbyope are such as will enable him to read No. 1
at ten or twelve inches. It is convenient to have
two pairs of spectacles: the stronger one for even-
ing use. Rapidly increasing presbyopia is to be
viewed with suspicion, as it is often a precursor of
glaucoma.
SECOND-SIGHT,
Popularly so called, occasionally comes to elderly
people who, after using glasses for years, find them-
selves able to dispense with their aid, and yet read
with tolerable comfort. Such persons have unusually
small pupils, so that, practically speaking, only the
central rays of light are admitted to the eye, and no
focusing power is called for.
MYOPIA SENILIS
May also occur, so that not only is the absence of
convex, but the substitution of concave glasses an
improvement to the vision. Such instances are due to
commencing cataract, when, as sometimes happens,
the lens has become more convex from swelling, but
still retains its central transparency.
CHAPTER V.
THE CONJUNCTIVA.
HYPERÆMIA OF THE CONJUNCTIVA
HYPERÆMIA of the conjunctiva is of
very common
occurrence, and is due to overuse or abuse of the
eyes, or to optical defects, as in asthenopia. The
appearance of the eye is very similar to that observed
in mild conjunctivitis, but there is no discharge from
the conjunctiva, and usually very little or no lachry-
mation, and the smarting, itching, and heaviness of
the lids is markedly increased in the evening. Read-
ing by strong artificial light, or by a too weak light,
and the very hazardous practice of reading habitually
in the horse and steam cars, and that worst and most
dangerous of habits for the eyes, that of reading in
bed by artificial light — produce constantly this con-
gestion, and if continued, still more serious troubles.
This state of the conjunctiva is often a reflex symp-
tom of a similar condition or more serious disease, of
the internal structures of the eyes. Use of the eyes
for any length of time continuously, increases the un-
74
THE CONJUNCTIVA.
pleasant sensations or the pain and asthenopic symp-
toms, if such are present.
TREATMENT.
To cure this affection, it is of course necessary to
remove its cause. Optical defects must be remedied
by appropriate spectacles. Injurious use of the eyes.
must be given up and overwork proscribed. As
palliatives, the use of the eye douche, always with
closed lids, is excellent, or bathing in tepid water, or
vinegar and water, a few drops of tincture of hama-
melis, or tincture of opium, or of hydrastis in a cup
of water, or a grain or two of sulphate of zinc, or of
acetate of lead any of these, adhering of course to
the one which seems most grateful to the eye, may
be used as a fomentation, either warm or cold, to the
lids several times a day. If preferred by the patient,
these lotions may be used to saturate a bit of lint or
linen which may be laid over the lids for a quarter of
an hour three or four times a day. The solution
need not enter the eye, but will, of course, occasion
no pain of consequence in case this should happen.
Sometimes, in severe pain, we may prescribe the
vapor from ether or chloroform, or from chloroform,
to one ounce of which is added a few drops of tincture
of iodine, or from bi-sulphuret of carbon, or from
spirits of rosemary, to which is added one-eighth its
CONJUNCTIVITIS.
75
quantity of ether. These should be kept in glass-stop-
pered, rather wide-mouthed bottles, or cup-mouthed
bottles if possible, and when used, the stopper being
removed, the bottle is brought near the closed lids,
which are subjected to the influence of the vapor a
few minutes at a sitting. The palliative and soothing
effect of the vapor is sometimes very marked. If
the skin is delicate, caution should at first be used
both as regards the strength of the application and its
repetition. A lotion of bell. ext. twenty grains to four
ounces of water as a fomentation will frequently quiet
pain but it will enlarge the pupil, which is not always
permissible. Irritating collyria, to be dropped into the
eye, are not usually serviceable in my experience.
Internally I often administer opium or ham., when
prescribing them externally, and also the remedies
mentioned under Accommodative Asthenopia. Bell.
and conium are also serviceable for the photophobia.
In other instances it is necessary to be guided almost
wholly by general indications in the selection of rem-
edies, and to look for the improvement in the eyes
only through the improving of the impaired health.
CONJUNCTIVITIS.
An inflammation of the conjunctiva is easy to diag-
nose, and yet a mistake is possible if one is not in the
habit of observing accurately the difference in the
76
THE CONJUNCTIVA.
appearance of a reddened eye in different kinds of
inflammation. For instance in the simplest conjunc-
tivitis, in place of the usually invisible vessels of the
conjunctiva, we have a network of bright red vessels
plainly seen to be superficial and movable by the
touch of the finger over the smooth surface of the
sclerotica. On the other hand, in a severer, deeper-
seated conjunctivitis, like the scrofulous, or lymphatic,
and the granular, we may see close parallel lines of
immovable subconjunctival vessels running towards
the edge of the cornea, forming around its circum-
ference a dull pinkish red zone.
In iritis the zone is
usually well marked. It is formed by the congestion
of the deep-seated vessels of the conjunctiva, and not,
as is often supposed, by inflammation of the sclerotic.
The congested vessels are on, but not of, the sclero-
tica. In scleritis, or episcleritis, there is presented
still another redness of a violet or purple tinge. It
appears nearly always in rather large and tolerably
well circumscribed patches, and is sometimes mistaken
by the general practitioner for conjunctivitis phlyc-
tenia, although the bright red color and papular
appearance of the latter, and the peculiar color of
the deep-seated spots of the former, render the dif-
ferential diagnosis easy.
CATARRHAL CONJUNCTIVITIS.
77
SIMPLE CONJUNCTIVITIS.
Simple conjunctivitis differs in degree, rather than
in form, from the acute catarrhal. It is generally the
result of slight injury to the eye, contact of a foreign
body, exposure of the eyes to dust, smoke, cold
winds or dampness, glare of light, impure air, pro-
longed exertion in accommodating the eyes for near
objects, or from some other local cause. The sub-
jective symptoms are very trivial usually. There
may be some itching and sensation of heat in the
lids, or a feeling as if there were sand in the eye.
We ought to determine by ocular inspection, when-
ever our patient complains of a sensation as if a
foreign body were in the eye, or when a simple
conjunctivitis does not yield readily to treatment,
whether there may not be some foreign substance
lodged beneath the upper lid. The immediate cure
of a conjunctivitis after three weeks of ineffectual
treatment, by the simple eversion of the upper lid
and the removal of a bit of quartz, is mentioned in
the chapter on Injuries of the Eye.
CATARRHAL CONJUNCTIVITIS.
The objective symptoms in catarrhal conjunctivitis
are more marked than in the simple form of the affec-
tion. The congestion of the superficial vessels of the
78
THE CONJUNCTIVA.
conjunctiva is greater, and in elderly people chemo-
sis is usually present. The edges of the lids appear
swollen, the palpebral conjunctiva is distended from
serous infiltration, particularly at its reflected por-
tion, its papillæ are enlarged, and its surface presents
a velvety appearance.
There is a secretion of
clouded mucus alternating sometimes with a secretion
muco-purulent in character. This discharge is often
abundant, but rarely as profuse as in purulent con-
junctivitis, and is slightly contagious. Probably the
contagiousness is in direct ratio to the increased ad-
mixture of pus globules in the discharge. A healthy
conjunctiva may be successfully inoculated with the
secretion of an acute catarrh.
The subjective symptoms are not very characteristic.
There is the complaint of not seeing well at a dis-
tance, and the common symptom of a feeling at first.
of dryness, and as if sand or some foreign body were
in the eye, and there is a heavy uncomfortable feeling
about the lids which leads to a desire to rub them,
and frequently a slight burning and smarting sensa-
tion is complained of. There is rarely severe pain,
nor is the photophobia marked. The above subjec-
tive symptoms vanish, to a great extent, as a case
becomes chronic. As to the treatment, it should be
very simple in acute cases. No doubt acute catarrh
of the conjunctiva, under proper hygienic conditions,
1
TREATMENT OF CONJUNCTIVITIS.
79
and under circumstances controlling the causes which
have produced it, disappears frequently in the course
of a week or two without any treatment whatever.
In other cases, however, it will not disappear of
itself, and may be sufficiently severe from the com-
mencement to require treatment.
TREATMENT.
In the first or inflammatory stage the cold douche,
or cold compresses with the internal administration
of acon., will afford great relief, and often effect a
cure. No irritating collyria are permissible at this
stage. Later, I prefer euph., arsen., nux, hydras, or
macrot., and if a considerable muco-purulent dis-
charge continues, then merc., hepar, zinc, and arg-
nit. Complications, such as blepharitis, or in rare
instances, ulceration of the cornea, or nasal, throat, or
bronchial inflammations, may call for other remedies
as intercurrents. The exciting cause of the disease,
whether exposure, contagion, abuse of the eyes, or
the sequence of exanthematous fever will influence,
in a degree, the selection of remedies. Simple col-
lyria, such as a solution of five to ten grains of borax,
two grains of alum, or one grain of sul. of zinc, one
grain of nitrate of silver, each to the ounce of water,
will often be found serviceable. I am in the habit of
administering the zinc or nit. arg. internally, when
80
THE CONJUNCTIVA.
prescribing it as a collyrium. If the affection prove
very obstinate, and the discharge assume a puriform
character, the case should be treated as directed
under Purulent Conjunctivitis. A solution of nitrate
of silver, of five grains to the ounce of water, may be
used, but not as a collyrium. The lids, upper and
lower, should be everted, and held in this position
with the left hand; the patient should close the eye
gently, this will bring the everted lids together and
prevent contact with the cornea. The conjunctiva
thus exposed is painted by means of a camel's hair
pencil with this solution, which after a second or two
is immediately washed off with tepid water from
another pencil. If the pain is afterwards severe, it
will be relieved by bathing the eyes in cold water,
by cold compresses, and frequently through simple
contact of the eyes with the cool out-door air. Often
a few applications like this at infrequent intervals,
cures the patient.
The object of the application is to create a slight
inflammatory condition similar to the conjunctivitis;
having occasioned this, the operation should not be
repeated until the artificial exacerbation has fully sub-
sided. Probably a repetition two or three times a
week will be sufficient.
If active inflammatory symptoms are present, or
such as are evinced by a very bright red, congested,
TREATMENT OF CONJUNCTIVITIS.
81
and swollen conjunctiva, when the sub-conjunctival
vessels are visibly involved, and when the ciliary
nervous system is sensitive, as shown by pain and
photophobia, irritating applications should never be
made. In all cases where irritating collyria are used
it is advisable not to push their employment too con-
tinuously, but rather alternate them from time to
time for a few days with the use of the cold compress.
It is always advisable to see that a collyrium which
the patient takes home be not too strong. It is
necessary also, to remember that in a conjunctivitis
occurring in two individuals of different nervous
organization, where in each case it seems to be of the
same nature and to require the same remedy, one
may use a wash with great benefit which the other
may be quite unable to bear. Whenever, therefore,
there is the least doubt about the strength of the
solution it is advisable to instruct the patient that if
the pain after its use continues beyond a minute, it
is too strong, and it should be diluted with an equal
quantity of water. It is safer, also, to direct that
the collyrium be used not oftener than twice a day.
It has often been my experience when called in con-
sultation with physicians of our school, to find that
in conjunctivitis complicated and uncomplicated,
collyria when used at all have been frequently too
strong, applied too often, and to eyes already too
sensitive and irritable. 6
82
THE CONJUNCTIVA.
We should bear in mind the contagiousness of
some catarrhs of the conjunctiva. The patient should
be warned of this danger, so that he may not propa-
gate the disease. Frequently the affection assumes
an epidemic character, attacking whole families and
neighborhoods. In the chronic form of this affection
the results of topical application to the lids will not
prove as satisfactory as in the acute. Improvements
will be followed by relapses, and with all the help
which homoeopathic medication affords, many cases
will prove extremely tedious in treatment. If how-
ever the affection seems to be purely local and con-
fined to the eyes, our prognosis will be more favorable
than when it is merely a part of a catarrhal affection
of the air-passages generally or of the lachrymal duct.
The most satisfactory application to the lid in old
cases of catarrh is to touch very lightly, and at first
very cautiously, the swollen papillæ at the retro-
tarsal fold with a smooth crayon of sulphate of
copper. This is an extremely harsh remedy if ap-
plied too freely, and it should not be reapplied
under any circumstances until the eye has fully re-
covered from the first application. As regards
internal remedies, I have only to say that the same
class is indicated as in the acute form of the disease,
and that too brilliant results must not be looked for.
We may, however, look for a great deal from
PURULENT CONJUNCTIVITIS.
83
HYGIENIC MEASURES.
In conjunctivitis of all kinds, great attention should
be given to hygienic regulations. The sensitive eyes
should be protected against bright light during the
day or night by plain blue or smoke-colored glasses,
which will afford also a measurable protection against
wind and dust. The patient should use the eyes
with great moderation especially by artificial light,
and should particularly avoid all places where the air
is necessarily impure, such as crowded rooms like
the theatre, lecture-room, ballroom, or rooms where
tobacco-smoke prevails. He should be counselled
also to avail himself as much as possible of the bene-
ficial influence of a pure out-door air, and should be
advised that when necessary to use the eyes in read-
ing, writing, or fine work, preference should be given
to the morning hours when the light is constantly
growing better.
PURULENT CONJUNCTIVITIS.
Purulent conjunctivitis, which is to be regarded
only as a severer and more dangerous form of the
catarrhal, is distinguished from the latter by the
character and greater abundance of the secretion,
the greater swelling of the lids in consequence of the
serous infiltration being also sub-conjunctival, the
great injection of the sub-conjunctival vessels as
84
THE CONJUNCTIVA.
well as the increased vascularity of the conjunctiva
proper, the chemosis so frequently present, and by
the increased size of the mucous papillæ often termed
granulations. One of the most practical and certain
methods of determining at once whether you have a
blenorrhoea or a simple catarrh to deal with, is, by the
easy proceeding so long taught in the clinics of Prof.
Arlt, of Vienna. The upper lid is to be everted, an 1
if the conjunctiva is sufficiently transparent for us to
see the lines of the meibomian glands running to-
wards the edge 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, a
granulated, a diphtheritic, or some graver form of
ophthalmia. In purulent conjunctivitis the cornea is
much more apt to become involved, and this form is
of course more contagious.
THE TREATMENT,
During the inflammatory stage in which there is
often considerable fever, must be purely antiphlo-
gistic. Ice-water compresses should be perseveringly
used, and these with the perfect quiet of the patient,
and the administration of aconite suffice to control
measurably the acute symptoms. I have never re-
sorted to the use of leeches, and I have often seen
them used in these cases when I thought them un-
MILITARY OPHTHALMIA.
85
necessary. If but one eye is attacked, the other
should be bandaged as a precautionary measure, and
in all cases of purulent ophthalmia the attendants
should be warned that the greatest cleanliness and
attention to the contagious character of the secretion
is necessary for their own safety. After the inflam-
matory symptoms are subdued, as shown by the
diminished swelling of the lids, and the pale red and
relaxed condition of the conjunctiva, a cautious use
of stimulating collyria is indicated.
If the cornea is
involved care must be taken that the application does
not come in contact with it, by painting it on the
everted lids and immediately washing it off as previ-
ously directed.
Egyptian, or Military, Ophthalmia is only a
variety of purulent conjunctivitis. It was first rec
ognized and named after an unprecedentedly severe
epidemic originating in the troops of the English and
French armies stationed in Egypt. It spread so
fearfully that after the Napoleonic wars England
alone had upwards of five thousand blind invalided
soldiers to care for. It is doubtful whether this form
of the disease is more contagious than any other.
Very likely any form of the affection getting a foot-
hold among masses of people crowded together, as in
armies, almshouses, and so-called charitable institu-
tions, would spread rapidly. Uncleanliness and bad
86
THE CONJUNCTIVA.
ventilation are very attractive conditions for this
disease. The contagion of a purulent ophthalmia, as
is well known, may engender a very light or a very
severe form of the affection, a mere catarrh or a
diphtheritis. In the beginning the disease is hardly
contagious, but becomes so as it progresses, and the
discharge increases in quantity and consistency.
form of the disease produced by contagion seems to
depend on local or atmospheric conditions as well as
upon the constitution or age of the person infected.
The
The internal remedies most useful in my practice
are zinc, nit. arg., merc., and hepar. The two first
in connection with their employment locally, and the
two last during the interregnum when stimulating
collyria, are temporarily laid aside for the topical use
of water or for the remission of all local measures.
CONJUNCTIVITIS IN THE NEW-BORN.
Ophthalmia neonatorum is a purulent conjuncti-
vitis which comes on a day or two after birth. It
begins as a very slight discharge, but sometimes in-
creases with great rapidity a few hours later. Its
cause is generally to be sought in a gonorrhoeal or
leucorrhoeal discharge of the mother. In mild cases
where the discharge is chiefly whitish, not very abun-
dant, and mucous in character, the free use of cold
compresses, a careful and frequent removal of the
CONJUNCTIVITIS IN THE NEW-BORN.
87
secretion with a soft sponge and tepid water, the
administration of aconite and later, puls., merc., or
hepar, will suffice to carry the case through to a
speedy and successful termination. Such are mild
cases. In other instances the affection is severe, and
requires prompt and energetic local treatment in order
to insure the most favorable results.
The respon-
sibility of the physician in a severe case of ophthal-
mia neonatorum is very great. Intelligent treatment
is surprisingly effective, but negligent or unskilful
treatment is often deplorable. Our asylums for the
blind afford far too many mournful examples of the
results of bad treatment in this affection.
TREATMENT OF SEVERE CASES.
If the disease increases in severity in spite of our
treatment, we ought never to neglect to determine
by fair ocular inspection whether the cornea be intact
or not, because upon this circumstance depends the
treatment and the nature of our prognosis. It is not
a very difficult matter to obtain a view of the cornea
even when the lids are very much swollen. The
child is to be held by the nurse, its head resting be-
tween the knees of the surgeon, and in this position
there is generally little difficulty in forcing the lids
apart. If the fingers alone are insufficient in conse-
quence of the swollen condition of the conjunctiva,
88
CONJUNCTIVITIS.
an elevator may be used. It is remarkable how
averse many physicians are to this simple procedure,
but in no other way can a case be treated so intelli-
gently or conscientiously. It is not at all difficult
of accomplishment, and never productive of the
slightest injury to the lids. Collyria of alum or
sul. of zinc, or injections of these by means of the
syringe are often used of the strength of three to
five grains of the former or one or two grains of the
latter to the ounce of water, but I rarely use them.
I prefer a collyrium of nit. of silver, one grain to
the ounce of water. It is quite as mild, and I believe
vastly more effective. It is particularly indicated
when the discharge is copious and wholly purulent.
This should be dropped into the eye, after it has
been carefully cleansed from the discharge, twice a
day. In a few days, if the profuse discharge still
continues, and especially if the slightest haze upon
the surface of the cornea indicates a complication in
this direction, a solution of three to five grains of
the nitrate of silver to the ounce, should be painted
with a brush upon the everted lids and immediately
washed off with tepid water or neutralized by the
application of a solution of common salt and water.
No evil consequences whatever can result from this
proceeding, and not unfrequently the beneficial results
of it are seen after a single application. It need not
!
TREATMENT OF SEVERE CASES.
89
be often repeated. Cold compresses should be em-
ployed to lessen the irritation immediately afterwards,
and I prefer as internal remedies after aconite in the
commencement, mercurius when the discharge is
profuse, and the alternation of arsen. with this rem-
edy if the cornea is ulcerated. It is advisable in this
as well as all other forms of conjunctivitis, when
there is ulceration of the cornea, to bandage the
eye closely so as to prevent all friction between the
lids and the ulcerated corneal surface. I will give
the outlines of a case in illustration of this mode of
treatment.
Mrs. G., of Boston, brought to me her babe, three weeks old.
It had been suffering from purulent conjunctivitis since two or
three days from its birth, and, up to the date of her visit, had been
steadily growing worse. The physician in attendance had not at-
tempted an examination of the cornea, but had advised her to keep
the eyes as free from the discharge as possible, to apply cloths wet
in cold water, and had administered small powders internally. The
lids were somewhat reddened and swollen in appearance, and con-
siderably puffed up, from the quantity of pus beneath them. After
the removal of the accumulated pus, which was accomplished by
repeatedly separating the edges of the lids, giving it exit, and wip-
ing it gently away with a soft sponge, wet in tepid water, I was
able, without difficulty, by means of an elevator, to open the lids
sufficiently to thoroughly determine the condition of the cornea,
and make a prognosis as well as diagnosis. The cornea of the
right eye was found hazy, and slightly opaque at its upper and
inner edge. In the left eye, the corneal opacity was greater; and
directly over the pupil was an ulcer, which had already broken
through, and occasioned, as I afterwards found, a deposit of matter
upon the anterior surface of the capsule of the lens, and a slight
adhesion of the free edge of the iris. The mother was informed
90
CONJUNCTIVITIS.
that the mischief done to the left eye was irreparable; that per
fect restoration of sight was impossible; that the disease would
probably progress no further, and that vision, to a limited extent,
would be preserved to this eye. As to the right eye, there was no
question as to its perfect restoration, in every respect. The lids
were reversed, and painted with a solution of argen. nit., ten
grains to the ounce of water, which was allowed to remain only a
second or two, and immediately washed away with tepid water.
The nit. argen. was used in an unusually strong solution, because
it seemed necessary to check at once, with absolute certainty if
possible, further progress of the disease. I have noticed that, when
a case is severe, the lids considerably thickened, and the mucous
papillæ very much swollen and prominent, it will bear, with good
results, and without marked reaction, a much stronger solution of
nitrate of silver than it would be prudent or advantageous to apply
in a milder case. In this instance, the mother informed me, on
her second visit, that the night after the application of the caustic
was the best which the child had passed since its birth. There
had been no reaction, and consequently no application of cold to
the lids had been necessary. Under the circumstances, I concluded
to touch the lids a second time with the same solution. This was
done on the second day; and again the child had a remarkably
comfortable night. On the fifth day, the discharge, which had
been very profuse, was considerably lessened in quantity. The
mother herself could see a decided improvement, and began to
have great confidence in the treatment. I now diluted the solution
with an equal part of water, making it five grains to the ounce ;
and, after a week, it was reduced still more, making it about two
grains to the ounce. I had taken the precaution, also, of dropping
into the left eye a solution of atropine, two grains to the ounce, in
order to draw away the edge of the iris as much as possible from
the corneal opening. The application of the solution above de-
scribed was made but six times, at intervals of forty-eight hours,
when the discharge having almost entirely ceased, I gave the
mother simply a solution of sul. of zinc, one grain to the ounce of
water, to be dropped daily into each eye; and in two weeks from
this time the child was well enough to require no further treat-
ment.
TREATMENT OF SEVERE CASES.
91
Usually it is not necessary nor advisable to use
the nitrate of silver nearly as strong as I felt obliged
to in this case. I have unbounded faith in the ho-
mœopathicity, so to speak, of a solution of nitrate
of silver for that diseased state of the conjunctiva in
which it secretes a profuse purulent matter It should
be employed judiciously, and the word judiciously
means a great deal in this connection; for probably
of all the remedies ever devised for the eyes, this
nitrate of silver has, by its injudicious employment
during the last twenty-five years, done the greatest
injury.
I am very glad to support my views in regard to
local treatment of purulent ophthalmias by so good
an authority as Dr. Dudgeon, of England. I quote
from a case reported in the "British Journal of Ho-
mœopathy" for the year 1853, page 361. The case
is that of an infant fourteen days old. He says, "It
is with great difficulty the lids can be separated so as
to obtain a view of the cornea, as the orbicularis
muscle everts them and displays a large fleshy mass of
inflamed and swollen conjunctiva. The child's gen-
eral health seems to be unaffected by the disease. I
prescribed a collyrium of two grains of nit. of sil. to
two oz. of water to be dropped into the eyes twice a
day, and for internal use, arg. nit. 6, a dose every
six hours." In two weeks the eyes were free from
92
THE CONJUNCTIVA.
discharge, and perfectly normal in appearance. Dr.
Dudgeon then goes on to justify-quoting Hahne-
mann's authority · the use of local means in the
treatment of local diseases generally.
GONORRHEAL CONJUNCTIVITIS.
Gonorrhœal conjunctivitis, so called, is a variety
of this affection associated with a similar discharge
from the urethra, through sympathy or extension of
the virus over the system, or, as more frequently
happens, is caused by direct contact of a urethral dis-
charge with the eye. In the former case, the attack
occurs simultaneously in both eyes; in the latter, it
commences in one eye first, generally the right, and
in its severe form is one of the most rapid and
destructive diseases to which the eye is subject. In
its mild form the disease resembles a light purulent
ophthalmia, and requires similar treatment. In the
contagious form, the inflammation is sometimes ex-
ceedingly violent. I cannot describe the nature and
treatment of this disease better than by giving the
main details of a case of a severe type under my care.
CASE OF GONORRHEAL OPHTHALMIA.
G. L., a young man of seventeen was brought me by his father,
Oct. 10, 1868, to be treated for an inflammation of the eyes. The
right eye was closed, the upper lid so largely swollen that, at first
glance, I thought of abscess. On turning my attention, for a mo-
CASE OF GONORRHOEAL OPHTHALMIA.
93
ment, to the other eye the lids of which were but little affected
externally, I noticed considerable injection of the vessels of the
conjunctiva on either side of the cornea. The affection of the right
eye had been noticed first two days previously; but the great swell-
ing had not come on until this morning. The pain was not very
severe; the patient, pale and anxious-looking. The lower lid was
but slightly distended, and by carefully drawing it downward and
away from the upper one which overlapped it, I could see a marked
chemosis of the conjunctiva of the globe. There was no doubt
about the diagnosis of the case. As the father seemed nervous and
apprehensive, however, I concluded to say nothing about its pecul-
iar nature for the moment, telling him simply that the affection was
severe, that the left eyelids, on the next day, would probably be
very much in the condition presented by those of the right eye
to-day; that the boy was not well enough to be out, and that he
must be treated in bed. Ice-water compresses to be applied to right
eye constantly, and to the left whenever the cold could be borne
or felt grateful. Acon. to be taken every hour.
The next morning the external appearance of both eyes was
about the same, the upper lids of both being enormously distended.
The right was a trifle less sore to the touch, and I was enabled to
determine the state of the globe more definitely. The cornea was
still intact, but considerably lessened in circumference through the
overlapping of the conjunctiva, the chemosis being very great. The
conjunctiva bulbi was very red and puffed, looking "like a piece of
raw meat." Pulse, one hundred and twenty. Ice-water compresses
to be continued night and day. Acon. internally. I now ascer-
tained that the patient had contracted a gonorrhoea three weeks pre-
viously. The discharge from the urethra is still rather profuse.
Oct. 12. Externally the swelling of the lids is somewhat lessened,
the internal appearance of the eyes the same. The discharge from
the eyes is rather thin and flocculent, not such as could be desired.
The pain is not severe; pulse about the same; prognosis doubtful.
The same treatment to be continued. The sanious discharge to be
wiped out from beneath the upper lid with a camel's-hair pencil
moistened in warm water, and the edges of the lids to be tenderly
cleansed with a soft sponge and tepid water.
Oct. 13. Swelling of the lids much lessened externally. In-
94
THE CONJUNCTIVA.
flammation is still too acute to admit of caustic application.
Appearance of the globe the same, the chemosis being very great.
Discharge still watery and slight. Used twice a day a weak solu-
tion of carbolic acid in cleansing the inner surface of upper lid.
Attendants getting weary and worn in changing the ice-water com-
presses night and day, I had two little ice-bags constructed and
connected by a bridge, like diminutive saddle-bags, to be saddled
across the nose, the little bags filled with small bits of ice to rest
one over each eye. The upper lid was found still too tender to
bear their weight, but a day later they could be borne, and were
afterwards used constantly, thereby saving the nurses much labor
Acon. merc. internally. The discharge during the next few days
became more copious and pus-like, and the external lids became
gradually less swollen and red.
Oct. 15. Internal appearance of lids as bad as ever; appearance
of conjunctiva bulbi ditto; cornea not fully transparent, that of the
right eye quite hazy at its upper third. Raised the upper lids and
painted them with nit. arg. five grains to the ounce of water, imme-
diately washing it off with tepid water.
Oct. 16. Treatment continued.
Oct. 17.
Considerable pain in the left knee, which I found
slightly swollen, and very sensitive to touch. A water compress
was applied; pulse, which had fallen to one hundred, now rose
again to one hundred and twelve. Acon. and macrot. internally.
Oct. 18. Left knee-joint largely swollen, measuring, with the
leg extended, fourteen inches at its largest circumference; sensi-
tive to pressure, and immovable; but less painful than yesterday.
Right knee painful, and beginning to swell. Discharge from ure-
thra continues. Eyes much the same in appearance. Cornea of
right eye the worse of the two. Prognosis, which had seemed for
a few days more favorable, now again doubtful, in consequence of
this new inflammation of the knee-joints, which bids fair to reduce
the vitality of the patient as it has already his courage, and renders
the question as to the power of the cornea to maintain the integrity
of its tissues a doubtful one. Upon the solution of this doubt de
pends the future of the patient. He will be cured in any event, but
will his vision be left? I confess that as his knees grew large
my hopes grew small. Treatment continued.
CASE OF GONORRHOEAL OPHTHALMIA.
95
Oct. 22. Fever lessened, more appetite, knees less painful, but
largely swollen, and the right one immovable. Eyes no better;
discharge quite copious. Treatment the same.
Oct. 23. Discovered, this morning, what I had been fearing from
the first; viz., ulceration of the cornea. The chemosis having in
a measure subsided, the conjunctiva bulbi had receded from the
edge of the cornea, which it had previously overlapped, and so un-
covered in the right eye a crescent formed ulcer extending nearly
around the upper half of its circumference. It was deep, its edges
sharp and clean, so that it was necessary to look closely in a favor-
able light to see its whole extent. An ulcer on the left cornea in
nearly the same relative position, not so great in extent, but still
ugly and dangerous looking, was discovered also. Both ulcers
looked, I thought, as though they were growing larger, therefore
without some change in my treatment the right eye would certainly
be lost, and perhaps the left one too. I therefore made an immedi-
ate change in my treatment. His pulse was one hundred, the tongue
was nearly clean, and he had expressed a strong desire for solid food.
I determined, if possible, in the present state of his digestive organs,
to gratify his wish to the fullest extent. A rare beefsteak was pre-
pared for him at once, and he was to be fed similarly three times a
day. Beef-tea was also to be in readiness, so that if he tired of
steak it could be substituted for it. He was to have of rare beef at
each meal all he desired, with no restrictions whatever. I further
substituted for the solution of nitr. argen. which I had been using,
one of fifteen grains to the ounce applying it thoroughly to the re-
flected portion of the upper and lower lids, and immediately wash-
ing it away with tepid water. It caused no pain whatever. Merc.
and macrot. were given internally.
Oct. 24. Ulcers look no better; knees improving slowly, and
can be drawn up or moved slightly without great pain, but are still
largely swollen. Patient eats freely of the steak and digests it
without trouble; slept better than usual through the night. The
discharge from the eyes is rather less: continued treatment; but
before the cauterization I dropped a solution of atropine into each
eye so as to keep the iris rigid, and as much as possible away from
danger in case of rupture of the cornea from the ulceration. After
the cauterization the eyes are bandaged sufficiently tightly to pre-
↓
96
THE CONJUNCTIVA.
vent movement of the lids. I find the eyes bear this cauterization,
repeated every twenty-four hours well, and it has already lessened
the discharge.
Oct. 26. Ulceration appears slightly improved, especially in the
left eye, where the edges of the ulcer are slightly tinged with
yellow, and at the bottom a gelatinous look, as though the repara-
tive process were commencing. Similar indications, but less
marked, are also to be seen in the more important ulcer of the right
cornea. Patient complains of shortness of breath, which I find is
probably occasioned by overtaxing the digestive organs, so I restrict
the diet somewhat in quantity, and give nux and bry. for twenty-
four hours. Other treatment continued.
Oct. 28. Shortness of breath gone.
better. The ulcers are slowly filling up.
The eyes are decidedly
Discharge from the eyes
less. The cauterization now causes quite severe pain, so that ice
compresses have to be resorted to afterwards, for a half hour before
bandaging. Internally merc. and macrot.
Oct. 30. Eyes improving; knees improving also, but very
slowly. The present solution of nit. arg. being now too strong, I
reduce it one-half, making about seven and a half grains to the
ounce which is borne readily. Discharge from the eyes much less ;
from the urethra, also, somewhat less. Patient's appetite good, and
he is allowed to indulge it in nourishing food, to the fullest extent.
Nov. 6. Improvement in all respects; he manages to walk
about the room moderately. Ulcer in the left cornea reduced to a
mere trace, that of the right surely but slowly filling up. He can
read coarse print.
:
Nov. 12. Acuteness of vision is nearly perfect, as the opacity
left on the cornea from the ulceration, and the reparative process,
does not encroach at all on the pupil.
I
may
mention here that, some three months after-
wards, this patient came again under treatment for
rheumatic iritis, a disease of the eye, which often
follows gonorrhoeal rheumatism. The affection of
iris in this instance was only of three weeks' duration.
♫
DIPHTIIERITIC CONJUNCTIVITIS.
97
Merc. internally, and atropine externally, were the
remedies used.
Conjunctivitis Diphtheritica is very rarely, per
haps never, seen in this country or in England. It
is occasionally epidemic in Berlin. It resembles the
preceding in many respects; but is usually more
severe and dangerous. The discharge is at first, yel-
low, thin, and flocculent, the swollen lids rigid from
deep-seated fibrinous effusion, the pain and heat very
great. In a few days the discharge assumes a puru-
lent character, the lids become less rigid, there may
be fibrinous exudation from the conjunctiva, the
cornea is very apt to grow hazy and ulceration or
sloughing ensues.
ous.
The treatment in the beginning should be vigor-
With the greatest care and attention the dis-
ease will often terminate unfavorably. Ice and ice-
water compresses with aconite until the discharge
assumes the character of pus, then the application of
a solution of nit. arg. to the lids avoiding contact
with the cornea, and the exhibition internally of arg.
nit., merc., and arsen. in case of ulceration of the
cornea, this, with a generous diet, would be my idea
of a treatment which might offer a tolerable chance
of saving the eye.
7
98
THE CONJUNCTIVA.
ACUTE CONJUNCTIVITIS GRANULOSA
Is characterized by pain in the eye, photophobia from
ciliary irritation, and particularly by the sensation as
of a foreign body beneath the lids. If the latter be
everted there will be noticed in addition to the swollen
papillæ, and intermingled with them, little gray points
which are true granulations. After a week or more,
the conjunctiva becomes more swollen, the discharge
abundant and purulent, and at this stage of the
disease it is difficult to distinguish the affection from
a conjunctivitis purulentia. This purulent stage con-
tinues for some weeks, and may be treated as a con-
junctivitis purulentia, exercising great care in regard
to the use of irritants. So long as photophobia and
lachrymation are marked, no irritating collyria can be
used safely. Later, with the exercise of this caution,
the affection may be treated like the chronic form
mentioned on the next page. The cause of this
affection is, generally, defective hygienic conditions
and contagion. It spreads rapidly, like the military
ophthalmia, among masses of people. Either from
neglect of all treatment, or from improper or imper-
fect treatment, or want of persistence on the part of
the patient, the disease is very apt to become chronic.
The secretion diminishes little by little, the general
inflammatory state of the conjunctiva disappears, and
99
1
CHRONIC CONJUNCTIVITIS GRANULOSA.
the disease concentrates itself beneath the upper lid,
and we have a
CHRONIC CONJUNCTIVITIS GRANULOSA,
And generally this is soon supplemented by an
affection of the cornea, called pannus.
Punnus is a vascular development in the epithelial
layer of the cornea. There is sometimes, but very
rarely, an extension of the granulations from the
upper lid to the ocular conjunctiva, and thence to
the cornea, but generally a pannus is caused by fric-
tion and pressure upon the cornea, of the roughened
surface of the palpebral conjunctiva, and usually
therefore, when we see it, we know, without further
examination, that we have a granulation of the lid.
The granulations are on the inner surface of the upper
lid, mostly upon the reflected portion, and the pannus,
of course, is generally found upon the corresponding
upper half of the cornea. When later, it has ex-
tended downward and encroached somewhat upon the
pupil, so that vision is impaired, the patient becomes
alarmed, and seeks the advice of the physician. The
indication in a case of this kind is invariably to cure
the granulated lid. This being accomplished, the
pannus disappears of itself.
Vorf
100
THE CONJUNCTIVA.
1
TREATMENT OF GRANULAR OPHTHALMIA.
The treatment of this class of cases is sometimes
difficult and discouraging, owing to frequent relapses ;
is always prolonged, but, so far as my experience
goes, successful. If, as is frequently the case, the
patient has suffered for many months or years, has
been previously treated unsuccessfully, is gloomy and
despondent in anticipation of coming blindness, he
should be assured at once that his case is not hope-
less; and that, with the proper amount of persever
ance on his part, a permanent cure, with a more or
less complete restoration of vision, is almost certain.
A pannus — something growing gradually over the
sight of the eye, and threatening eventually to shut
out all vision — is usually a disease of fearful omen to
the patient. He comes to the surgeon, also, with
great fear and trembling, from the idea that the
growth upon the cornea must be cut off. No doubt
this view is sometimes imparted by the physician who
confounds the growth with that of pterygium. The
latter, however is, pathologically, a different forma-
tion. The patient then, in the first place, should be
rendered as cheerful and hopeful as possible.
possible. Hy-
gienic regulations, such as previously mentioned,
should be strictly enforced, and above all, the general
health, which in these cases is apt to be deficient, must
TREATMENT OF GRANULAR OPHTHALMIA. 101
be restored. Without an improved condition of the
entire system of the patient through internal medica-
tions and the enforcement of salutary rules of living,
the most judicious local treatment will be but tem-
porary in its effects. No outline even of internal
treatment can be given within the space at my com-
mand, as each case must be individualized and treated
according to the nature of its deviations from the
standard of good health.
As a local means of curing the granulated lid, I
employ a smooth crystal of alum, a crystal of sul-
phate of copper, and occasionally a crayon composed
of one part nit. of silver to two parts nit. of potash.
Pure nit. of silver in substance I never use, nor do I
believe its use ever necessary. I prefer in these old
and difficult cases, and use by far the most frequently,
a smooth crystal of sulphate of copper. The upper lid
being reversed, it is drawn lightly and quickly across
that portion of the lid seen to be thickened and gran-
ulated, and those portions of the conjunctiva not
involved are carefully avoided. Considerable pain.
will ensue; and, if the patient is very sensitive, it is
advisable to apply tepid water or weak salt and water
to the conjunctiva the instant after the touch with
the caustic. Otherwise, the patient may, after the
lapse of a few minutes, if the pain does not cease of
itself, bathe the eyes in cold water. Immediately
102
THE CONJUNCTIVA.
}
after this application the eye will present a reddened
and injected appearance, and should on no account
be used until this injection disappears, which will be
perhaps in an hour or more. There will also be a
feeling of irritation in and about the eye, and until
this artificial irritation has fully disappeared, no
second application of the crayon should be made.
Whether, therefore, the process is to be repeated
once in twenty-four, forty-eight, or seventy-two
hours, or not oftener than once a week, must depend
entirely upon circumstances. Meantime, cold or
tepid water may be used freely; simple cerate, if the
lids adhere together in the morning, and the admin
istration of constitutional remedies persevered in. In
sub-acute cases, where there is considerable secretion,
the application of a solution of arg. nit. in water, of
the strength of five to ten grains to the ounce, will
be useful. It should be painted upon the reversed
upper lid, and after fifteen or twenty seconds, neu-
tralized by weak salt and water, from a second brush.
Five or ten grains of salt to the ounce is sufficient.
After these applications, cold compresses should be
freely used until the eye is free from the increased
pain.
cases.
Pressure is frequently a potent auxiliary in these
It can be accomplished by placing a dry
compress over the gently closed lids, so arranged
TREATMENT OF GRANULAR OPHTHALMIA. 103
that it shall be thickest at the angles, and diminished
gradually towards the meridian, in order that the press-
ure exerted may be as uniform as possible over the
granulated surface. An elastic band — flannel makes a
good one is then passed around the head, to hold
the compress firmly in its place, and may be drawn
as tightly over the eye as can be conveniently borne.
This bandage is to be worn night and day, and the
compress is to be readjusted upon the eye as often as
it becomes in the least displaced.
I will relate a case or two in illustration of the
mode of treatment which I find usually so satisfac-
tory.
Miss B., aged twenty-four, visited me first in April, 1865. She
complained of irritation and weakness in the left eye, and had recent-
ly become much alarmed at the discovery that she could scarcely see
to read with it. I found a fully developed pannus extending nearly
to the centre of the pupil well supplied with vessels extending down-
ward across the limbus cornea on to its substance. The prognosis,
as far as improvement of vision in this eye was concerned, was favor-
able; complete restoration, a sharp, distinct vision like that of the
normal eye is very often impossible. The faintest remnant of
haziness of the cornea, a cloud upon its polished surface so faint
as to be perceptible only by the most favorable lateral illumination
will occasion indistinctness sufficient to annoy the patient. When
no cloudiness remains, and the cornea regains its perfect transparency,
if there is the least irregularity of surface, minute depressions or
flattened facets, the rays of light will be abnormally bent in pass-
ing through the cornea, and the image upon the retina will be
deformed and more or less indistinct. If, therefore, a doubt
exists as to a complete restoration of the cornea it is unwise to
promise a perfect recovery of vision. The case of this patient
104
THE CONJUNCTIVA.
was a very old one. In her early youth she remembered an affec-
tion of her right eye, and the sight of this eye since, had never
been as clear and perfect as that of the left previous to the present
attack. On examining the cornea of the right eye by lateral illu-
mination the rays falling obliquely upon the surface, little irregular
flattened facets were distinctly seen, which accounted for the lack
of sharpness of vision. The lid of the left eye was reversed, and
the cause of the growth upon the cornea was found in the gran-
ulated state of the conjunctiva. The diseased surface was lightly
touched with a crystal of sulphate of copper, very carefully at first,
until the eye became somewhat accustomed to the process. Severe
pain followed the operation for the first two or three times, but this
was effectually controlled by bathing the eye in cold water and im-
mediately going into the open air. This eye had suffered from an
acute attack of inflammation as she informed me, more than a year
before, but had apparently fully recovered after a few weeks. For
a while it continued strong, but gradually grew more and more
irritable, until within a few months she had scarcely been able to
use it at all without pain. She was under my care nearly five
months, and completely recovered. This process of cauterization
was repeated on an average about once in three or four days. Mer-
curius was the remedy principally administered, although she had
other remedies for disturbances in her general health during this
period. Towards the end of the treatment my attention was called
to the benefit of bandaging the eye in similar cases, and she em-
ployed this means also with the effect, I think, of hastening the
On visiting me nearly two years later, while with the right
eye she was unable to read No. 1 type, with the left eye, the one
which had been under treatment so long for the pannus, she could
read it with ease.
cure.
Miss W. came to me first in May, 1867. She also, like the other,
was suffering from pannus upon the left eye, and from the same cause.
Like the other, also, she had suffered years previously from a prob-
ably similar affection in the other eye. The right eye she affirmed
had been cured by a doctor in Boston, who had cut the cornea
across its upper portion superficially, and had also made longitudinal
incisions upon the inner surface of the upper lid. These incisions,
she said, were painful, but always afforded her relief, and event-
TREATMENT OF PANNUS.
105
ually cured her eye. She wished me to treat her left eye now in a
similar manner. I declined her method, and touched the gran-
ulated lid lightly with a bit of sul. of copper, but it would not do.
After a week I gave up the attempt to touch the granulations at
all. The eye was rather the worse for my treatment. The ciliary
system of nerves was involved to such a degree that the irritation
caused profuse lachrymation and severe and prolonged pain and
photophobia. The patient was also of exceedingly delicate and
sensitive organization. I therefore gave up temporarily the use of
irritants of all kinds. Tepid water was used several times a day,
and a compress and bandage, as previously described, was applied,
to be worn always at night, and, when convenient, during the day.
After two or three weeks there was much less congestion, and the
pannus had so far disappeared that the patient could read large
print without pain, and with tolerable fluency. I now commenced
brushing the granulations beneath the lid with a weak solution of
sul. of zine, which I found could be borne every two or three days.
The bandage was continued with great benefit, and during the first
part of the treatment, while the eye was irritable, macrotin and
spigelia, and later, mercurius were administered internally. After
two months' treatment no trace of the pannus was left, and acute-
ness of vision was the same in each eye.
Aqua chlori is recommended by Graefe for obstinate
pannus from granulated lids, and Donders finds two
to four parts of olive oil to one of oil of turpentine
efficacious. Inoculation of the eye with pus to create.
an acute purulent inflammation has been more or less
successful in desperate cases in clearing up the cornea
and restoring vision. Peritomy, an operation in
which the conjunctiva with its subtissues is excised
with forceps and scissors, around the edge of the
cornea, I have seen Mr. Bowman, of London, per-
form with good results. Favorable results, it is said,
106
THE CONJUNCTIVA.
have also followed the operations of lengthening the
palpebral fissure, so as to remove the pressure of the
upper lid upon the cornea.
SCROFULOUS CONJUNCTIVITIS OR SCROfulous OPHTHALMIA
I place in this chapter, inasmuch as its primary seat
is usually the conjunctiva; the cornea, iris, and scler-
otica becoming later involved.
DIAGNOSIS.
It is hardly necessary to dwell on the diagnosis.
The mere circumstance that ciliary irritation and
photophobia so affect the orbicularis that its spas-
modic closure nearly renders it impossible to see
the eye at all, is of itself an almost unerring in-
dication of the nature of the disease. It is necessary,
however, to see the eyeball, in order to determine its
precise condition, and form a correct prognosis. A
few whiffs of chloroform or ether will sometimes
quickly relax the orbicularis; but I prefer a resort to
the lid-elevators to be used, as mentioned in Ophthal-
mia neonatorum. Separating the lids we shall find
the palpebral conjunctiva red, swollen, and velvety
looking, the ocular conjunctiva injected, the pinkish
zone around the periphery of the cornea well marked,
the cornea probably dull, opaque, or ulcerated, and
the iris perhaps contracted. There is sometimes a
DIAGNOSIS OF SCROFULOUS OPHTHALMIA. 107
good deal of ciliary neuralgia present, and the dread
of light may be so intense that the child cannot be
induced to turn its face towards the most moderate
light even with its eyes tightly closed.
Fortunately the disease is not always of so severe a
grade as this, and the photophobia much less severe.
In these cases, by means of coaxing, and some little
artifice to excite their curiosity, we may, through the
exercise of considerable patience, arrive, with most
children, at a hasty view of the cornea sufficient for
our purpose.
Often, the cornea will be found
nearly transparent, and the disease confined to the
conjunctiva and edges of the lids. Generally, how-
ever, even if the cornea appears unaffected, the ocular
as well as palpebral conjunctiva is involved, and the
inflammation is so deep seated as to reach the vessels
beneath the conjunctiva, as shown by the pinkish
zone around the edge of the cornea. The irritation
of the ciliary plexus of nerves is very great, the eye
is exceedingly sensitive to all external influences,
there is copious lachrymation and any irritation is fol-
lowed by most violent reaction. In some chronic
cases these symptoms are measurably lessened in
severity, but after all a leading characteristic of these
cases is the ciliary irritation, and the consequent ex-
treme sensitiveness of the eye. I dwell on this point
because of its importance in the treatment.
108
THE CONJUNCTIVA.
TREATMENT OF SCROFULOUS OPHTHALMIA.
The treatment of these cases must be almost
wholly internal. The disease of the eye is but one
of the manifestations of a disorder that pervades the
entire system, and topical means can at best be only
palliative. Soothing applications, however, like tepid
water, milk and water, quite warm fomentations of
water, or warm water medicated with belladonna or
chamomile or poppy leaves, will frequently quiet a cil-
iary neuralgia or great restlessness, when internal rem-
edies like bell., cham., coff., or spigel. alone, do not
act with sufficient promptness, and should therefore
not be overlooked. There are, moreover, some phases
of this disease, such for instance as when its chief seat
appears to be the edges of the lids, where a mild mer-
curial ointment, a grain or two of white precipitate,
or one grain of red precipitate, to the ounce of lard
or cerate, rubbed gently between the cilia, if neces-
sary while the child is asleep, will produce some-
times marvellously favorable results. It should be
continued a long time, nevertheless, if we hope for
permanent benefit, and merc. should be given inter-
nally at the same time. It is customary, I know,
at the present time in the "regular" school (so called
probably from the regularity with which it changes)
to apply an unguent of merc., zinc, lead, or nit. of
TREATMENT OF SCROFULOUS OPHTHALMIA. 109
silver washes to the inner surface of the lids in these
cases; but from pretty frequent and continued obser-
vation of the treatment in this way in the hospitals
of Europe, I am convinced that it seldom does good
and very often does harm; and that in homoeopathic
practice, we may better discard it altogether. An ex-
ception to this sweeping condemnation ought perhaps
to be made in favor of the mercurial ointment to the
inside of the lids, but I do not find its use at all
necessary.
This is not the place, nor is it necessary, for me to
remark at length on the nature or pathology of what
is called scrofula, and its appropriate treatment in
general. In the management of these diseases of the
eye, hygienic and dietetic regulations are of the first
importance. Fresh air, light, warm clothing, and
good diet are indispensable always. In regard to
light, I do not believe in keeping the patient in a
dark room.
If there is no ulceration of the cornea,
no special attention in a hygienic way need be given
in this affection to the patient's dread of light.
celebrated Prof. Beer, who formerly had charge of
the department of the general hospital for diseases
of the eye during many years in Vienna, used to
take children affected with severe photophobia and
place them in a position so that the sunlight might
fall directly into the eye, and then force the lids apart.
The
110
THE CONJUNCTIVA.
This appears like a very dangerous proceeding, but I
have the authority of the grandson of the operator,
the present Prof. Ed. von Jäger, to the effect that no
injury to the eye or brain was occasioned by the treat-
ment. This kind of procedure, however, is not
practised in Vienna at the present time. A rather
heroic method, or one which mothers at least would
consider so, was practised by Prof. Graefe, in Berlin.
When the eyes were much better and yet the photo-
phobia did not yield, he dipped the child's head under
water, perhaps several times, thoroughly frightening
it, and usually with the result of overcoming the
spasm of the orbicularis.
When there is an ulcer on the cornea or a vescicle
near its edge in the stage of excoriation, the photo-
phobia may arise from the exposure of denuded nerve
fibres, and then the progress in reproducing an epithe-
lial covering for the exposed nerves will be very much
hastened by bandaging the eye. The bandage will
also serve the purpose of preventing friction of the
lids in winking, and tend to prevent rupture of the
cornea if it happen to be the seat of a deep ulcer.
Children also have a disposition to constantly rub
their eyes, — a trifling circumstance enough, but one
which frequently has seemed to me the chief cause
of the continuance of the inflammatory state, and
this the bandage of course completely remedies.
-
TREATMENT OF SCROFULOUS OPHTHALMIA. 111
This bandage should be changed several times a day,
and the discharge washed from the eye, if discharge
be present. Sometimes great pain and restlessness
will be promptly relieved by dropping a solution of
atropine, one or two grains to the ounce of pure
water, into the eye; and its quieting influence seems
to expedite the cure. The atropine should never be
dissolved in alcohol or alcohol and water, because al-
cohol applied to the eye is an irritant, and usually
contra-indicated in cases where atropine is likely to
prove useful as a sedative.
eye
It is almost, or quite, impossible to give even an
outline of the treatment that may be required in scrof-
ulous ophthalmia, because, aside from the different tis-
sues of the eye which may be affected, the patient, so
far as my experience goes, invariably suffers from gen-
eral disturbance of the health. A child now under my
care, aged eighteen months, has, in addition to the
trouble, great irritation of brain from the teething
process, distension of the abdomen, constipation, loss
of appetite, and an appearance of languor. The
general status of the child, and especially the consti-
pation, is improving under bry. Possibly opium or
collin. might have been as good. With the im-
proved health has come an improvement of the eyes,
and yet I cannot say that either of the three remedies
mentioned is to be regarded as especially indicated
112
THE CONJUNCTIVA.
for scrofulous affections of the eyes. The fact is,
constitutional symptoms are so generally present, and
are so diverse, that almost any remedy of our materia
medica may be indicated and prove serviceable to
the eyes, through the improvement to the general
health, brought about by its administration. It is to
be borne in mind that a cure of the eyes is not likely
to be permanent unless there is a corresponding benefit
to the general health. Hence, local measures need
only concern the removal or palliation of the local
irritability and pain.
In looking over our homœopathic periodicals,
without by any means exhausting them, I find of
one hundred and sixteen cases noticed, all of which
resulted in satisfactory cures, the following seemed
to be the curative agents: merc. in various prepara-
tions in thirty-nine cases; sulph. in fifteen cases;
calc. in thirteen; bell. in nine; ars. in nine; con.
in six; rhus in six; hepar in five; apis in four;
silex in two, and a few other remedies in one case
each.
Fleischmann, in one hundred and thirty cases
treated at his hospital in Vienna, found hepar and
sulph. the most serviceable. I doubt the clinical
value of general résumés like the above, but I pre-
sume that there is no doubt that in this affection the
remedies above mentioned will be very fiequently in-
1
PHLYCTENULAR CONJUNCTIVITIS.
113
dicated, and prove very useful. I would add to them
spig., and the new American ones, macrot., gelsem.,
hydras., and baptis. When general symptoms ad-
mit, I find myself oftenest giving merc., either vivus
or biniodatus, frequently sulph., and when there is
corneal ulceration, arsen. Tart. emet. will also prove
exceedingly useful in the photophobia of scrofulous
ophthalmia, and also when herpetic eruptions are
present. Dr. Gray reports * some twenty-five cases
cured by merc. nit. externally and internally. He
uses externally one grain of the merc. to one hun-
dred and fifty drops of water.
PHLYCTENULAR CONJUNCTIVITIS,
Or herpetic or pustular conjunctivitis, as it is fre-
quently termed, may be considered as a phase of
scrofulous ophthalmia. It occurs usually in children,
and mostly in those of a so-called scrofulous diathe-
sis, and very rarely in children otherwise in good
health. It is characterized in its simple form by the
appearance of a reddened point upon an inflamed
base of the conjunctiva, slightly raised, and situated
usually either at the limbus of the cornea, or upon
the sclerotica, near its junction with the cornea.
This red point usually terminates in a vesicle, which,
changing into a slight excoriation or ulcer, gradually
* N. A. Journal of Homœop., Feb., 1860.
1
8
114
THE CONJUNCTIVA.
:
disappears, and leaves no trace behind. There is
generally some irritation of the ciliary nerves, and,
as a consequence of this, some photophobia and
lachrymation. These symptoms being greatly in-
creased when the vesicle or vesicles happen to come.
on the cornea or at its limbus. If the vesicles are
not developed in too great numbers, and are not too
near the cornea, the disease is very slight, and re-
quires very little treatment. I was once consulted,
by an adult, in a case of herpetic conjunctiva, whose
physician had informed him that he had probably a
pterygium growing over the sight of the eye, and it
would have to be removed by an operation. He was
a sculptor, and I advised him to remain at home for
a few days, so as to avoid the dust of his studio, and
he was soon cured, without any further treatment
whatever. Many cases, however, are much severer
than this and not as easily disposed of; and in all the
tendency to recur again and again is strongly marked.
TREATMENT
One of the best remedies for this disease is merc.
internally, and externally at the same time, powdered
calomel. The inspissations of the powder should
be made by taking up a minute quantity of the fine
powder on a camel's-hair pencil, then holding the
pencil vertically before the affected eye, between the
TREATMENT OF HERPETIC OPHTHALMIA. 115
forefinger and thumb of the right hand, having ex-
posed the surface of the under lid with the left hand,
tap the handle of the brush rather smartly with the
ring finger of the right hand, at the same instant
tossing the brush slightly towards the lids, and some
of the fine dust will be projected directly into the
eye. This manoeuvre is simple, but it requires a
little practice to do it neatly. The calomel should
be very fine, but little should be taken up on the
brush, and no lumps of it thrown into the eye.
Neither should it be blown into the eye through a
tube: it is too coarse treatment for a delicate eye,
even if well enough for the nose and other parts of
the body. The calomel seems to exercise a specific
influence in these cases, and cannot be replaced by
other powdered substances. For instance, powdered
magnesia appears to act simply as an irritant, no
curative effect following. I formerly thought the
calomel simply an irritant used in this way, but am
now convinced to the contrary. It does irritate, and
should therefore be used cautiously if the eye is very
sensitive and dreads the light. For the photophobia,
tart. emet. will often be serviceable. Ciliary neu-
ralgia may often be quieted by cham., using at the
same time warm fomentations of chamomile water
over the closed lids. Generally speaking, the inter-
nal remedies will be mostly such as have been men-
116
THE CONJUNCTIVA.
tioned under Scrofulous Conjunctivitis, and directed
to the constitutional symptoms so often manifested
by an eruption similar to that of the conjunctiva, at
the alæ of the nose, angles of the mouth, behind or
in the ears, and about other parts of the body.
Sometimes a herpetic point appears in the sub-
conjunctival tissue, just at the edge of the cornea.
When this is the case, and the sclera or the episcle-
ral tissue is involved, the progress of the disease is
tedious in the extreme, and all the more tedious from
the circumstance that remedies seem to be of little
service. I have had a case of this sort where one ves-
icle of this kind remained imbedded beneath the con-
junctiva for more than three months. It is difficult
sometimes in such instances to determine whether
such a case should be regarded as a conjunctivitis or
an episcleritis. See Phlyctenular Corneitis.
Exanthematous conjunctivitis, occurring during
eruptive fevers, does not usually demand special
treatment. It is always present to a certain extent
in measles, scarlatina, and variola. Any discharge
should be removed, and the eyes should be protected
against bright light. Bathing in tepid water, or milk
and water, is often grateful, and if the edges of the
lids adhere, or are tender or excoriated, the application
of simple cerate, olive oil, or glycerine will be useful.
Pterygium is a hypertrophied condition of the con-
PINGUECULA.
117
junctiva, usually of a triangular form, the apex
towards the cornea, the base at the semilunar fold.
The growth is tendinous, and supplied with vessels.
If it is not particularly annoying, and does not in-
crease rapidly so as to threaten impairment of vision,
by encroaching on the pupillary area, it is better not
to disturb it. The operation for its removal is not
always permanently successful. A less severe form
of the disease consisting merely of a slight hypertro-
phy of the conjunctiva is readily and successfully re-
moved with the forceps and scissors.
The cause of the disease is usually some injury of
the eye or exposure which irritates the conjunctiva,
and it sometimes results from a phlyctenular or other
ophthalmia. A warm climate predisposes to the af-
fection. My friend, Dr. H. B. Clarke, of New Bed-
ford, informs me that it is rather a common affection
among the sea captains in his circle of practice. It
comes very rarely under my observation, although
cases are sent to me purporting to be pterygium not
unfrequently. Rhatania and zincum are accredited
with having cured it. For the more pretentious
operations for pterygium, I must refer the reader to
the larger works on Surgery or Ophthalmology.
118
THE CONJUNCTIVA.
PINGUECULA.
The little elevation of a yellowish color observed
in elderly people at the margin of the cornea, called
pinguecula, is not annoying except from its conspicu-
ousness. If desired it may be seized with delicate
forceps, and snipped off with the scissors.
Warts of the conjunctiva may be treated in the
same way.
Cysts of the conjunctiva are to be treated sim-
ilarly.
Dermoid tumors, generally seated at the corneal
margin, are best dissected out with the knife, care
being taken not to go too deeply into the corneal and
sclerotic tissues.
CHAPTER VI.
THE CORNEA AND SCLEROTICA.
PHLYCTENULAR CORNEITIS.
THE cornea is frequently the seat of excoriation or
ulceration in the herpetic or phlyctenular variety of
scrofulous ophthalmia. The objective symptoms are
those of herpetic conjunctivitis more strongly marked,
with much greater ciliary irritation, congestion, and
photophobia. When we meet with a case of scrofu-
lous ophthalmia in which the dread of light is intense,
we may be sure that the cornea is implicated. The
seat of the vesicle is very apt to be the limbus of the
cornea.
TREATMENT.
Arsen. is the most serviceable remedy by far, and
comes as near being a specific for this form of cor-
neal ulceration as possible. Tart. emet. frequently
acts admirably in the photophobia, and spig. is
serviceable for the irritation and redness. Merc.,
hepar, bell., con., macrot., and gelsem. I also
120
THE CORNEA AND SCLEROTICA.
prescribe frequently. To quiet ciliary neuralgia,
the instillation of a solution of atropine in water, one
grain to the ounce, is very useful, and warm soothing
fomentations are also grateful. No irritating appli-
cations whatever are to be made to the eye, and a
bandage should be applied, for reasons given under
the head of Ulceration of the Cornea. After the cor-
neal ulcer or excoriation is healed, and the eye has
become less irritable, if the conjunctiva seems to be
the primary seat of the affection, as is often the case,
powdered calomel, applied as directed under Conjunc-
tivitis Herpetica, will be serviceable, especially in pre-
venting relapses.
ULCERATION OF THE CORNEA.
Corneal ulceration is nearly always an indication of
impaired health and weak vitality. There is always
more or less congestion of the conjunctiva, and gen-
erally pain, lachrymation, and photophobia.
Strumous ulceration, not as the sequence of a
vesicle, deeper, and nearer the centre of the cornea,
occurs in scrofulous ophthalmia, beginning as an
opaque speck. The
Ulceration in ophthalmia neonatorum is similar to
this in appearance. A grayish opacity, its centre
nearly transparent, the gray then giving place to a
tinge of yellow, and this, as resolution sets in,
THE DANGER FROM ULCERATION.
121
changed again to gray. A blood-vessel or leach of
vessels, may often be seen to run from the sclerotic
to the ulcer.
Transparent ulcer of the cornea is sometimes ob-
served, in which the vision of the patient, instead of
being clouded, suffers only from the irregular refrac-
tion of rays of light in passing through the uneven
portion of the cornea. All objects appear distorted.
The above are generally superficial ulcerations.
Among the deep-seated ulcerations, the
Crescentic ulcer of the cornea, as described in the
details of the case of gonorrhoeal ophthalmia, is one
of the more common, while the
Sloughing ulcer, from suppurative corneitis in the
weak and ill fed, and the analogous indolent ulcer
seen in the aged, frequently complicated by hypopium
and suppuration of corneal tissues, are more rarely
met in private practice.
THE DANGER
The chief danger of ulceration lies in the tendency
to leave a more or less opaque scar or cicatrix in the
corneal tissue, and which, if it happen to be situated
in or near the centre of the pupillary area, renders
vision imperfect. Another danger lies in the direc-
tion of a perforation of the cornea, which may occa-
sion a prolapse of the iris, resulting in adhesion
122
THE CORNEA AND SCLEROTICA.
1
between the iris and cornea, displacing the pupil, or
distorting it, and perhaps engendering an iritis, or if
the perforation happen to be small and central, caus-
ing a deposition of matter on the surface of the lens
capsule, and forming what is termed a capsular
cataract.
TREATMENT OF CORNEAL ULCERATION.
The most potent local agent in promoting a speedy
healing of a corneal ulcer is a protective bandage.
It is just as essential that the exposed surface of the
cornea should be protected from the air, as that any
other portion of the body, under similar circum-
stances, should be covered artificially. The quicker
a fresh layer of epithelium is formed to cover the de-
nuded nerve fibres, the sooner will the photophobia
vanish. Place a single thickness of fine muslin over
the closed eye, then fill the orbit, especially at the
inner angle, with fine charpie, so that the band of
elastic flannel may press uniformly, but gently, upon
the ball of the eye, just sufficiently to prevent winking.
It has been found serviceable sometimes when an
ulcer threatens perforation, to anticipate the rupture
by puncturing it with a fine needle. The advantage
of this is that the opening made is very small and
regular, the aqueous humor flows off gently, and the
iris falling against the opening, adheres over a very
་
TREATMENT OF CORNEAL ULCERATION. 123
minute surface, and when the aqueous humor once
more accumulates, it will be quite likely to be torn
away uninjured, and there will remain as a sequence
of the disease but a small corneal opacity. Sometimes
a perforation has been prevented by a paracentesis
of the cornea at its edge, which relieves tempora-
rily the intraocular pressure. In perforation it is of
course advisable to prevent the iris being involved,
if possible, and to this end the pupil should be kept
widely dilated by atropine when the ulcer is situated
centrally. If the ulcer is towards the margin of the
cornea, it should not be applied; calabar bean may
be substituted, in order to contract the pupil as much
as possible, and draw its edge away from the seat of
the threatened breach.
The diet, in cases of this kind, ought to be as nu-
tritious as the condition of the digestive organs will
permit. Fresh meat should be prescribed, and the
child should be kept in the open air as much as pos-
sible. No darkening of rooms should be permitted ;
on the contrary the sun should be allowed free access
to the nursery, and welcomed as one of the best
auxiliaries to the treatment. The dread of light is
of course provided for by the bandage, which prevents
access of all light, as well as air, wind, dust, smoke,
and all deleterious external influences. The heat
from the bandage need not be feared; it is beneficial
124
THE CORNEA AND SCLEROTICA.
rather than the reverse. In some instances of
chronic, indolent ulcerations, heat, either dry or in
the form of hot fomentations, is found to hasten a
cure admirably. The notion that hot applications
soften the corneal tissue, is a fallacy, there is prob-
ably just as much reason for asserting that cold
hardens it. The examination of an ulcer on the
cornea is much facilitated by lateral illumination.
This is not feasible when the photophobia is very
great, but when it can be resorted to, gives us a cor-
rect idea of the depth, extent, and progress of the
ulcer. No local applications to the ulcer should be
attempted. When the ulceration occurs in the course
of a granular or purulent ophthalmia, such applica-
tions as are necessary for the cure of the diseased
conjunctiva are to be made as previously directed,
care being taken that no irritating substance comes
in contact with the cornea.
The internal treatment in ulceration of the cornea
must be determined to a great extent from the symp-
toms of the patient apart from those of the eye. I
use by far the most frequently arsen., and then merc.
and hepar. When photophobia is obstinate or very
severe, I frequently alternate with the arsen. either
conium, bell., macrot., or tart. emet. The cause of
the affection will generally be found in some derange-
ment of the digestive and assimilative functions, and
TREATMENT OF CORNEAL ULCERATION.
125
this derangement is the thing, to the removal of which
our internal medication must be chiefly directed. I
have recently treated in an adult an ulcer of the cor-
nea, following an acute syphilitic affection of the
genitals. The cure was speedy and complete under
merc. bin. internally, and the use of the bandage and
the instillation of atropine, as auxiliaries.
Corneitis frequently occurs in scrofulous ophthal-
mia, and a similar form of diffuse corneitis* often
complicates a purulent conjunctivitis or a granular
state of the lids. It is easily recognized from the
hazy, grayish appearance of the corneal surface, and
the loss of transparency and polish. Lateral illumi-
nation will frequently reveal a minute mottled appear-
ance.
Suppurative corneitis, which is sometimes met
with as a result of severe purulent ophthalmia or from
chemical or mechanical injury to the eye, or from sur-
gical operations in the corneal tissue, is a much graver
form of the disease. It is frequently accompanied
by severe ciliary neuralgia. The rose-colored zone
around the cornea, contraction of the pupil, and fre-
quently chemosis, are present. We notice a gray
opacity, which changes afterwards to yellow as the
tissues become broken down, and the end may be a
perforation of the anterior chamber. Or there may be
extensive corneal abscess, perhaps interstitial infil-
* This form is also noticed in children whose notched teeth
(upper ircisors) indicate an inherited syphilitic diathesis
126
THE CORNEA AND SCLEROTICA.
tration forming onyx. Or a hypopion may result from
precipitation of pus to the bottom of the anterior
chamber. The matter may reach the anterior cham-
ber from perforation, from extension of the suppura-
tive inflammation to the iris without perforation, or
finally from suppuration of the posterior layer of
the cornea. Suppurative corneitis is very readily
produced by injuries of the cornea in the aged or
weak, and is not unfrequently met with as a sequence
of typhus, typhoid, cholera, or diabetes.
An indolent or non-inflammatory form of corneitis,
where the absence of pain and irritation is a charac-
teristic feature is of still more dangerous nature.
The infiltration sometimes extends with great rapidity;
and necrosis not only of the whole cornea ensues, but
in rare instances the suppuration extends to the entire
globe.
TREATMENT OF CORNEITIS.
The treatment of corneitis occurring during the
course of the various ophthalmiæ has been sufficiently
indicated. In the severe suppurative forms the eye
should in the first place be bandaged, and the flannel
band should be long enough to pass twice around the
head, so that considerable pressure may be exerted on
the ball of the eye. Pressure seems to have a con-
trolling influence in limiting the extent of the suppura-
TREATMENT OF CORNEITIS.
127
tion, and every hair's-breadth of transparent cornea
saved to the patient multiplies infinitely his visual
power in the end. If the inflammatory symptoms are
so marked as to indicate the cold compress, then the
application of the compress bandage may be alternated
with the use of cold water. It is hardly worth while
to attempt to combine the cold and the compress at
the same time. One or the other will be pretty sure
to be inefficiently attended to. In the non-inflam-
matory form of corneitis hot water fomentations of a
temperature from ninety to one hundred Fahrenheit are
indicated, the object being to create inflammatory re-
action. The same treatment for the same object may
sometimes be serviceable in the ordinary form of cor-
neitis if the inflammatory appearance is lost and resolu-
tion still doubtful. These fomentations are very potent
agents for good, or, when indiscreetly used, for evil,
and their application should not therefore be intrust-
ed to other than the most trustworthy attendants.
When a marked injection of the eye has been induced
they should be discontinued, and not again resorted
to, unless called for by a recurrence of the former
symptoms. It is plain therefore that they should not
be used too hot too long at a time; the cloths
should be changed before they become too reduced in
temperature, and if too great reaction has been pro-
duced it must be neutralized by cold. Paracentesis is
128
THE CORNEA AND SCLEROTICA.
sometimes resorted to as a relief from intraocular
pressure, to preserve the integrity of the cornea, but
very rarely, as of old, for the evacuation of hypopion
or interstitial matter.
The instillation of atropine will frequently relieve
pain, but if it causes increased irritation, may be
replaced by the solution of belladonna, five to ten
grains of the extract in pure water.
Aconite, internally, is the remedy to be employed
when the reaction is sufficient to warrant the applica-
tion of cold to the eye, afterwards arsen., for ulcera-
tion if it exist, and for the keratitis probably merc.
and hepar will be oftenest demanded, although it is
quite impossible to forestate what remedies the con-
stitutional symptoms may require. I often recur to
cannab., nit. ac., sulph., silex, or in case of ciliary
irritation and neuralgia, to macrot., gelsem., spig., con.,
cactus, nux. vom., and others as intercurrents. Severe
pain will usually be relieved if internal remedies fail,
by warm medicated fomentations of cham., bell., or
opium, administering the remedy also internally at
the same time.
STAPHYLOMA ANTERIOR.
Staphyloma of the cornea and iris sometimes
occurs as a sequel of perforation or sloughing of
the cornea. The iris falls against the opening, lymph
STAPHYLOMA ANTERIOR.
129
is secreted and a cicatricial tissue something of the
nature of opaque cornea is formed. Being weak
and inelastic under intraocular pressure, it bulges
forward, and forms a partial or total staphyloma of
the cornea and iris. The disease is to be treated
surgically. The intraocular pressure is most cer-
tainly relieved by iridectomy beneath that portion of
the cornea which still retains transparency, so that
the operation may serve at once the double purpose
of improving sight and removing pain and disease.
This presupposes the staphyloma to be only partial.
When it is total the bulging of the eye is so con-
siderable as to present an unsightly appearance; it is
irritable, painful, and all sight inevitably lost. All
that remains to be done is to remove the staphyloma,
not by the old method of excision with the cataract
knife and scissors, but after the method of Mr.
Chritchett who passes four or five needles armed with
fine silk through the base of the growth just behind
the line of the contemplated incision, bringing them
out at corresponding points opposite; then cutting
out an elliptical piece of the cornea within the bounds
described by the entrance and exit of the needles, he
afterwards draws the needles through and forms a
close and even suture. Borelli still more recently
practises the removal by strangulation, using two
needles which transfix the growth at right angles.
9
130
THE CORNEA AND SCLEROTICA.
A thread is then passed around the staphyloma be-
hind the pins, and tightly tied, and in three days
pins, thread, and protrusion come off together. I
have never seen the latter operation performed, but it
is said to be particularly successful in partial staphy-
loma.* After the operation an artificial eye may be
inserted.
Conical cornea is most readily diagnosed by
noting the difference in the size of the image of the
window on the two cornea, or by viewing the eyes in
profile. It may also be recognized by the ophthal-
moscope. By direct examination we see a central
red illuminated space, around this a dark zone, and
still outside of this a red ring of light. The dark
zone is occasioned by the complete reflection and
diffusion of the rays of light at the base of the cen-
tral cone, where it joins the normal cornea through
the periphery of which the outer red ring of light is
reflected. One may also get an inverted image of
the fundus of the eye, as in myopia, in consequence
of the increased refractive power of the centre of the
cornea. The bulging is not due to intraocular pres-
sure, for the eyeball is softer rather than harder than
in the normal condition. It seems to be due rather
to a thinning and weakening of the corneal tissue, the
exact nature and cause of which is not well under-
stood. The progress of the disease is generally slow,
* Where vision is wholly lost it is often better to remove the
entire eyeball.
CONICAL CORNEA.
131
and this circumstance among others favors the belief
that under proper constitutional medication, and fa-
vorable hygienic and dietetic influences, the disease
might prove curable. I have had no opportunity for
lengthened treatment of a case as yet. Ordinarily
the treatment is surgical, and by no means entirely
successful. The pupil is transformed by the opera-
tion of double iridodesis into a narrow slit. This
form of pupil neutralizes to a certain extent the
astigmatism caused by the unsymmetrical surface of
the diseased cornea, by lessening the "circles of
diffusion." Some operators, however, prefer a simple
enlargement of the pupil by iridectomy towards the
peripheral part of the cornea. Graefe sometimes
succeeds in flattening the apex of the cornea by pro-
ducing a minute ulcer upon it, which heals without
leaving a permanent opacity. It is a very delicate
operation, owing to the extreme thinness of the cornea
at this point. Sometimes concave glasses and a
stenopaic apparatus with a slit-shaped aperture are
useful for the patient in regarding near objects.
*
Arcus senilis, a line of opacity extending partially
or entirely around the periphery of the cornea, caused
by fatty degeneration, requires no treatment, as it
produces no visual disturbance. It is often hereditary,
and sometimes indicates similar disease of other parts
of the body.
* Bader, of London, has recently practised successfully the
removal of a small oval piece of the whole thickness of the cornea
at the summit.
132
THE CORNEA AND SCLEROTICA.
Opacities of the cornea, resulting from previous
disease of its tissue when slight and recent or when
dense, the edges not sharply defined, and, in children,
usually disappear in course of time without treat-
ment.* Appropriate medical and hygienic treatment
will, however, hasten this result. Internally, calc.,
cann., hepar, merc., sulph., silex., puls. nutt., and
other remedies are accredited, and probably justly,
with having removed such opacities. The remedy
must be selected often according to other irregularities
apart from those of the eye. When there are no
irregularities in the general condition of the patient's
health to guide us, and the eye is not abnormally
sensitive, we may try the cautious use of irritating
collyria. One or two grains of sul. of zinc or sul. of
copper, ten or twenty grains of borax, three to five
grains of iod. of pot. each to an ounce of water are
sometimes useful. In these cases atropine should
be occasionally used to diminish intraocular pres-
sure, and promote absorption. I have used pow-
dered calomel daily with satisfactory effect, as directed
in phlyctenular conjunctivitis, and sul. of soda is re-
cently recommended, to be brushed with a camel's-hair
pencil over the conjunctiva of the reversed upper lid.
Whatever agent we may use to promote local reaction
* Fresh opacities of the cornea are a much greater disturbance to
vision than old ones of the same size and apparent density.
TATTOOING THE CORNEA.
133
it should be changed often, as the eye soon becomes
accustomed to the same irritant, and is no longer
favorably affected by it. It is hardly necessary to
remark that none of those local irritants are admissi-
ble until after all inflammation of the cornea has
disappeared.
When an opacity is old, and has assumed a white,
pearly, glistening appearance, its margin well defined,
and especially if in an adult, we shall fail in any attempt
to remove it either by internal or external means.
We have then the resource of an artificial pupil, to
be made exactly behind such part of the cornea as
retains most of its normal transparency.
We may also resort to the operation of tattooing
the cornea. The coloring matter, usually India ink,
is pricked into the cornea with a needle or delicate
knife, and not only hides the unsightly opacity, but
may improve vision in some cases by lessening the
diffusion of light, just as the small aperture in
stenopaic glasses, and the pin-hole in a card, render
vision more acute.
Nussbaum, of Munich, some years since, tried the
plan of removing the central portion of an opaque
cornea, and inserting a circular window of glass. It
was not successful; suppuration and expulsion of the
glass followed. The operation of transplantation of
134
THE CORNEA AND SCLEROTICA.
cornea has also failed. It is always melancholy to
see a patient, the interior of whose eyes is perfect,
and who could see, if only the foggy cornea could be
replaced by some transparent medium, and sadden-
ing to be obliged to tell him that there is no hope left
for sight. It is not unreasonable to believe, I think,
that the future of surgery will provide some remedy
more or less complete for these unfortunates.
EPISCLERITIS.
As
Episcleritis commences in the form of a dusky-
red circumscribed spot, beneath the conjunctiva in
the episcleral tissue or superficial tissue of the
sclerotic, generally near the edge of the cornea.
it progresses the color usually changes to a purplish
hue. It causes a good deal of ciliary irritation and
neuralgia if it involves the edge of the cornea.
Otherwise there is little or no pain and little injection
of the conjunctiva. It is of not unfrequent occur-
rence in the course of a scrofulous ophthalmia, and is
then accompanied by a conjunctivitis and perhaps
some mucous discharge. It must not in these cases
be confounded with a pustular or phlyctenular oph-
thalmia. No ulceration or excoriation ensues, but
the spot or nodule gradually pales away.
The cause of the affection when idiopathic is gen-
erally debility from overwork, or some depressing
EPISCLERITIS.
135
influence. It is not difficult to relieve or cure when
the patient can be thoroughly under control. Warm
fomentations are always soothing, and atropine when
necessary will quiet the ciliary neuralgia which is apt
to come on at night. All use of the eyes is to be
prohibited, and a shade worn when in the open air.
Constitutional disturbances will frequently indicate
the choice of internal remedies, otherwise I rely
almost wholly upon the protiodide of mercury, which
in my hands has seemed to be very serviceable.
Next to this remedy bry. especially in sudden redness
and irritation in the course of the disease, brought on
by overuse of the eye.
An unnatural bulging of the sclerotic often occurs
as the result of old choroiditis or irido-choroiditis.
It is not unusual in cases of glaucoma. It is
situated commonly at the anterior part of the sclerotic
behind the ciliary region, and is called frequently
anterior staphyloma in distinction to a posterior
staphyloma of the sclerotic seen in progressive my-
opia. The disease is not idiopathic, but supervenes
upon
inflammation of some portions of the uveal tract,
and presents no characteristic features except in the
bulged and bluish appearance of the thinned sclerotic.
The treatment will be directed to the iris, choroid, or
ciliary body. Sclerotico-choroiditis posterior is no-
ticed under Myopia.
CHAPTER VII.
THE IRIS.
HYPERÆMIA OF THE IRIS
PRESENTS symptoms similar to those of simple
iritis, except that they are less marked and the exu-
dation is absent. It may be caused by over-exer-
tion of the eyes for near objects, and often indicates
a congestion of the deeper seated structures of the
eye. It is frequently noticed in scrofulous ophthal-
mia, and is not unfrequently one of the results of an
injudicious use of caustics. The treatment will de-
pend upon its course, and the nature of the associated
affection. Generally it will require a treatment
similar to that for iritis.
SIMPLE IRITIS, OR RHEUMATIC IRITIS.
The objective symptoms are injection of conjunc-
tiva, also subconjunctival injection, the rose-colored
zone around the cornea being well marked; generally
there is contraction of the pupil and always sluggish-
SUPPURATIVE IRITIS.
137
ness in dilation and contraction, discoloration, a blue
iris becoming greenish, and a brown iris reddish-
brown, and there may be observed frequently a plastic
exudation at the pupillary edge or on the surface of
the iris. In severe cases there is sometimes swelling
of the lids, injection of the conjunctiva, chemosis
and the posterior surface of the cornea may be mot-
tled by minute depositions of lymph. The subjec-
tive symptoms are sometimes merely dimness of
vision and slight dread of light. At other times we
find them very severe; there is great pain in the eye-
ball, around the orbit, and in the temple, generally
worse at night, severe photophobia and lachrymation.
SUPPURATIVE IRITIS,
The symptoms of which correspond generally to
those above given, is a deeper seated form of in-
flammation, the tissues of the iris being attacked and
becoming swollen and thickened. This is the form
which a syphilitic iritis usually takes, while the rheu-
matic form, so called, when it occurs in rheumatic
subjects, is a simple iritis. In suppurative iritis.
the exudation is copious, the swollen tissues of the
iris impede circulation, the vessels become con-
gested, and soon large tortuous veins appear on the
face of the iris. Observation by lateral illumina-
tion will be of great help in noting the struc-
138
THE IRIS.
tural changes which occur.
Little yellowish nodules
may be seen about the edge of the pupil, the mis-
chievous purpose of which seems to be to stick the
edge of the pupil firmly to the capsule of the lens.
The aqueous humor becomes increased in bulk, and
turbid from the admixture of pus and lymph thrown
out by the iris. The latter is sometimes completely
covered by a thin veil of exudation so as to be quite
indistinct, and the exudation may be so extensive as
to settle to the bottom of the anterior chamber,
forming a hypopium. In syphilitic iritis there are
also frequently the tuberculous nodules on certain
portions of the iris, reddish-yellow in color, and
which attain often to considerable size, and may even
project so far into the chamber as to touch the pos-
terior surface of the cornea. I never saw these con-
dylomatous nodes in a non-syphilitic case; such
instances have, however, been observed; but, gener-
ally speaking, these nodes determine the nature of the
case at once.
A SEROUS IRITIS
Is observed generally in children with the pecul-
iar notching of the incisors which indicates heredi-
tary syphilis. There is increased secretion of the
aqueous humor which is turbid, and deposits small
specks of lymph upon the posterior surface of the
THE CAUSE OF IRITIS.
139
cornea; hence the affection has been called keratitis
punctata. It is frequently associated with choroiditis,
and the prognosis is not as favorable as in most other
forms of iritis.
THE CAUSE OF IRITIS
Is frequently the exposure to changes of tem-
perature, cold rain, wind, and like influences. The
same causes which tend to develop a rheumatic
attack, often occasion this, and it is then as well
as at other times often called rheumatism of the eye
or rheumatic ophthalmia. The pain in this form
often extends over the whole of one side of the head
and face, and the patient is apt to suffer from re-
lapses. It is frequently of traumatic origin, and
frequently of syphilitic. Most cases of idiopathic
iritis in children are probably of syphilitic origin. A
chronic iritis, though not very often seen apart from
a choroiditis, may supervene upon an acute attack.
The prognosis of iritis when seen in the beginning,
before extensive adhesions between the iris and
capsule of the lens have formed, is very favorable.
Adhesions almost preclude the possibility of a perma-
nent cure, unless they can be overcome.
The edge
of the pupil once firmly glued to the capsule, the
iris is for ever being irritated by the efforts of the
pupil at dilation and contraction, and this irritation
140
THE IRIS.
constantly tends to produce a sub-acute attack of
iritis, and may finally lead to irido-choroiditis and
loss of sight.
THE TREATMENT.
The treatment should in the first place look to the
prevention of these adhesions by the enlargement of
the pupil to the full extent by atropine. For this
purpose it should be used of the strength of four
grains to the ounce, and be dropped into the eye at
intervals of five minutes three or four times, morn-
ing, noon, and night. Less frequent use than this
will sometimes keep the iris dilated to its maximum,
but not always. In mild cases a drop or two once a
day will often suffice. Another benefit of the use
of atropine is, that it gives the inflamed muscular
tissue of the iris perfect rest through the complete
paralyzation of the constrictor pupillæ. Otherwise,
the iris is in constant motion attempting to regulate
the size of the pupil according to the nature of the
light. An inflamed muscle in any other part of the
body we should hardly attempt to cure, unless we
could first be certain of the condition of rest being
fulfilled. Another advantage of the atropine also is,
that the intraocular pressure being lessened by its
use, as shown by diminished tension (hardness) of
the eyeball, interior circulation is relieved and the
congestion of the iris and ciliary body is lessened.
:
THE TREATMENT OF IRITIS.
141
Sometimes recent adhesions have been broken up
quickly by the alternate use of a solution of atropine
and calabar bean, thus producing extreme alternate
dilation and contraction of the pupil.
bell.,
Atro-
For internal medication I rely chiefly on acon.,
merc., and bry. Acon. at the commencement, partic-
ularly when the pupil is much contracted, with bell.
in alternation, or bry., if in a rheumatic subject.
Severe pain in the eye and about it is often relieved by
warm fomentations medicated or unmedicated, and
the administration of spig., cham., macrot., gelsem.,
or other remedies, according to special indications.
Merc. will often be serviceable for pain, especially
when aggravated at night. I have recently been
treating a case of iritis, following an attack of rheu-
matism with bry. and merc. in alternation.
pine twice a day served to keep the pupil sufficiently
enlarged and to quiet the neuralgia. A case of
syphilitic iritis, showing the characteristic nodules
on the iris, very severe, with great exudation, great
tension of the ball, and severe ciliary neuralgia, so that
I thought strongly of a paracentesis cornea to relieve
the two last symptoms, recovered perfectly, leaving no
adhesions, under atropine, warm fomentations and
the internal use of acon., merc., and later, when I
found a tendency to complication of the choroid, kali
hydriod. It is much safer in treating iritis, even if
142
THE IRIS.
not very severe, to confine the patient to the house,
and to the bed, if the attack be important. The
darkened room will not be so necessary if atropine
be used, still in all cases it will be more agreeable
to the patient to have the bright yellow light moder-
ated to a certain extent. When necessary for the
patient to go out, he should wear a blue or green
shade. In chronic iritis, when adhesions are left and
irritation of the iris is kept up by them, a strong solu-
tion of atropine being of no avail in breaking them
up, the operation of Corelysis may be indicated.
After ascertaining the exact position of the posterior
synechiæ by lateral illumination, a small incision is
made through the cornea with a needle, and a blunt
hook,* called, from its form, a spatula hook, is intro-
duced, and the adherent iris separated from the lens.
The great danger in this procedure, as indeed in all
operations on the iris, lies in the difficulty of avoid-
ing the rupture or incision of the capsule of the lens.
A chronic iritis, or irido-choroiditis may, some-
times be mistaken, at first, for a glaucoma; the diag-
nosis is readily corrected in such an event by testing
the extent of the field of vision. If glaucoma is pres-
ent we shall generally find it limited. Choroido-iritis
is an affection primarily of the choroid, the iris being
involved secondarily. The prognosis in the latter is
more unfavorable; for while in the former an obscu-
* The recently devised operation of Passavant, in which the
iris is seized by delicate forceps, and gently broken from its
attachments, is preferable.
CYCLITIS.
143
rity of vision may be due to a deposition of matter
or pigment upon the capsule of the lens, in the latter
it is due to changes in the deeper structures of the
eye. The medical and hygienic treatment of these
cases will be that of iritis and choroiditis.
PROLAPSUS OF THE IRIS
Frequently occurs from perforation of the cornea
from ulceration or otherwise. If slight, we may
succeed in replacing it with a delicate probe, or
by enlarging the pupil with atropine, it may be
pulled away from the gap. In any event the eye
should be covered by a firm compress bandage, to
prevent increase of the protrusion. If the prolapse is
rather large and bulged outward from the aqueous
humor it should be pricked with a needle, causing it
to shrink and dwindle away gradually. It may
sometimes be necessary, after pricking it, to prevent
its refilling, to cut it off with scissors close to the
cornea. It should never be touched, according to the
custom of many surgeons, with caustic, as it causes
great iritation, and may set up an iritis, and because
under any circumstances it is quite an unnecessary
risk to run.
CYCLITIS.
Cyclitis, or irido-cyclitis may arise from a severe
form of iritis in which there is an irrepressible ten-
1
144
THE IRIS.
dency to cell proliferation, so that the disease soon
reaches the ciliary bodies, or from injury of the eye.
The inflammation in the ciliary body, when not idio-
pathic, corresponds in character to the nature of the
iritis from which it originates. It is recognized
by the tenderness of the eyeball to touch in the
ciliary region, and it is generally the occasion of a
good deal of ciliary neuralgia. Its treatment in the
main is that given for iritis. It may arise also from
the extension forward of a choroiditis, and would then
require the treatment principally of a choroiditis. It
is always a serious complication, and our prognosis
should be guarded. It is noticed further under Sym-
pathetic Ophthalmia.
ARTIFICIAL PUPIL.
The formation of an artificial pupil is indicated
when the natural one has become closed by disease,
and also, when the pupil being normal or otherwise,
the cornea has become opaque to a certain extent,
but has still a transparent portion left. Behind this
transparent bit of cornea exactly, the new pupil
must be made. Or, if the cornea be transparent
over considerable of its surface, we enlarge or extend
the natural pupil in a direction which will render
it most serviceable to the patient. Other things
being equal, the extension of a pupil downward and
inward is best for vision.
ARTIFICIAL PUPIL.
145
The operation usually is that of iridectomy, the
same, with an important exception, that of the loca-
tion of the incision, as the iridectomy made for the
relief of glaucoma, or intraocular pressure.
A
small incision is made into the cornea near the point
beneath which we desire the new pupil. This incision
is made generally with a keratome-a lance-shaped
knife. If a gush of aqueous humor has not already
prolapsed the iris we enter the anterior chamber with
a pair of delicate forceps, and grasping a portion of
the iris near the incision, draw it through the wound
and snip it off with a pair of curved scissors.
A narrower and sometimes better pupil, optically
considered, is sometimes formed by the operation of
iridodesis. The incision is made at the edge of the
cornea with a broad needle. The chamber is entered
with a blunt hook, and the iris caught between its
pupillary and ciliary edge, and drawn through the
wound, around which has previously been placed a
fine loop of silk. The portion of iris drawn out is
ligatured with the silk, and in the course of a few days
sloughs off. A double iridodesis is frequently per-
formed in opposite directions which gives a narrow slit
for a pupil like that of a cat. This is the operation
usually done for conical cornea.
When the anterior
chamber is very narrow, the slender cataract knife of
Graefe may be used instead of the lance-shaped
•
10
146
THE IRIS.
keratome, in order to avoid the risk of wounding the
capsule of the lens. The opening is made along the
rim of the anterior chamber, as in the flap operation
for cataract, only shorter.
Iridodialysis is not so formidable an operation as
its name would indicate. It is simply entering the
anterior chamber with a hook or forceps, and tearing
away a part of the iris from its ciliary attachment.
This forms a pupil, which answers when only a nar-
row line of the cornea at its periphery is transparent.
Artificial pupil by incision simply, with a broad
needle, may be performed for a pupil entirely closed.
when there is no lens, as after cataract operation.
After the puncture, the fibres of the iris, if it is tol-
erably healthy, will retract sufficiently to form a
pupil; if not, a bit of the cut edge of the iris may be
drawn out at the small aperture in the cornea and
excised with the scissors. A much more difficult
operation, that of excising a triangular piece of iris
with delicate scissors is sometimes resorted to under
similar circumstances.
AFTER-TREATMENT IN THESE OPERATIONS
May be very simple. A bit of linen is laid over the
closed lids, the orbit filled out with a little charpie,
and a light bandage applied, and for forty-eight hours
aconite may be administered hourly when the patient
MYDRIASIS.
147
is awake. It is rarely necessary to resort to the cold
compress.
MYDRIASIS
Is the name given to a state of the pupil when
abnormal dilatation and more or less immobility
are present. It is a well known symptom, when
binocular, of grave diseases of the brain. It is gen-
erally however of much less serious import, and
may follow a rheumatic attack from exposure to cold
or wet. It follows upon partial or complete paralysis
of the third nerve, and is often of syphilitic origin.
A very common extra-ocular cause, according to my
experience, is irritation of the sympathetic, from dis-
order of the digestive organs, spinal irritation, or, in
children, helminthiasis. Monocular, as well as bi-
nocular, it is often owing to deep-seated diseases of
the eye, which, by diminishing the sensitiveness of
the retina, impair the reflex action upon the ciliary
nerves which control the pupil. It frequently follows
injury of the eye. I have lately had under my care
a man who, while cutting wood, was struck not very
forcibly on the ball of the right eye by a splinter.
No wound or discoloration occurred, but the pupil
immediately enlarged, and has, up to the present
time, some two months, not regained its former con-
traction. Occasionally I have had a case of monocular
dilatation of the pupil from over-exertion of the eye.
148
THE IRIS.
This is to be explained probably by the fact that the
eyes differed slightly in refractive power, and the
affected eye did most of the work. The affection
occasionally follows injury of the sphincter of the
pupil from pressure of the lens in extraction. A
constant subjective symptom is the impairment of
vision for near objects.
I cannot define any particular plan of treatment.
It must vary constantly according to the nature of
the exciting cause. The affection is often a concomi-
tant of paralysis or disease of other parts of the eye,
and the treatment, is spoken of elsewhere. Calabar
bean applied to the eye is generally of temporary
benefit in restoring the size of the pupil, and improv-
ing the vision for near objects: the same remedy is
reported occasionally to have been of permanent
benefit also.
MYOSIS,
The opposite of the above condition, an abnor-
mal contraction of the pupil, is sometimes seen in
iritis, and frequently in disease or injury of the
upper part of the spinal cord. It has also been ob-
served in hyperæthesia of the retina and in persons
who work at small objects, like watch-makers. Idio-
pathic myosis is extremely rare.
Congenital anomalies of the iris occasionally ob-
served are irideremia, absence of the iris, coloboma,
ATROPINE AND CALABAR BEAN.
149
or cleft iris, corectopia, an eccentric position of the
pupil, and polycoria, more than one pupil.
ACTION OF ATROPINE AND CALABAR BEAN.
Atropine, to be used in the form of a solution of
sulphate of atropine, which is exceedingly soluble in
water, acts on the iris principally by paralyzing the
circular fibres, but also by contracting the radiating
fibres. The iris is extremely susceptible to its influ-
ence, a solution in water of enlarging the pu-
10.000
pil, which it reaches by absorption through the
cornea, with great certainty, in the course of an hour
or two. The disadvantage of a weak solution lies in
its feebleness in overcoming any adhesions between
the iris and capsule of the lens, and also in its uncer-
tainty of effect when the iris is diseased. For the
enlargement of the pupil when the iris is healthy,
a weak solution, such as a grain to ten or twelve
ounces, is preferable, from the fact that its effect
passes off in the course of a day or two. A solution
of a grain or two to the ounce of water, is often de-
sirable on account of the promptness of its action, a
half hour only being required for its full effect. A
solution of four grains to the ounce will act still more
promptly, and will be certain also to completely par-
alyze the accommodation when this is desirable; the
effect of such a solution will not pass wholly off for
150
THE IRIS.
eight or ten days. A solution two or three times
this strength may be used in attempting to break up
old adhesions between the iris and lens capsule. Very
strong solutions, thirty to fifty grains, are not to be
commended, lest cerebral symptoms supervene.
A
long continued use of atropine renders the eye intol-
erant of it, and in very rare instances it proves too
great an irritant to be used at all. It must be re-
membered that liquids of all kinds, when dropped
into the eye, reach the throat through the lachrymal
duct almost as readily as when taken into the mouth.
I am not aware that attention has been called to this
fact in any medical work, but it would seem to be
one of considerable importance. Any one who will
take the trouble of testing in his own eye the effect
of a few drops of a solution of two or three grains of
iodide of potash to an ounce of water will, I think,
be surprised to find how soon he will get the char-
acteristic bitter of the alkali in the throat. I had
long noticed the favorable effect of a collyrium of
atropine (one grain to the ounce of water) in the
photophobia of scrofulous ophthalmia, before it oc-
curred to me that the internal effect of the belladonna
might be, at least partially, the cause of the improve-
ment. In prescribing collyria for the eye, we should
therefore always take into account the possible, or
perhaps we may say the unavoidable, internal effects.
CYSTS OF THE IRIS.
151
CALABAR BEAN.
The calabar bean (Physostigmatis Faba) appears
to exercise on the eye an effect exactly antagonistic
to that of atropine. It contracts the pupil, rendering
the eye temporarily myopic. Its effects are more
rapid and less permanent than those of atropine, and
as with the latter, are more rapid and permanent, the
stronger the solution made use of. The usual strength
is that of about four grains to the ounce of water. It
will neutralize the action of atropine to a certain extent,
restoring the pupil to its natural size, but the effect
is evanescent, passing off in a few hours, when the
pupil again enlarges, the atropine resuming its
control.
Iridodonesis, tremulousness of the iris, is a certain
indication that the iris has lost the support of the
lens, as after extraction, in dislocation of the lens, or
as in hydrophthalmia, when the anterior chamber
becomes enlarged.
Cysts of the iris, may be excised together with
that portion of the iris to which they are attached,
by the operation of iridectomy.
CHAPTER VIII.
THE CHOROID AND VITREOUS.
HYPEREMIA OF THE CHOROID
Is undoubtedly of frequent occurrence, but is
very difficult to diagnose with the ophthalmoscope
as the vessels of the choroid are, except in very
light-complexioned persons, almost completely hid-
den by the pigment layer. Nor unless the iris and
ciliary bodies are also congested does it seem pos-
sible to diagnose it without the ophthalmoscope.
When its existence is determined, and it may always
be suspected in hyperemia of the retina, if venous or
passive in character, ham., externally and internally,
should be used. See Treatment of Hyperæmia of
the Retina and of the Conjunctiva.
CHOROIDITIS SIMPLEX, OR DISSEMINATED CHOROIDITIS,
Can hardly be diagnosed with certainty without the
aid of the ophthalmoscope, as the otherwise noticeable
symptoms are common to other affections. There is
usually some dilatation and sluggishness of the pu-
CHOROIDITIS.
153
pil, some failure of sight, irregular obscuration of
the field of vision, so that perhaps but parts of ob-
jects are seen at once, and usually little or no pain.
Sometimes the external appearance of the eye is
quite normal. The
Ophthalmoscopic signs are general cloudiness of
the choroid or vitreous, but oftener we see small yel-
low-white patches of lymph, first at the periphery,
afterwards about the macula lutea and optic disc, and
later, if atrophy of the choroid occurs, the white scle-
rotic will be seen shining through in spots. White
patches with a pale-red zone around them indicate a
syphilitic origin of the disease. Still later, we may
find consecutive atrophy of the retina and optic
nerve. We know that the exudation at first is in the
choroid from the observation that the retinal vessels
are distinctly seen over these patches, and are not in-
terrupted in their course or obstructed, and from the
fact that the retina retains its normal transparency.
The prognosis must of course be guarded owing
to the tendency to complication and atrophy of the
retina and optic nerve. Sometimes, however, the
exudations are absorbed, leaving but faint traces of
their existence behind, and sight is quite restored.
THE TREATMENT
Must be governed to a great extent by the state
of our patient's health otherwise, and the cause of
!
154
THE CHOROID AND VITREOUS.
the disease. This is frequently syphilis. Generally
it will be found that the liver, digestive organs, or
the uterus, are disordered. All these circumstances
will influence our treatment. At all events, the
patient should abstain from the use of the eyes in
reading or sewing, and guard them against bright
light out of doors by wearing blue glasses. I have
more faith in the administration of merc. than in that
of any other one remedy, for this disease, and for
affections of the choroid generally. No doubt ars.,
iod., sulph., kali hydriod, or bell., cactus, con., nux.,
spig., and many other of our remedies, may prove
useful in choroiditis. My experience has not enabled
me to fix upon definite and reliable indications for
the selection of one of these drugs in preference to
another, as far as eye-symptoms are concerned. I
would give the first group in connection with mercury;
the second, occasionally with the first, in irritability,
congestion to the choroid and retina, and in photo-
phobia.
In old cases of irido-choroiditis the operation of
iridectomy will frequently be indicated for the pur-
pose of breaking the adhesions between the lens cap-
sule and iris, as well as for the purpose perhaps of
laying a pupil before a transparent portion of the
capsule. The operation is, under these circumstances,
beset with difficulties from the narrowness of the
1
SUPPURATIVE CHOROIDITIS.
155
anterior chamber and the degenerated rotten condition
of the iris. If the lens is wounded in the attempt, it
must be extracted. In these cases some operative
interference is necessary, as no medicines can be of
avail so long as the irritation is kept up by the adhe-
sions. These adhesions may generally be detected at
once by the use of atropine; unless the entire pupil-
lary margin is adherent, the enlarged pupil will be
irregular in form.
SUPPURATIVE CHOROIDITIS,
Called also panophthalmitis, or ophthalmitis, is
a very grave disease and its course often very rapid.
The eyelids are usually red, swollen, and odema-
tous, the chemosis very great, so that the eye appears
swollen. The iris is bulged forward and discolored, the
eyeball sensitive to touch, the tension increased, and
we notice, if the pupil is sufficiently clear, a yellow
reflex from behind the lens, due to a purulent infil-
tration of the vitreous. Sometimes the pain in the
eye and the region about is of the most intense
nature, at other times less severe. Sight is, of
course, rapidly and greatly impaired, and frequently
all sensation of light disappears.
The causes are suppurative inflammation of the iris
and cornea in bad subjects, typhus, typhoid, pyæmia,
injuries of eye, surgical operations, or sympathetic
ophthalmia.
156
THE CHOROID AND VITREOUS.
THE TREATMENT OF OPHTHALMITIS
In the commencement should consist of ice-water
It may
compresses and the internal use of acon.
be necessary afterwards if hot fomentations and the
administration of the indicated remedies do not
relieve the severe pain, to resort to the subcuta-
neous injection of morphia in the temple, or what is
perhaps still more efficacious generally, the paracen-
tesis of the cornea. If the febrile symptoms will per-
mit, the patient should be allowed a most nourishing
diet, and perhaps a tolerably free use of stimulants.
It is of course often impossible to save the sight
of the eye, and indeed frequently any part of the eye-
ball, in these cases, but unfortunately it has not been
considered safe always to remove the eye in panoph-
thalmitis lest the suppurative process extend to the
brain. When the disease is foreseen and before
the suppuration has become general, enucleation of
the ball is probably the best course to pursue. Re-
cently the operation has been frequently performed
during the suppurative stage, and no harm to the brain
has ensued. Perhaps no danger is to be apprehended
unless the brain be previously affected.
Tubercles of the choroid have been detected by the
ophthalmoscope. They are seen as small circular
rose-colored or gray-white spots mostly in the neigh-
HYALITIS.
157
borhood of the optic disc. The disease coexists with
acute miliary tuberculosis. The vision is generally
normal. Tumors, ossifications, carcinoma, and sar-
coma are met with in the choroid occasionally, but
they are comparatively rare.
HYALITIS,
Or inflammation of the vitreous humor,* though
usually an accompaniment of disease of other struc-
tures of the eyeball, may nevertheless occur idio-
pathically. In simple hyalitis we notice with the
ophthalmoscope that the whole vitreous is clouded so
that the details of the fundus are indistinct, while
floating about in it are discovered delicate shreds of
various size and shape. Generally with this form
of hyalitis there coexists a retinitis, choroiditis, or
cyclitis.
A suppurative hyalitis supervenes upon suppura-
tive iritis or irido-choroiditis, and occurs after cataract
operations and injuries of the eye, and is sometimes
but the beginning of an ophthalmitis which destroys
the entire globe. The treatment of hyalitis must.
have reference to the primary seat of the disease,
which is in the choroid or retina. I have never met
with it in its idiopathic form.
Opacities of the vitreous are frequently due to
remains of effusions of blood or lymph, degenerated
* Galezowski asserts, in opposition to De Wecker, that the
hyaloid membrane only can become inflamed, as the vitreous
humor has no organized structure.
158
THE CHOROID AND VITREOUS.
fatty or pigmented cells, membranous débris of vari-
ous form and size. These opacities may be seen
with the ophthalmoscope in the upright image best.
Let the patient turn his eye in different directions in
quick succession and the opacities will be noticed mov-
ing slowly about across the pupillary field. Such
opacities must not be confounded with the phenome-
non called muscæ volitantes, usually a physiological
condition.
Muscæ volitantes are either transparent or opaque,
and are best seen by looking towards a white surface.
They are probably caused in most cases by overuse
of the eyes, and consist of the débris of cells, shreds
of tissue or fibre floating about in the vitreous, and
slowly changing their position with every movement
of the eye. They appear transparent and bead-like,
or in other cases shred-like or as dark queer shaped
bodies. Rest of the eyes should be enjoined, the
general health attended to, and, if very troublesome,
blue glasses may be worn which will render them less
apparent.
Hemorrhage of blood into the vitreous is not
very uncommon, either from disease of the coats of
the vessels, or as a result of a traumatic injury to
the choroid. It is sometimes distinguishable by a
red reflex, with the ophthalmoscope; at other times
the fundus is completely darkened, and cannot be
lighted up.
CYSTICERCI.
159
THE TREATMENT OF OPACITIES OF THE VITREOUS
Must be directed to the removal of the cause, which
will generally be found to be an irido-choroiditis, or
choroido-iritis, or some affection of the deeper struc-
tures of the fundus. I see no reason why ham.
should not prove an excellent remedy in diseases of
the choroid affecting the venous coats particularly,
and to this might be added arn., phosph., arsen.,
caust., sulph., and other of our remedies. Oc-
casionally fixed opacities of the vitreous have been
torn through with a fine needle, and the visual
powers of the patient improved by the operation.
Synchysis is the name for a fluid condition of the
vitreous, in which its gelatinous consistency is lost.
It is difficult to diagnose with certainty in all cases.
The free movement of opacities presupposes it, and
when vitreous is lost from a wound or during an
operation for cataract, we know that its loss is made
good by a fluid or serous substance. Sparkling
synchysis expresses a state of fluid vitreous holding
crystals of cholesterine, which present a very strik-
ing and characteristic appearance under the ophthal-
moscope. Their origin or mode of production is
undetermined.
CYSTICERCI IN THE EYE.
Graefe has had, in eighty thousand patients,
eighty cases of cysticerci in the vitreous or retina :
1
160
THE CHOROID AND VITREOUS.
three cases in which it was in the anterior chamber;
beneath the conjunctiva, five; and in the lens and
orbit, one each. The result, when the cysticercus
is deep seated, is the loss of the eye from inflam-
mation, and degeneration of the choroid and vitre-
ous. Von Graefe has occasionally succeeded in
saving the eye through the extraction of the para-
site, but the operation is very difficult when the ani-
mal is seated behind the lens. The original seat of
the cysticercus is usually beneath the retina, where
it may be seen with the ophthalmoscope as a grayish-
blue vesicle, and from whence it emerges later into
the vitreous.
CHAPTER IX.
GLAUCOMA.
THIS is one of the most dangerous of all the dis-
eases to which the eye is subject, and, without timely
surgical interference, generally terminates in blind-
ness, and, later, in complete degeneration of all the
tissues of the eye. It is not a new disease, but up to
the time of the invention of the ophthalmoscope it was
not much understood. No remedies, surgical or other,
having proved of much avail, it was quite natural
that an almost uniformly fatal disease, of which very
little in regard to its nature was known, should re-
ceive less attention than others better understood, and
which permitted of satisfactory alleviation or cure.
In 1854, Ed. von Jaeger, soon followed by Von
Graefe, gave accurate descriptions of the morbid
changes in the fundus occurring in the course of the
affection, which drew attention to the disease, the in-
terest in which was widely and quickly spread over
Europe when Von Graefe, in 1856, discovered a suc-
11
162
GLAUCOMA.
cessful surgical remedy for it in the operation of
iridectomy. Perhaps the most convenient and practi
cal way in considering the disease is, to divide it into
three forms, the acute, sub-acute, and chronic.
MONITORY
THE PREMONITORY SYMPTOMS
Of acute glaucoina are usually, first in order, an
increased tension (hardness) of the eyeball. This is
to be determined by touch, as previously described.
The subjective symptom of fulness and swelling, so
often felt in conjunctivitis, iritis, or scleritis, is not to
be mistaken for increased tension of the ball which
indicates the approach of an acute attack of glau-
coma. With this tension come its first legitimate
fruits, periodic dimness of vision, such as one may
produce by pressure of the finger upon the normal
eye, lasting for a few moments or hours, and a rapid
development of any previously existing presbyopia.
The pupil is somewhat, but not greatly, dilated; and
as a sequel of this there is constantly noticed by the
patient a halo or rainbow around a candle. The ring
around the light is at its outer side red; its inner,
bluish-green. There may be more or less ciliary
neuralgia over the eye, in the forehead, temple, and
face; but in my experience this symptom at this time
is very apt to be absent. The above premonitory
symptoms are all observable without the use of the
CONFIRMED GLAUCOMA.
163
ophthalmoscope, and may occur merely at intervals
of months; but gradually the intervals shorten, and
only weeks or days intervene between the recurrence
of the symptoms, and the next stage of the disease,
confirmed glaucoma, may be looked for.
Hereafter, though there are to be perhaps peri-
odic exacerbations, there are not to be, as in the
premonitory stage, any perfect intermissions. The
patient may be suddenly seized with a terrible neu-
ralgia over the eye, in the forehead, temple, face,
down the side of the nose, with severe constitutional
symptoms, high fever, nausea, and even vomiting;
so that the affection may be mistaken for severe bil-
ious or typhoid fever. In one case, I found the
disease had been diagnosed as an inflammatory affec-
tion of the brain. An examination of the eye, how-
ever, will correct the diagnosis at once. The lids will
be found puffy and swollen, the conjunctiva injected,
there is chemosis, more or less cloudiness of the
aqueous humor, discoloration of the iris, which
appears bulged forward almost against the cornea,
dilatation of the pupil, and decided tension of the
eyeball. Vision is always greatly impaired. I have
never known it wholly lost at this stage, although
this has not unfrequently happened. Patients will
generally see a hand held very near the eye, or be
able to distinguish the large gilt letters on the back
·
164
GLAUCOMA.
፡
of a bock. They are also disposed to speak of sud-
den flashes of light before the eyes, and perhaps other
spectral phenomena. The above, with some photo-
phobia and lachrymation, are the marked symptoms
observed in the beginning of confirmed glaucoma.
As the acute attack passes away, the sight will
grow better, and perhaps be almost wholly restored,
but the appearance of the eye with a modification of
the severe inflammatory aspect, remains. The at-
tacks recur, the sight being left after each in a worse
condition. The tension of the eye increases, the iris.
shrivels, the anterior chamber becomes still narrower,
the subconjunctival veins become turbid and tortu-
ous, the field of vision becomes very much contracted,
the sensibility of the cornea diminished, the so-called
green reflex is marked. I I say so-called green reflex,
because I find the green usually absent. The reflex,
to my eye, is simply slate-colored. No doubt it is
sometimes greenish. The peculiar hue is produced
in the glaucomatous eye of an elderly person by ad-
mixture or blending of the reflex from a brownish-
yellow lens, with a dirty bluish-gray aqueous humor.
The result is a very dirty greenish reflex, which to
me is scarcely green at all. There is sometimes a
bluish-green to be seen, but if one looks for a decided.
green reflex, such as is frequently noticed in the eye
of a cat, he will be disappointed. The diminished
i
THE OPHTHALMOSCOPIC SYMPTOMS.
165
sensibility of the cornea is easily determined by
touching it with a bit of paper twisted to a point.
THE OPHTHALMOSCOPIC SYMPTOMS,
In the premonitory stage, are wholly absent, or at
most, frequently of merely negative value, from
cloudiness of the aqueous humor. In the stage of
confirmed glaucoma, there may be more or less exca-
vation of the optic disc, dilation, and turgescence and
tortuosity of the retinal veins, and venous pulsation.
At a later stage of the disease we may find the arte-
ries thin and pale, arterial pulsation, hemorrhage
into and general cloudiness of the vitreous. The
large excavation of the optic nerve differs from the
physiological and amaurotic excavations, in size,
depth, and in the abruptness of its edge, in conse-
quence of which the retinal vessels, in curling over
the margin at the border of the disc, are much dis-
placed. Frequently, however, the media in glau-
coma are so turbid that nothing whatever can be seen
with the ophthalmoscope. Fortunately, when this is
the case, the other symptoms are so characteristic
that no error in diagnosis need occur.
Sub-acute glaucoma does not differ in character
from the acute. The symptoms are less severe, and
its course less rapid, but the end is similar. It is
not necessary to describe it.
166
GLAUCOMA.
Chronic inflammatory glaucoma is merely an ad-
vanced stage of the acute form when the exacerba-
tions having diminished somewhat in intensity, the
inflammation is fixed and gradually progressive, and
the sight gradually failing.
Chronic non-inflammatory glaucoma, sometimes
called glaucoma simplex, is very insidious in its
course, and of rare occurrence compared to other
forms of the affection. It has not very unfrequently
happened that patients have been unaware of the
existence of this disease in one eye, the other being
well, until it has completely destroyed the sight.
Generally the disease is far advanced before aid is
sought. Vision fails, glasses are not of service, there
may be a slight inflammatory attack, and they seek
surgical advice. Frequently the eye appears normal,
with perhaps the exception of a slightly dilated and
sluggish pupil. That constant and characteristic
symptom of glaucoma, increased tension of the
globe, is usually present, and the ophthalmoscope
will show a glaucomatous excavation of the optic
nerve. As the disease progresses, sooner or later
inflammatory symptoms are apt to be manifested,
as in the inflammatory forms previously spoken of.
Whether this be the case or not, the eye gradually
assumes the glaucomatous aspect as the globe grows
harder.
THE NATURE AND CAUSE OF GLAUCOMA. 167
Glaucoma fulminans is the name given by Pro-
fessor Graefe to a very rare form of glaucoma, the
most dangerous of all, in which the disease progresses
with such fearful rapidity, that the sight of a previ-
ously sound eye may be wholly destroyed in a few
hours, or even in half an hour.
Absolute glaucoma, as the disease is termed, when
all perception of light has disappeared, is frequently
distinguished at a glance by a pale-greenish opacity
of the lens. At this stage of the affection the patient
may suffer from severe attacks of ciliary neuralgia.
Later, the iris becomes completely atrophied, the
cornea opaque and softened, the choroid and retina
degenerated, and hemorrhagic effusion takes place
within the fundus, staphyloma of the sclerotic, and
frequently inflammation and atrophy of the globe
follow.
THE NATURE AND CAUSE OF GLAUCOMA
Are not yet fully understood. There is first an
affection of the iris, ciliary body, and the choroid,
then an increase of the humors of the eye, and
increased tension and excavation of the optic nerve ;
then the cornen, sclerotic, and retina become in-
volved. The fact that the sclerotic in this disease
is found rigid and unyielding, is supposed to be of
importance; for the disease attacks generally only
168
GLAUCOMA.
1
those of an age above thirty-five or forty, in whom
the sclerotic coat has already attained a firmness
and rigidity unknown in youth. An interesting
and perhaps rational theory, is that which attributes
the hyper-secretion of the fluids of the eye to some
abnormal irritation of the nerves controlling these
secretions, this irritation being reflex from the sym-
pathetic. This hypothesis makes the increase of
fluids the essence of the disease, and the conse-
quent tension of the globe the cause of the inflam-
matory symptoms. The interior tissues of the eye
become irritable and inflamed from this mechanical
pressure, and finally degenerate from disease and
lack of nutrition.
TREATMENT.
In the treatment of glaucoma during its premon
itory or very earliest stages, I have no doubt we may
do much better than our colleagues of the allopathic
school. When we reflect that in a great majority of
cases there coexist serious constitutional disturb-
ances, such as gout, rheumatism, functional or other
disease of the digestive organs, hemorrhoids; and, in
females, that the affection is apt to occur at the period
of cessation of menstruation, it seems almost impos-
sible to avoid the conclusion that the affection is
primarily extraocular; and that seen at the earliest
THE TREATMENT.
169
stage, a careful homœopathic medical treatment, com-
bined with strict hygienic regulations, might prove
curative. In estimating the effect of our remedies,
we must not overlook the circumstance that, with or
without treatment, an acute attack in the earliest
stage may repeatedly pass off leaving the sight unim-
paired. No doubt our remedies may prove very ser-
viceable in relieving or shortening the duration of an
attack, but, to be curative, they must prevent its re-
currence, just as the operation of iridectomy when
successful prevents its recurrence. In order to afford
remedies the best possible chance of proving of
permanent benefit, they should be administered also
during the period of intermission. We can only be
sure that the treatment is proving of real service
when we find that it reduces the hardness of the
globe. Whatever will reduce the tension of the eye-
ball in glaucoma will cure it. It is probably the
intraocular pressure that, long continued, produces
blindness.
In addition to the faithful and long-continued ad-
ministration of remedies, the habits of our patients
should be scrupulously looked after. Of course, a
most moderate use only of the eyes should be allowed;
bright lights and crowded places are to be avoided,
sunlight to be modified and deprived of its piercing
yellow rays by the use of light blue glasses when in
170
GLAUCOMA.
the open air, especially to be used to protect the eyes
from the sunlight upon the snow, white sand, or
water. In addition to this, all habits which affect
the general health unfavorably, such as excessive use
of tobacco, alcohol, or other stimulants, all dissi-
pations and exhaustive labor, mental or physical,
should be strictly prohibited, under penalty of loss of
sight.
The diet should be attended to, any idiosyncrasies
of the patient in this respect ferreted out, and indi-
gestible articles forbidden. The diet, however,
should be good and nutritious, and, particularly in
elderly persons, the confirmed habit of indulgence
in stimulants like tobacco, alcohol, tea, and coffee
should not be interfered with, unless it be necessary
to substitute moderation for excess.
Merc., I believe, to be one of the remedies upon
which reliance should be placed in glaucoma. It
would seem to be equally indicated whether the
complications be of hepatic, hemorrhoidal, or uter-
ine character. Ham., collin., arn., and nux v. will
often be useful where hemorrhoidal complications are
present. Kali iod. is, in my experience, always
useful in inflammations and congestions of the cho-
roid. Arsen., phyto., colch., macrot., spig., and bry.
may be serviceable for rheumatic and arthritic symp-
toms, and, with many other remedies, will be useful
1
OBSTACLES IN THE TREATMENT.
171
when indicated by symptoms apparently only re-
motely connected with the disease of the eye.
A serious obstacle to the success of the medical
treatment of this disease lies in the fact that patients.
rarely consult a physician until the disease is con-
firmed, and too great changes have occurred in the
fundus to be completely stayed through constitutional
means. Many patients sent to me are such as have
been completely blind for months, and sometimes
years. In other cases of complete blindness, an
operation is indicated simply for the relief of a tor-
menting neuralgia over the eye. No restoration of
sight is possible. Only now and then does a case
present itself at the most favorable time for a suc-
cessful operation. If we inquire into the cause of
the delay, we find that no attention whatever was
paid to the early symptoms; the attack was re-
garded as a headache, a rheumatism from cold, a
neuralgia in the head, or something else of a trivial
nature, and no advice was sought until after the
advent of a terrible attack of acute inflammation, or
until the sight was found permanently impaired, and
spectacles of no service.
It is very difficult to relieve the severe ciliary
neuralgia which occurs so often in acute attacks,
except by surgical interference. An iridectomy, and
frequently a simple paracentesis of the anterior cham-
172
GLAUCOMA.
!
ber, will relieve the pain as if by magic. Division
of the ciliary muscle will also relieve the pain, and,
like the others, accomplishes its result by removing
the intraocular pressure. Warm fomentations of
simple water or warm water medicated with bell.,
cham., or opium, are usually of some service. In-
ternally, I have administered mostly bell., spig.,
cham., con., macrot., merc., and val. of zinc during
the paroxysms of severe suffering.
SURGICAL TREATMENT.
Iridectomy in the early stages of glaucoma is
almost a certain cure for it. In the later stages, it
is always a palliative, and sometimes a cure. The
operation is painful, and usually performed under
the influence of an anesthetic. It is similar to the op-
eration for artificial pupil already described, except
that we enter the eye from the sclerotic near its
junction with the cornea, and the opening is as large
as the keratome or iridectomy lance will allow. The
large opening and the placing it in the sclera, are
for the purpose of excising a large segment of the
iris, and insuring the section to reach quite back
to the ciliary border. This has been demonstrated
to insure a more certain and permanent relief of the
intraocular pressure. A smaller iridectomy made.
through the cornea, as in artificial pupil, is not pro-
WHEN TO MAKE THE IRIDECTOMY. 173
ductive of permanent results. After the operation
the eye is simply bandaged, and the patient kept
quiet for a few days, until the corneal wound heals
and the artificially produced irritation is gone. Very
rarely is the reaction sufficient to call for the appli-
cation of cold compresses. The administration of
aconite, for a day or two, is always advisable after
the operation.
WHEN TO MAKE THE IRIDECTOMY.
An important point to be determined is the length
of time we may wait in case our remedies fail of the
desired effect before resorting to an operation. The
ready answer, and the true answer, to a question of
this kind is, the sooner the operation is performed
in a case of glaucoma the better. Delays are ex-
ceedingly dangerous. But the patient is not often
willing at the very commencement of the disease to
submit to an iridectomy, even if we happen to be
fortunate enough to be consulted thus early. As a
rule, then, he may safely postpone the operation so
long as the intermissions of congestion, pain, and
blindness are complete. When there is simply re-
mission instead of intermission the eye is in great
danger, and if vision is continuously impaired, and
especially if the field of vision is contracted, the
operation should be postponed no longer than is ab-
174
GLAUCOMA.
1
solutely necessary. We must, as before observed,
always bear in mind that with or without medical
treatment the subjective symptoms are constantly
changing, and that, while our measures may be
palliative, they cannot be curative unless they reduce
the abnormal tension (hardness) of the globe. In
the estimation of this tension we are to be guided
by our sense of touch, rather than by any sensations
of the patient. Both his eyes being closed, we press
very gently, either together or in alternation, upon
both eyeballs, determining their comparative hard-
ness, and comparing them in this respect, if neces-
sary, with our own.
The prognosis, when iridectomy is performed in
the premonitory or the very early stage of acute
inflammatory glaucoma, is favorable. Tension is
reduced, vision perfectly recovered, and the eye
restored to a healthy condition. In order that this
success should be nearly certain, the patient should,
before operating, be still able to see large print, and
the disease in its confirmed state ought not to be of
more than a week or two in duration. Still, success
may crown an operation in acute glaucoma when
vision is reduced to a mere perception of light, and
good sight be permanently restored.
In later stages of acute glaucoma, if vision be not
too much impaired, and the field of vision not much
THE PROGNOSIS.
175
contracted, permanent good results may be looked
for; but if the reverse of this obtains, the visual
field is narrow, sight very much impaired, and the
excavation of the optic nerve considerable, the result
of the operation, though good, and offering the only
chance for the patient, may not be permanent.
In subacute and chronic glaucoma we may expect
to prevent further loss of vision and preserve the eye
from future inroads of the disease, provided sight is
not wholly gone and the field of vision is not too
much narrowed. In these cases, indeed, vision
sometimes improves considerably; not rapidly always,
as after an operation in acute glaucoma, but after the
lapse of some months. In non-inflammatory glau-
coma the prognosis is not quite so favorable, unless
the operation be performed while there is still consid-
erable vision left. In glaucoma fulminans, per-
formed early, the operation has been successful.
In absolute glaucoma, when all perception of light
is gone, the operation of iridectomy is only indicated
to cure pain, and prevent the recurrence of the
inflammatory attacks. According to my own expe-
rience, it is almost certain to do this.
It is not surprising when we consider that the
operation of iridectomy offers a chance, however
slight it may be, of restoring sight even in old and
unfavorable cases, that it should often be performed
176
GLAUCOMA.
against all indications, and even against all hope, and
as a natural consequence that it should often fail.
This occasions disappointment, and sometimes dis-
trust of the value of the operation generally. It
must not be forgotten, however, that there are pretty
definite indications in the state of the patient's vision
which cannot be ignored, if we wish our prognosis
to prove correct, and that it is rather too much to
expect of any operation that it shall prove successful
when not indicated. It is not affirmed of the opera-
tion that it is a sure cure for glaucoma, but simply
that when indicated it is the only reliable cure for
glaucoma known at the present time, and that in a
vast majority of instances it has proved successful.
The rationale of iridectomy in this disease is not
demonstrated as yet. The theories advanced on this
point are neither remarkable nor attractive enough
to make it worth while to devote sufficient of our
limited space to their examination. We know that
iridectomy at its best permanently reduces tension,
but how it does this is still a question.
OTHER OPERATIONS FOR THE CURE OF GLAUCOMA
Are those of division of the ciliary muscle and
paracentesis corneæ. The first has not proved as
permanent and certain in its results as would be
desirable, and the second requires a too frequent
SECONDARY GLAUCOMA.
177
repetition to be generally feasible. Both of these
procedures are serviceable as has been stated, in
temporarily relieving ciliary neuralgia, and may
sometimes answer the purpose of relieving pain in
those old cases of glaucoma where the sight is irrev-
ocably lost, and nothing more than relief from intol-
erable suffering is hoped for. The operation for
division of ciliary muscle is described at page 309.
SECONDARY GLAUCOMA.
Glaucoma sometimes supervenes upon injuries of
the eye, and more rarely from deep-seated disease of
the globe, such as choroiditis or irido-choroiditis, sym-
pathetic ophthalmia, and other affections. It is to be
treated surgically, but the chances of success are
greatly lessened.
12
i
CHAPTER X.
THE RETINA AND OPTIC NERVE.
RETINAL HYPERÆMIA.
A hyperæmia of the retina is more readily diag-
nosed than a similar condition of the choroid. In
the active or arterial form there is some photophobia
and lachrymation. In the passive or venous form,
these are absent. In the first the ophthalmoscope
shows a reddened disc from congestion of the capil-
lary vessels upon its surface, and the larger retinal
vessels may be somewhat increased in size. It is
difficult to determine this, as in florid persons the
vessels appear larger and more active than in pale or
lymphatic individuals. If one eye only is affected
we can, by comparison, make our diagnosis quite
certain. In the venous or passive form the retinal
veins are dilated, dark, and perhaps tortuous. We
notice venous pulsation, or it can readily be produced
by pressure on the eyeball.
RETINITIS.
179
THE CAUSE AND TREATMEnt.
Very often in these cases we find some abnormal
state of the refraction or accommodation. I have
treated scores of such cases, and suitable glasses is
the remedy. It is caused also by exposure to bright
light or very fine work by artificial light, and a radi-
cal change of occupation will do much to promote a
cure. Very often there will be found disorder of the
heart, liver, or uterus as a cause. Cactus I find
admirable in retinal congestions, and especially when
heart troubles are present. Bell. and macrotin in
connection with uterine symptoms. Merc., leptand.,
bry., sulph., and nux v., when the liver is at fault;
and in other conditions I use opium, collinson., or
spigel. and conium. Blue or smoke-colored glasses
are advisable for out-of-door use, if the photophobia
is considerable. When the affection is very severe,
complete rest of the eyes should be enjoined.
RETINITIS.
In the serous form of retinitis we notice, with
the ophthalmoscope generally, a veiled or hazy appear-
ance of the retina, less marked at the macula lutea,
where the normal membrane is always of diminished
thickness, and more decided about the optic disc,
which is somewhat swollen from oedema, and its out-
180
RETINA AND OPTIC NERVE.
line rather indistinct.
The arteries are normal, but
the veins look dark and tortuous.
Nor are
Externally, the eye looks well. Perhaps the pupil
may be slightly dilated and sluggish; but, in my
experience, this is not usually the case.
there any of those symptoms of irritability of the
eye which are so often and erroneously supposed to
exist in iritis, such as photophobia, pain, lachrymation,
and the phenomena which accompany retinal hyper-
æsthesia. The causes of this affection do not differ
materially from those mentioned under the Affections
of the Retina, previously described, and the treatment
must be similar in character, but of course more
prolonged, and cannot, in many cases, result as suc-
cessfully. Our prognosis should be more guarded ;
for, from the beginning, the sight is more impaired.
The veil or cloud grows thicker until frequently the
patient is almost totally blind. Frequently, if the
disease continues many weeks atrophy of the retina
may ensue, and the sight be permanently destroyed.
The eyes should always be protected by dark-blue
glasses, and no use of them whatever for near objects
be permitted.
In retinitis exudativa, the deeper-seated or pa-
renchymous form of retinitis, the ophthalmoscopic
- appearances of the eye are much more striking. The
optic disc is reddish-gray, and its outline indistinct
RETINITIS.
181
and irregular, so that it is almost impossible to find
the line of demarcation between it and the retina.
The arteries are more or less diminished in size, and
the veins swollen and tortuous, and hidden here and
there by extensive exudations of a whitish or grayish
color, and blood extravasations are seen in various
parts of the retina. The above is an ophthalmoscopic
picture of a pathological condition in which the
inflammatory condition of the retina has produced
hypertrophy, stasis, proliferation of cells, colloid or
fatty degeneration and sclerosis; of course the ophthal-
moscope will not afford so complete a picture as the
above in all cases of the kind, but I have observed
on more than one occasion appearances almost exactly
corresponding to those described. Even in cases
nearly like the above, the blood stasis is sometimes
relieved, the exudations and extravasations absorbed,
and the patient may regain considerable vision to
remain permanently. This, however, is by no means
the usual course. It more frequently ends in atrophy
of the retina and optic nerve. Vision during the pro-
gress of the affection is often tolerable until the region
of the macula lutea is invaded. Micropsia is often
noticed; that is, all objects appear smaller than they
really are. If you ask the patient to draw a given
circle, he invariably draws it smaller than the reality.
This is the result of a derangement in the position
182
RETINA AND OPTIC NERVE.
་
of the rods and cones of the inflamed retina upon
which the image is caught.
THE CAUSE AND TREATMENT.
The cause is frequently a neglected hyperæmic
condition of the retina and optic nerve, disease of
the heart, of the abdominal viscera, pregnancy,
Bright's disease, diabetes, syphilis, or cerebral af-
fections. The treatment should be directed to the
removal of the cause when this can be ascertained.
When of syphilitic origin, the treatment will be more
apt to result favorably than in cerebral or Bright's
disease. Merc. should, I think, be relied upon to
meet the retinal in lications in this form of the affec-
tion, and arsen. and zinc for the nephritic variety,
using such other remedies temporarily as the state of
the patient's health or any special symptoms may
require. Hygienic rules should receive the greatest
attention, and the eyes must always be protected
from bright light by the use of colored spectacles.
With the wisest treatment in every respect, the result
will often prove unsatisfactory.
BRIGHT'S DISEASE OR RETINITIS ALBUMINURICA.
The ophthalmoscopic appearance of the eyes in
Bright's disease does not differ very much from that
already described, except at a later stage of the affec-
RETINITIS ALBUMINURICA.
183
tion, when we sometimes find around the optic disc
a broad, white ring, and in the region of the macula
lutea small stellated white spots, which are later
merged in the general exudation.
The pathological changes are principally the
serous infiltration of nerve and retina,
the fatty
degeneration making the white patches, hypertrophied
and sclerosed nerve fibres, giving rise to a striated
appearance of the fundus under the ophthalmoscope,
capillary hemorrhages, due either to disorder of the
circulation from hypertrophy and dilatation of the left
ventricle, which is almost always present in Bright's
disease, or to disease of the coats of the vessels.
Sight is very much impaired, although the extent
of the field of vision is not limited greatly. Certain
portions of the field are generally faulty, and of
course vision is rarely very acute. Sudden amaurosis
is liable to occur in this disease from uræmic poison-
ing. The patient becomes suddenly blind, and suffers
from headache, vertigo, sickness, convulsions, and
other general symptoms of uræmic poison.
Why disease of the retina and kidney so uniformly
coexist is not known. It has happened not unfre-
quently that failing sight, and the consequent ophthal-
moscopic examination of the fundus of the eye, has
led to the detection of disease of the kidney, con-
firmed by later microscopical examination of the
184
RETINA AND OPTIC NERVE.
urine. As a rule, nephritic retinitis does not lead to
complete loss of sight; but normal vision, in cases
of any severity, is not always regained. The amount
of vision retained will finally be determined by the
extent of disease of the nervous structure of the
retina. If this has been great it may lead to atrophy
and blindness. The prognosis is, of course, most
favorable in albuminuria after fevers or in pregnancy.
The treatment, as far as the eye is concerned, will be
merely hygienic, and medication must be directed to
the cure of the primary seat of the disease, the kid-
ney.
SYPHILITIC RETINITIS, OR CHOROIDO-RETINITIS,
Does not present so characteristic a picture for the
ophthalmoscope, and the history of the case with the
constitutional symptoms sometimes require to be con-
sulted before the diagnosis is rendered certain. The
appearance of the fundus is striated, and similar to that
in retinitis albuminurica, but not so well marked. The
stellated spots in the region of the macula lutea appear
and disappear rapidly, and the vision improves and
retrogrades correspondingly. Extravasations of blood
are not usually noticed. The pathological changes
are serous infiltration of retina, inflammation and de-
generation of the choroid, but fortunately the nervous
structure of the retina is less apt to be impaired, and
our prognosis is therefore favorable, and especially so
RETINITIS APOPLECTICA.
if the disease comes early under treatment.
185
The
disease is usually coincident with the constitutional
symptoms of secondary syphilis, and the treatment
must be directed to the removal of the constitutional
affection. The retinitis progresses very slowly, and
the patient is often troubled by relapses. The visual
disturbance presents very nearly the same features as
in retinitis nephritica. The choroid is usually in-
volved, and the treatment recommended for choroid-
itis will generally be applicable in this form of
retinitis.
IN RETINITIS APOPLECTICA
There is great tendency to extravasations of blood,
which are sometimes so extensive as to hide partially
the vessels of the retina, and the infiltrations are
slighter, and serous in character. The sight is not so
much impaired as the ophthalmoscopic appearance of
the eye would indicate, unless the hemorrhage is situ-
ated about the yellow spot. The disease shows great
tendency to relapses, and if hemorrhages recur often,
and are at all extensive, our prognosis is not so favor-
able as otherwise. Apoplexy of the retina is caused
by disturbances of the general circulation, frequently
due to tumors within the orbit or cranium, which pre-
vent the return of venous blood from the eye. Hy-
pertrophy of the left ventricle or disease of the aortic
valves, is not a very unusual cause.
In elderly per
186
RETINA AND OPTIC NERVE.
sons, degeneration of the coats of the retinal vessels
may be the cause. It would be very difficult to state
the precise treatment to be adopted in such cases.
The general health should be made as perfect as possi-
ble, and the patient should, of course, be scrupu-
lously correct and regular in his habits. Further
than this, the general aspect of each case must deter-
mine the course to be pursued in regard to medicine,
diet, change of air, climate, and the like.
RETINITIS PIGMENTOSA,
As its name indicates, is an inflammation of the
retina characterized chiefly by great pigmentation.
The ophthalmoscope reveals the disease at a glance.
The retina is covered by large irregular patches of
pigment, more at the periphery of the fundus where
the deposit commences first. The veins are enlarged,
the arteries diminished in calibre, the choroid becomes
degenerated, so that its vessels are visible, and
even the glistening sclera may often be seen shining
through it. In such a case the fundus presents a
wonderfully mottled and parti-colored picture under
the ophthalmoscope.
The striking subjective symptom in this affection is
night blindness. This is the result of a torpid condi-
tion of the retina, produced by the insufficient supply
of blood through the narrowed vessels, in consequence
DETACHMENT OF THE RETINA.
187
of which the retina requires a bright light to receive
the impression of objects. This disease must not be
confounded with a functional disorder of the retina
called hemeralopia, or night blindness, mentioned
under Amblyopia. The field of vision is often very
much diminished in extent, so that while in a direct
line one may still read fine print, all around may be
involved in darkness.* The disease is generally con-
genital, or hereditary, and sooner or later leads to
blindness. It often occurs in marriages of consan-
guinity and with deaf-mutism. Treatment can only
be palliative, but this may undoubtedly postpone
blindness for years. The patient's general health
should be kept in the best possible condition, and
above all, the eyes should be spared fatiguing occupa-
tions, and guarded from bright light and heat.
DETACHMENT OF THE RETINA
Is occasioned by serous effusion between it and the
choroid. It most frequently occurs in the lower half
of the fundus, and commences at the periphery.
With the ophthalmoscope we must look for it always
by direct examination. The light need not be very
* In a patient of mine, a student of Harvard College, the extent of
the field of vision is so limited at the distance of one foot, that its size
is just about realized with a normal eye, in looking through a tube
eight inches in length and a half inch in diameter.
188
RETINA AND OPTIC NERVE
strong. Notice that the bright red of the fundus is
only seen at the upper part of the pupil; all below
is dark; or perhaps you catch the illuminated part of
the pupil only after directing the patient to turn his eye
in different directions. Do not approach the eye too
nearly, and you will see by carefully regarding the un-
illuminated part of the pupil, and apparently almost in
contact with it, a grayish-blue cloud which undulates
with every movement of the eye. For lack of the
simple precaution of using the upright image, and re-
garding the eye from the distance of twelve or fifteen
inches at first, I have known an excellent ophthalmo-
scopist to overlook a large detachment of the retina.
Once having made the diagnosis, we may examine the
details with either the direct or reversed image. We
find the floating opacity or retinal cloud crossed by
dark, shrivelled, crooked vessels. Slight degrees of
detachment of the retina are much more difficult to
diagnose. This is sometimes best accomplished by
commencing with a retinal vessel at the optic disc and
following it towards the periphery, where we may
detect a change to a darker color, and a tortuousness
in its course; and we make out at the same time a
slight fold in the retina.
Vision is, as a matter of course, very much im-
paired. That portion of the retina separated from
the choroid by serous effusion, no longer performs
DETACHMENT OF THE RETINA.
189
its function; but the part which maintains its con-
nection with the choroid performs its function as
usual. Hence it happens that the upper part of the
field of vision is entirely obscured, or, if the detach-
ment happen to have occurred in the upper part of
the fundus, the obscurity is in the lower part of the
visual field. Impaired vision is first noticed by the
patient as a delicate cloud with indistinct wavy out-
line, at that point in the field of vision corresponding
exactly to the situation of the effusion beneath the
retina in the fundus. Linear objects appear wavy
and broken, due, probably, to the disturbed connec-
tion of the retina at the edge of the detachment.
The cause of the disease is sometimes difficult to
determine. It is frequently occasioned by a blow on
the eye. In a patient of mine, during the past year.
it could be traced directly to a fall a few months
previous. It is due, not unfrequently, to hemor-
rhage in disease of the choroid or retina. The
commonest cause is, perhaps, the elongation of the
optic axis, as seen in myopic patients. The choroid
adheres to the sclera, and is distended with it; but as
the less elastic retina is not, its connection with the
choroid becomes weakened, and any effusion finds its
way easily beneath it.
The prognosis is unfavorable, as the separation
generally goes on until the eye is rendered blind.
190
RETINA AND OPTIC NERVE.
Fortunately it is, in a vast majority of instances, con-
fined to one eye. Sometimes, however, the disease
ceases to progress after reaching a certain point, and
the sight may improve; and if the detachment is not
too extensive, sight may be wholly restored through
the absorption of the exudation and reunion of the
retina and choroid. I have no doubt that, under favor-
able conditions for proper medical and hygienic treat-
ment, this result might often be reached. I have had
no opportunity of testing the effects of judicious treat-
ment of the five cases which I have had in private
practice, three were old and incurable, and the others
lived too far away to be under my control. The
general health would guide us chiefly in the selection
of internal remedies, but I have no doubt that merc.,
ars., hepar, kali iod., and some other of our reme-
dies, might exercise a controlling influence over the
affection.
Surgically, the disease is treated by puncture of
the retina, allowing the fluid to escape into the
vitreous, or to be drawn from the eye. The punc-
ture is made through the sclera at a point corre-
sponding to the detachment, with a sharp needle or
with a minute trocar. Temporary improvement usu-
ally follows, and sometimes the improvement in vision
has been known to continue several months, and, in
a few instances, one or two years.
GLIOMA RETINÆ.
191
"
GLIOMA RETINÆ
Is the name given by Virchow to a tumor
originating in the retina, and occurring mostly in
young children, known generally by the name of
encephaloid disease or fungus hæmatodes. In the
commencement of the affection, the eye appears
healthy externally, and there is no pain. The pupil
is, however, more or less dilated, and the sight of the
eye is gone. The disease is readily diagnosed with
the ophthalmoscope at this stage; a circumscribed
portion of the retina is mottled, opaque, and thickened
in appearance. Soon the growth protrudes as a yel-
lowish-white mass into the vitreous humor, and its
vascular character in all its detail is observable.
Rapidly now the growth increases, pushing before it
the lens and iris, augmenting the intraocular pressure
and pain, the cornea or anterior portion of the sclera
bursts, and the tumor increases still more rapidly.
It assumes later a dark hue from exposure to the
atmosphere, exudes a sanious fluid which becomes
incrusted on its surface, and bleeds easily.
The prognosis is always grave, and especially so
if the disease is in an advanced stage. If the patient
is seen early, the eye should be immediately enucle-
ated, as cases are recorded where, after the lapse of
several years, the disease has not returned. The
192
RETINA AND OPTIC NERVE.
optic nerve, in performing the operation, should be
excised far back near the optic foramen, so as to
include the whole of the diseased portion, if possible.
Even after the tumor has burst through the eye an
operation will give the only chance of prolonging
life, and will certainly alleviate a great amount of
suffering. The tumor breaks through, and appears
externally in from one to three years from its com-
mencement.
The cause of glioma is often very obscure. It
occurs most frequently in children from two to ten
years old. It is sometimes complicated with cerebral
disease, as evidenced by headache, drowsiness, stu-
por, or paralytic symptoms. It is often hereditary.
I have seen two of four children of the same mother
affected by it.
Ischemia retina is a name given to an extremely
anæmic condition of the retina, which has been
noticed a few times, and has been cured by removing
the intraocular pressure by paracentesis of the cornea
or by an iridectomy.
Complete paralysis of the retina and total blind-
ness have been observed after blows, and after a stroke
of lightning. The ophthalmoscope does not always
reveal the great change which one might expect to
find under such circumstances.
Embolism of the central artery of the retina 13 a
NEURITIS OPTICA.
193
rare disease. I have noticed the publication of only
one case in this country. The loss of sight in these
cases is sudden, and almost total. The ophthalmo-
scope shows a pale optic disc, transparent however,
and the vessels running over it much attenuated.
The arteries of the retina are very small, and partially
bloodless, so that at certain points of their course they
appear like white threads. The veins of the retina
present a somewhat similar appearance, though less
strongly marked. Later, a bluish opacity is observ-
able in the region of the macula lutea. The disease
is sometimes, but not uniformly, accompanied by
valvular disease of the heart. Probably the class of
remedies indicated in cardiac affections might fre-
quently be of service in this disease. Patients re-
cover, in exceptional cases, sufficient sight to be able
to read with the affected eye.
OPTIC-NEURITIS.
Optic-neuritis, or neuro-retinitis, is the name
given to a condition in which the optic nerve is the pri-
mary seat of the inflammation. This condition is very
often connected with disease of the brain. Vision is
generally greatly impaired, and in a large number of
instances, atrophy of the retina and optic nerve and
blindness ensue. This sad termination, however, is
not always certain. Even when the affection is
1
13
194
RETINA AND OPTIC NERVE.
cerebral in origin the sight may remain unimpaired.
A good prognostic symptom is afforded by testing
the extent of the field of vision. If this is dimin-
ished in extent we may expect more or less atrophy
of the nerve.
When the affection comes from the
brain, there will usually be cerebral symptoms pre-
ceding, such as headache, giddiness, vomiting, failure
of memory, loss of taste, hearing, smell, convulsive
or paralytic attacks. In all cerebral fevers optic-
neuritis should be looked for with the ophthalmo-
scope, because it may exist for some time before
vision is sufficiently impaired to direct our attention
to the eye. In all suspected disease of the brain, of
whatever nature, the ophthalmoscope should also be
resorted to as an aid to diagnosis.
The ophthalmoscopic symptoms in the beginning
are a hyperæmia and oedema of the disc, which is
reddish, its outline indistinct, and afterwards quite
indefinable, loss of its transparency, while the effu-
sion of lymph in the optic nerve gives it a striated
and woolly aspect. The inflammation extends to the
retina, rendering it hazy, its veins dark and tortuous,
its arteries shrunken so as hardly to be visible, the
vessels here and there hidden in their course beneath
the infiltration. Around the disc are blood extrava-
sations, and the exudations upon the disc itself are
sometimes so considerable that the vessels upon it are
195
I
nerve,
A CASE OF OPTIC-NEURITIS.
completely covered, and can only be traced to its mar-
gin, followed from the retina. Although both nerve
and retina are usually involved, when the origin of
the affection is cerebral, it is more limited to the optic
a neuritis rather than a neuro-rctinitis.
The disease does not always, fortunately, present
so unfavorable an aspect as this. In young and
delicate females, for instance, it is much less grave
usually, and the prognosis, when they come early
under care, is more favorable. These cases are not
cerebral, and indeed the patients are sometimes other
wise in good health. Generally, however, there is
catamenial disorder, more or less spinal irritation,
and abnormal sensibility of the central nervous sys-
tem. In a case of this kind under my care two
years since, that of a young girl of seventeen, from
New Hampshire, there were no catamenial trou-
bles, but considerable spinal irritation in the region
of the lower cervical vertebræ. She suffered also
from congestive headaches in the forehead and tem-
poral region, general irritability with perhaps slight
attacks of hysteria. She was perfectly healthy look-
ing, well formed, but not very robust. When she
came to me vision was very imperfect. Jan. 5,
1867, she reads No. 8 print with the right eye and
only No. 13 with the left. There is hyperæmia of
the optic disc in both eyes, and in the left fundus, the
196
RETINA AND OPTIC NERVE.
disc and its immediate vicinity are slightly obscured
by a delicate reddish-gray haze. The pupils are
abnormally dilated, but not much sluggishness is
observable in their response to the action of light.
Field of vision nearly normal in extent. Photophobia
not marked, and no pain in the eyes. Bell. and merc.,
in alternation, were prescribed. Jan. 24. - Patient
about the same in general health. Sight of right
eye the same; of the left, a little worse. Acuteness
of vision with the best eye about one-eighth; that is,
print that a normal eye could read at twenty-four
feet she could only read at three feet. Partly owing
to her obstinate attacks of congestive headache, I
prescribed cactus and sanguin. in alternation night
and morning. March 6.— Her headaches are less
frequent and violent, and her sight in the right eye
has improved. Acuteness of vision about one-quar-
ter. The left eye is no worse: continued medicine.
March 27.- Better: acuteness of vision three quar-
ters. Left eye better. May 17.-She can read
No. 1 test type with either eye. General health very
much improved. The cause of the disease in this
case was very obscure. Fortunately the affection
in the left eye did not progress so far as to occasion
any structural alterations in the nervous element of
the retina. A rather curious feature of the case re-
mains to be stated. More than seven months after
i
PROGNOSIS IN OPTIC-NEURITIS.
197
she passed from under my observation she called on
ine, stating that her eyes had remained well, but that
she believed she was getting near-sighted. On ex-
amination I found a myopia of about one-twelfth, for
which concave glasses, of fourteen-inch focus, were
prescribed. It would seem that this myopia should
be the result of a sclerotico-choroiditis posterior,
but I saw no ophthalmoscopic indications of the
existence of this affection. Eleven months later, on
Dec. 3, 1868, my patient visited me again to see if I
thought her glasses the proper ones for her to wear.
She had recently begun to find some fatigue of the
eye in wearing them. I found her myopia less, and
substituted glasses of twenty-four inch focus.
In most cases of neuro-retinitis, however, the prog-
nosis should be very guarded. It will be most favor-
able, of course, when the affection can be traced to
disorder of the uterine or some other important func-
tion that admits of a cure, and also in cases that
supervene on convalescence from febrile disorders, es-
pecially if in these instances the ophthalmoscope does
not show great or dangerous change of appearance
in the optic nerve or retina. Neuritis descendens as it
is sometimes called, when it arises from intra-cranial
causes, generally terminates sooner or later in total
blindness. Generally speaking, it has been noticed
that when the progress of the disease and loss of
198
RETINA AND OPTIC NERVE.
:
sight have been rapid, the prognosis is more favor-
able than when the progress and loss of sight have
been gradual. In relation to the medical treatment,
it must of course vary according to the cause, the
general health of the patient, and the exigencies of
each individual case. Other things being equal, I
should trust sooner to merc., ars., zinc, aurum, kali
iod., and phosph., than to bell., nux, cactus, gel-
sem., con., spig., macrot, and crocus, although the
last mentioned will, some of them, be called for as
intercurrents in many cases.
ATROPHY OF THE OPTIC NERVE,
Amaurosis, cerebral or cerebro-spinal amaurosis.
I limit the signification of the term amaurosis to
primary disease or degeneration of the optic nerve.
(See chapter. on Amblyopia.) A marked symptom
of amaurosis, noticeable at a glance, is the dilated
and sluggish pupil, and generally, when the eye is
quite blind, its complete immobility. Exceptionally
the pupil retains its activity, and, in spinal amauro-
sis, it may even be contracted.
*
The ophthalmoscopic appearances of the fundus
are very characteristic. The nerve disc is pale, from
the attenuation or disappearance of the small nutrient
vessels on its face, there is bluish or bluish-green dis-
coloration, especially seen in spinal amaurosis, the
THE FIELD OF VISION IN AMAUROSIS. 199
transparency of the disc is lost, its outline is clear
and distinct, the retinal vessels are generally dimin-
ished in size, notably the arteries, and there is fre-
quently an excavation of the optic nerve. This
excavation must be distinguished from a very slight
physiological one, which is congenital and often seen
in the normal eye, situated at the centre or a little
towards the temporal side of the disc. In the phys-
iological excavation of course none of the symptoms
of atrophy above mentioned obtain, the nerve being
in its normal condition. In the atrophic excavation,
which is shallow, its edges are gradually sloped, quite
unlike the abrupt margin of the glaucomatous exca-
vation described under Glaucoma. Hence the retinal
vessels, in passing into the cavity from the normal
surface of the disc, do not appear under the ophthal-
moscope as if displaced, as in glaucoma, but describe
simply a curve. Sometimes in the physiological ex-
cavation this curve may also be abrupt enough to give
a vessel the appearance of displacement.
The patient's sight is more or less impaired, and
the field of vision contracted. The proper investiga-
tion of the extent and nature of the limitation of the
field of vision is of the utmost importance in this
affection as determining our prognosis. The contrac-
tion of the visual field usually commences at the
temporal side, but in glaucoma, at the nasal side.
200
RETINA AND OPTIC NERVE.
The contraction of the field may be symmetrical in
both eyes, or it may be equilateral; that is, at the
temporal half of one and the nasal half of the other.
The former is very unfavorable, the latter sometimes
a very favorable, symptom. It must be remembered
that the optic nerve fibres decussate at the optic com-
missure, so that the right nerve passes partly to the
temporal or right side of the retina of the right eye,
and to the nasal or right side of the retina of the left
eye, while the left optic nerve supplies the left half
of the two retinæ in a corresponding manner. Now,
if the temporal side of each field of vision is limited
the disease must be seated at the commissure, and
this augurs a bad termination. Blindness often
comes on very rapidly. But if the field of vision is
contracted equilaterally, total blindness is pretty
certain not to ensue, indeed rarely or never ensues,
unless the disease extend afterwards to the commis-
sure or some new cerebral symptoms manifest them-
selves.
The patient is also apt to be troubled with dark
spots before the eyes. If such a scotoma happen to
be seated directly in the axis of vision it proves quite
troublesome to sight.
THE CAUSE OF AMAUROSIS
Is sometimes very obscure. Meningitis of the base
of the brain is a frequent one, especially in its chronic
THE PROGNOSIS IN AMAUROSIS.
201
form, as is also periostitis at the base of the brain.
Tumors of the brain, through implication of, or press-
ure upon, the optic nerve cause progressive atrophy.
Disease of the spinal cord may produce the same
through the medium of the sympathetic.
Atrophy of the nerve presenting ophthalmoscopic
appearances characteristic enough to warrant the
name of tobacco amaurosis, has been thought by
some to exist; but it is by no means proved as yet
to differ sufficiently from atrophy due to the excessive
use of alcohol, and other enervating habits, to war-
rant its name. The absorption of lead into the
system has been known to produce atrophy of the
optic nerve, but consecutive upon neuritis-optica.
THE PROGNOSIS
In atrophy of the optic nerve is bad enough;
but, as has been observed, the condition of the field
of vision frequently holds out hopes of a not too
unfavorable termination. Sudden accession of blind-
ness is not to be considered an unfavorable symp-
tom, especially in children. It is favorable if the
disease remains stationary for a considerable time,
and bad if it manifest a slow, but certain progress.
If the visual field is not contracted after the affection
has continued for some time it is a favorable sign, as
is likewise the fact of the line of demarcation between
202
RETINA AND OPTIC NERVE.
the good and bad of the field, being very distinct.
Irregular contractions of the visual field occurring
simultaneously or in quick succession in both eyes.
are unfavorable. Central scotoma are unfavorable
if the visual field is much contracted, otherwise not
particularly so. When the field of vision beyond the
scotoma is impaired it shows a lack of the power of
transmission on the part of the retina, and progres-
sive atrophy is to be feared. All auxiliary or ac-
companying symptoms are of great importance,
because it is quite impossible to decide from the
appearance of the optic nerve alone, whether in
many cases the atrophy be progressive or stationary.
The medical treatment must differ so much in differ-
ent cases that I do not know that I can do more than
refer the reader to the indications and remarks in re-
gard to treatment made under the head of Neuritis-
optica.
Recently, Dr. Driver, of Chemnitz (Archives of
Ophthal. and Otol., vol. iii. No. 1), has used the
constant current in cases of neuro-retinitis, amblyopia,
and progressive atrophy, more or less successfully.
Hypodermic injections of strychnia have also been
used with benefit.
CHAPTER XI.
AMBLYOPIC AND OTHER AFFECTIONS.
AMBLYOPIA.
THIS term, strictly speaking, is limited to those
cases of imperfect vision in which the affected eye
presents no recognizable objective symptoms, with or
without the ophthalmoscope, and in which the im-
paired vision is not due to anomalous refraction, as
in hypermetropia, myopia, and astigmatism.
In a general way, the term amblyopia is used to
express impaired sight from any and every cause ex-
cept that of optical defect. Thus we say, if we find
that no glasses improve the acuteness of vision, that
the patient is amblyopic,
nothing more definite than that the blindness is not
to be attributed wholly to abnormal refractive power,
and that some disease of the fundus of the globe is
present.
meaning by the remark
DIAGNOSIS OF AMBLYOPIA.
A simple, practical, and quite reliable method of
diagnosing amblyopia, as well as other diseases of
204
AMBLYOPIC AND OTHER AFFECTIONS.
ì
the eye, involving loss of vision, from those of anom-
alous refractive power, requiring only proper glasses
for their cure, is by the easy device of permitting the
patient to look through a large pinhole in a black-
ened card. If this improves vision, refraction is
faulty, and will be corrected by suitable glasses. If
vision is not improved, the loss of visual power must
be sought in some of the inner structures of the eye,
and an ophthalmoscopic examination will be neces-
Of course nicer methods than this to determine
faulty refraction, when the requisite concave and con-
vex glasses are at hand, are those mentioned in the
chapter on Anomalies of Refraction; but the requisite
glasses are frequently not at hand in the office of the
general practitioner, and the above test of Giraud
Teulon will prove very convenient.
sary.
In a recent number of the "American Journal
of Medical Sciences," Dr. Thomson shows how this
test may be made to indicate the exact nature of a case
of anomalous refraction. In looking through the pin-
hole at a gas-light at twenty feet distance, if the eye
is ametropic (of defective refractive power), when
the card is moved rapidly before the eye, the light
will seem to dance. If the eye is emmetropic, the
light will remain steady. In testing the eye of a
patient in this way I found that the dancing of the
light was removed by permitting him to look through
DIAGNOSIS OF AMBLYOPIA.
205
No. 16 concave glasses, those appeared to render
his eye emmetropic. His eye was myopic. In
another instance the light danced when the card was
moved up and down, but not when it was moved
horizontally. This indicated ametropia in the vertical
meridian, and it was found by trial that a concave
cylindrical glass, No 36, the axis horizontal, reme-
died the defect. The case was one of simple astig-
matism. With two pinholes, one-eighth of an inch
apart in the card, an emmetropic eye will see one light,
an ametropic eye, two. In myopia, the second image
will be at the right, in hypermetropia, at the left. In
the case of the myope just mentioned, by covering one
of the pinholes with a red glass he saw the red flame
about eight inches at the right of the yellow, at a
distance of forty feet. Through his No. 16 concave
glass the red and yellow flames were one. In the
case of astigmatism mentioned above, with the two
holes held one above the other, at a distance of forty
feet, he saw the red flame about four inches above the
yellow. His cylindrical glass nearly fused the two
images. In determining a hypermetropia by this
method it will frequently be necessary to first paralyze
the accommodation with a solution of atropine. An
emmetropic eye may easily be made to test the cor-
rectness of these various methods by placing before it
a convex glass which renders it myopic, or a concave
206
AMBLYOPIC AND OTHER AFFECTIONS.
glass when it becomes hypermetropic, or a cylindrical
glass which renders it astigmatic.
CAUSE AND TREATMENT OF AMBLYOPIA.
Temporary congestion of the brain and nervous
structure of the eye may be occasioned by suppression
of exhalations from the skin through exposure to
the cold or wet, by suspension of the catamenia, and
by large doses of quinine or other drugs, the result
of the congestion being dimness or entire suspen-
sion of vision. The reverse of this, a diminished
supply of pure blood to the brain and retina, will also
produce amblyopia. This enfeebled condition may
be due to severe illness, excessive drain on the system
through hemorrhage, discharge from the uterus,
gestation, too long suckling, and like debilitating
causes.
In such instances of impaired vision we should not
neglect an ophthalmoscopic examination. Our prog-
nosis will be uncertain unless we can first establish a
correct diagnosis. This cannot always be done, but
it can often be done. The fact that the ophthalmo-
scopic examination frequently yields but negative
results is of itself a favorable omen for the prognosis.
Sometimes the examination of the interior of the eye
reveals enough to make the future of the patient ex-
tremely doubtful. A few days since a case of ambly-
CAUSE AND TREATMENT OF AMBLYOPIA. 207
opia from pregnancy at the eighth month, was sent
to me, and on examination I found an optic neuritis
with considerable effusion in the retina. The prog-
nosis needs to be extremely guarded in such instances.
Less perceptible changes than this in the fundus of
the globe are followed by permanent impairment of
vision. A number of cases have been published in
which the blindness of pregnancy has terminated
unfavorably. The significance of the different limi-
tations of the field of vision is noticed under Atrophy
of the Optic Nerve.
We have many remedies suitable for congestion
to the nervous tunic of the eye. Cactus I have
often given with favorable results in hyperemia of .
the retina. Bell. and macrot. I have also given fre-
quently, and less often puls., bry., sang., phosph.,
glon. and opium. Generally these remedies have
been administered with reference to the cause and to
the totality of symptoms, including those of the eye.
For instance, in menstrual suppression, puls.; in
rheumatic cases, bry. ; complication of heart troubles,
glon., cactus; severe throbbing headache, sang.;
rush of blood to the head and epistaxis, phosph. Hot
pediluvia are sometimes serviceable, and the judicious
use of the Turkish bath will benefit disordered func-
tion of the skin. That the Turkish bath will also
diminish the flow of blood to the brain has been
208
AMBLYOPIC AND OTHER AFFECTIONS.
proved by ophthalmoscopic examination made before
and after the bath.
In those cases clearly due to impoverished state
of the blood, chin., ferr., arsen., phosph., and other
remedies will be indicated; but in addition to the
appropriate medicines, a nutritious diet and sufficient
rest and sleep should be prescribed. Hemorrhage
and all unusual drains on the vitality of the patient
must be controlled before improvement can be looked
for.
Amblyopia from fright or mental shock might
undoubtedly be treated successfully by remedies such
as ignat., coff., hyos., or the new ones, cyp., scut.,
and others.
Blood poisoning, from drugs like lead, and nar-
cotics like alcohol and tobacco, will produce ambly-
opia. Total abstinence from alcohol and tobacco
would seem to be the only course for such as cannot
draw the line between a stimulating and narcotizing
use of these substances. Drug poisoning requires a
specific line of treatment for each case; lead poison-
ing is said, recently, to be successfully treated by
opium, through the hypodermic injection of morphia.
Amaurosis may be the direct result of blood poison-
ing, but even in blanching and apparent atrophy of
the optic nerve, a very grave symptom indeed, there
are many cases recorded in which a more or less per-
CAUSE AND TREATMENT OF AMBLYOPIA. 209
fect recovery of vision is known to have taken place
after the lapse of months or years of blindness.*
Dental neuralgia sometimes impairs vision,
through reflex irritation from a branch of the fifth
nerve. Removal of the offending tooth generally
cures.
The exclusion of an eye from participation in
vision is a very common cause of unilateral ambly-
opia. Of several hundreds of cases of strabismus in
which I have tested the acuteness of vision or seen it
tested by others, I recall few in which a certain de-
gree of monocular amblyopia was not present. This
subject is discussed more fully under the head of
Strabismus. The cure for amblyopia produced in
this way is, in exercising the eye regularly, either
with or without a convex glass, according to the
degree of vision still left it. The eyes of children
become amblyopic much sooner when excluded from
participation in sight than those of adults.
Temporary, and indeed persistent, amblyopia is
sometimes due to disorders of digestion from impaired
functional or other disease of the stomach or liver.
These affections cause, through the medium of the
sympathetic nerve, some disturbance in the nervous
structure of the eye whereby vision is impaired. The
* Vide "Royal London Ophthalmic Hospital Reports," Vol. VI.,
Part iii.
14
210 AMBLYOPIC AND OTHER AFFECTIONS.
same effect is produced on the sight, occasionally, from
nervous or other apparently slight affections of the
uterus. In these instances, especially if the ophthal-
moscope shows no changes in the interior of the eye
sufficiently marked to account for the visual disturb-
ance, the treatment must be directed chiefly to the
cure of the disordered viscera.
SIMULATION OF BLINDNESS
In one eye, by nervous or hysterical persons, by con-
scripts or prisoners, is readily detected by holding the
finger or a ruler midway between the eyes and the
print while the patient reads. If the patient sees
with only one eye, vision will be interrupted, if with
both, not. If this is not wholly satisfactory, by
moving the ruler slightly from side to side so as to
cover each eye in alternation, any further simulation
of blindness will generally be detected. The decep-
tion may also be shown by means of a prism, base
inwards or outwards, before the normal eye. If
there is a corrective squint or change in the direction
of the eyes as the prism is removed, binocular vision
is proved, or the base of the prism being upward or
downward, if the patient sees double, binocular vision
is certain. The stereoscope may also be used as a
test, as binocular vision is requisite in order to appre-
ciate its effects. Simulation of blindness in both
HEMERALOPIA, OR NIGHT BLINDNESS.
211
eyes, may be detected by observing the action of
light on the size of the pupil. Mobility of the iris
under the stimulus of light is a tolerably sure indica-
tion of sight in one or both eyes.
HEMERALOPIA, OR NIGHT BLINDNESS,
Is generally considered a purely functional disease
of the retina, in which no changes are observable with
the ophthalmoscope. It is an affection confined in
its origin almost wholly to warm climates, and will be
remembered as one from which our soldiers on duty
in the extreme South suffered considerably. Sailors,
in tropical regions, are also frequent sufferers. The
distinguishing characteristic of the disease is, a torpor
of the retina, so that a bright light is required in
order to stimulate it sufficiently to receive distinct
impressions of objects; hence by night the patient's
sight is unusually bad. The time of the day has no
significance, such as the name of the affection would
indicate; for by a bright artificial light, he sees
as well by night as if no affection of the eye were
present.
The cause of the disease is exposure to glare of
light, and impoverished condition of the blood.
Both these conditions are present with our soldiers
and sailors in warm latitudes. It is often met with
in conjunction with malarial fevers, and the ill-fed
212 AMBLYOPIC AND OTHER AFFECTIONS
and ill-housed peasants in the south of Europe and
in Central America are subject to it. Sailors afflicted
with scurvy are often subjects of it.
the
The treatment is very simple and efficacious.
Rest, protection of the eyes from bright light, such
constitutional remedies as are necessary for the res-
toration of the general health, or change of climate,
generally cure speedily. In Italy, where the affec-
tion is quite common, a popular remedy among
people is fumigation with the vapor from the liver of
a sheep or other animal. Quaglino, and some others,
have observed symptoms of retinitis in the ophthal-
moscopic appearance of the fundus of the eye in this
affection. Night blindness is a prominent symptom
also of the disease called retinitis pigmentosa. In
this affection the field of vision becomes limited, a
subjective symptom which is characteristic enough
to distinguish it clearly from hemeralopia.
COLOR BLINDNESS
Is sometimes congenital. In these cases there is
usually an inability to distinguish the shades of red,
and red from its complementary color, green. Achro-
matopsia, inability to distinguish all colors, is due
to disease of the optic nerve or optic nerve and
retina. It has been noticed also as a symptom of
myelitis.
HYPERÆSTHESIA RETINÆ.
213
HYPERÆSTHESIA RETINÆ, OR RETINAL ASTHENOPIA,
Is characterized by severe photophobia, lachryma-
tion, and all the symptoms of an irritation of the
ciliary plexus of nerves. There are no ophthalmo-
scopic changes observable in the fundus of the
globe. In cases which have come under my care
there has been, uniformly, dilatation of the pupil. The
sight is good in a diminished light, but the field of
vision is usually somewhat contracted. It occurs
mostly in young females in delicate health, of irritable
nerves, hysterical, and suffering from catamenial
disorder. The disease of the nervous structure of
the eye is but an indication of the state of the ner-
vous system generally, and the treatment must be
directed to the removal of the constitutional symp-
toms. I have found quite a variety of remedies
necessary in different cases, and sometimes in the
same case. Macrotin, I believe to be more widely
serviceable than any other one remedy, but I have
frequently given puls., nux, gels., ignat., hyos.,
scut., bell., and con., according to general indica-
tions; gels. is not as reliable in photophobia perhaps
as many remedies, but I do not find this symptom to
contraindicate it. Blue glasses should be worn in
the open air, and it may be necessary to moderate the
light to a certain extent in-doors. I have never yet
214
AMBLYOPIC AND OTHER AFFECTIONS.
found it necessary to confine persons for days in
complete darkness, as has been practised and recom-
mended. Indeed, it has seemed better to encourage
the patient in attempting to accustom the eyes grad-
ually to the daylight, as the general health is im-
proved. The strong light is unpleasant rather than
injurious. I never hesitate to use the ophthalmo-
scope freely in these cases, throwing a strong light
directly into the eye. No sensitiveness whatever is
noticed under the examination after the first few
seconds, and I never heard of any after ill effects.
Anaesthesia retinc is an affection produced by ex-
posure of the eyes to extremely bright light for a
long time. Snow blindness is a form of this disor-
der and it is frequently brought on by continued ap-
plication of the eyes under strong artificial light.
The blindness takes the form of a cloud before the
eyes, and may be of only short duration, or may
continue for weeks. I was the subject of the affec-
tion myself during the past summer.
After gazing
out upon the ocean from a pleasant window for an
hour, on going down on to the green lawn I found
that the grass appeared to be veiled by an exceed-
ingly delicate blue haze. My friends declared that
no such haze existed, and after a few minutes' rest, I
saw no more of it. My own case is the only one I
have treated, and doubtless the same treatment, rest,
NEURALGIA OCULI.
215
and perhaps some safeguard against a too bright light,
will generally effect a restoration of acute vision.
Since writing the above, I have treated a severe
case of ten weeks' standing. It was caused by ex-
posure to brilliant gaslight for several successive
evenings at a festival. Vision was reduced to,
right, left. The ophthalmoscope showed no
changes. The field of vision was not limited, but, as
the man was a tremendous smoker, I felt some doubt
about the prognosis. I gave him zinc internally, a
collyrium of sul. of zinc, one grain to the ounce of
water, and limited his smoking to a pipe after each
meal. In two weeks his sight had considerably im-
proved. Later I learned that the improvement was
so marked that he did not consider further advice
necessary. Dr. Dudgeon, of London, relieved a
severe case of snow-blindness, in a member of the
Alpine Club, with ignatia.
NEURALGIA OCULI
Is usually associated with, or is merely a symptom
of, a disease of the eye such as iritis, choroiditis, glau-
coma, or some other affection, the treatment of which
has been already indicated. In hysteria, it is but a
phase of the neuralgias common in that disorder of
the nervous system, and can only be cured by re-
storing the general health of the patient. It may be
relieved by such measures as are recommended for
ciliary neuralgia.
CHAPTER XII.
THE CRYSTALLINE LENS.
CATARACT.
CATARACT is an opacity of the lens, its capsule, or
both lens and capsule, and may therefore be called
lenticular, capsular, or capsulo lenticular.
DIAGNOSIS.
The subjective symptoms are dimness of vision,
in proportion to the age or density of the opacity,
which increases gradually, except in traumatic cata-
ract, when it may be sudden, and in congenital
cataract. The patient sees better generally in a dim
light, because, the pupil being larger, the periphery
of the lens is uncovered, and this portion of the lens
is usually clearer than the centre. For the same.
reason the instillation of atropine improves vision
somewhat. The first symptom usually noticed by
the patient with beginning cataract, is, that distant
objects appear slightly hazy, or as if surrounded by a
DIAGNOSIS OF CATARACT.
217
halo; afterwards, as the cataract develops, vision for
near objects is similarly impaired.
Objective symptoms. The pupil is generally nor-
mal in size and movement. The vacant look, roll-
ing of the eyes, and tendency to look upward of
amaurosis is not present. The patient is inclined to
look downward, and is able usually to fix the eyes
on objects. If the affection has made considerable
progress, a gray opacity is at once noticed exactly
filling the area of the pupil, the opacity being sharply
limited by the pupillary margin. A corneal opacity
may hide a portion of the iris, but a lenticular
opacity can only obscure the pupil. The pupil
should be enlarged with atropine, and the eye exam-
ined by oblique or lateral illumination.
Examination by lateral illumination enables us
to determine the extent and nature of the opacity,
whether complete or ripe, its color, its formation,
whether nuclear or striated, and other details.
Direct examination with the ophthalmoscope is
chiefly serviceable in detecting slight and beginning
opacity of the lens, which would otherwise escape
observation. The light should not be very strong.
and the eye of the observer should be twelve or fif-
teen inches from that of the patient. There may be a
general, but very slight, cloudiness of the whole lens,
or the nucleus alone may be obscure, or delicate
218
THE CRYSTALLINE LENS.
striæ may be seen running from the periphery to-
wards the centre of the lens. These opacities will
appear black instead of grayish, as in the lateral ex-
amination. Beginning cataract may be confounded
with separation of the retina, a fact which is noticed
under Retinal Diseases. In cases where the cataract
is dense or far advanced, the ophthalmoscopic signs
are negative, as no light can be thrown into the eye.
COMPLICATION, WITH OTHER DISEASES OF THE EYE.
The most common complications are,
The results of iritis,
Choroiditis,
Separation of the retina,
Softening of the vitreous humor,
Sclerotico-choroiditis posterior,
Amblyopia.
We may determine a complication or its absence,
by testing the patient's visual power after the cataract
is fully matured. He may be able to distinguish
night from day, or the light from a window, and to
note a hand before his eyes, even at a distance of three
feet, and still we should not be justified in pronoun-
cing the retina sound beyond a doubt. To render the
absence of all complications sure, the patient should
be able to discern a dim light in a darkened room at
a distance of ten to fifteen feet. There should be no
contraction of the field of vision as tested by moving
a lighted candle from one part of the visual field to
the other. The patient's eyes should be fixed on his
HARD OR SENILE CATARACTS.
219
finger at the distance of a foot during this test, and
the candle should be shaded while its position is
being changed; the tension of the eyeball should be
noticed, and in cases of doubt the whole history of
the failure of sight investigated thoroughly. Pain,
photophobia, flashes of light, spectra, and like symp-
toms, are to be regarded as indicating unfavorable
complications.
THE CAUSE
Is probably faulty nutrition of the lens. This may
be due to old age, as in senile cataract; to disease
of the kidney, as in diabetic cataract; or to abnor-
mal change in the deep structure of the eye, as in
secondary cataract. There is also a congenital cata-
ract dating from birth, and a traumatic cataract,
from injury. Opacities of the lens fall, practically,
into two great divisions, the hard and soft.
HARD OR SENILE CATARACTS
Are distinguished from soft cataracts by their color,
which is gray, and approaching the centre, yellowish-
gray; they are of uniform appearance, or more fre-
quently striated, the striæ presenting a pearly aspect.
Senile cataract is also probable in all opacities of the
lens in subjects above the age of fifty. Soft cataracts
occur generally in younger persons, and are known
by a lighter, more bluish tint, are less apt to be
220
THE CRYSTALLINE LENS.
striated, or, if so, the striæ are less symmetrically
arranged. Sometimes it is difficult to decide, when
the age of the patient furnishes little help, whether a
cataract be hard or soft. Less common forms of hard
cataract than the nuclear, where the nucleus is opaque,
the marginal portion remaining for a time transparent,
and the striated form, presenting lines from the pos-
terior or anterior cortical portion of the lens, or from
both, and all running towards the centre, are the so-
called black cataracts, the centre or nucleus of the
lens being dark-brown, and the siliquose where the
lens is atrophied or over-ripe, and lies in its shrivelled
capsule.
The progress of hard cataracts is very variable,
sometimes slow for a time, and then rapid. It is bet-
ter not to answer the invariable question of patients
decidedly, as to the time when the cataract will be
perfect. It is very certain that a cataract of one eye
will, sooner or later, be followed by the same affection
in the other.
THE OPERATION OF EXTRACTION
Is indicated as soon as the cataract has ripened.
We may judge of this by the appearance of the opac-
ity, which is denser, deeper in color, and extends
through the entire lens, so that the shadow of the iris
at the circumference of the lens is scarcely visible.
The vision is also more indistinct. Dilation of the
THE PROGNOSIS IN EXTRACTION.
221
pupil with atropine is less serviceable, as the periph-
ery of the lens is involved in the opacity. When the
cataract matures very slowly, it has been recom-
mended to hasten its development by pricking the
transparent portions with a fine needle, and keep-
ing the patient in a darkened room for a few days
afterward, until the irritation subsides. We may
also operate before the cataract is fully ripe. The
disadvantage of this, is, that the transparent corti-
cal portion of the lens being softer than the opaque part,
may separate from it, and be left to a great extent in
the eye, and act afterwards as a foreign body, irritat
ing the iris, and producing disturbance of vision.
Operators are not fully in accord as to the necessity of
maturity of the cataract before extraction is indicated.
It is safer not to operate on both eyes at once.
THE PROGNOSIS.
The prognosis in extraction is very favorable. In
uncomplicated cases there are probably not more than
three or four per centum of entire failures.
The operations mostly practised for extraction are
the flap, the peripheric-linear, and the Liebreich op-
erations. It is advisable to dilate the pupil before
operating, with atropine, particularly on account of
the effect of the atropine in keeping up the dilatation,
after the extraction, thus lessening somewhat the
chances of subsequent iritis.
222
THE CRYSTALLINE LENS.
THE FLAP OPERATION.
The patient being in a recumbent position, a prac-
tised assistant separates the lids, the operator fixes
the eye by pinching up a fold of the conjunctiva with
a pair of small forceps. He then enters the cornea,
at its outer edge, with a cataraçt-knife, carries it
steadily forward, cutting out either above or below,
and making, according to his predetermined inten-
tion, either a superior or inferior flap. Allowing the
patient now a moment's respite, the eye is again
opened, the needle or cystotome introduced, and the
capsule of the lens thoroughly lacerated. This being
accomplished, the opaque lens, with or without the
aid of gentle pressure upon the eye, emerges slowly
from between the lips of the wound. Any remains
of the soft cortical substance of the lens are then
gently removed with a curette or spatula, and the
operation is finished.
Exigencies may arise during an operation like this
to modify it somewhat. The corneal wound may
have been made too small to admit of the passage of
the lens. If so, it must be enlarged by cutting with
curved scissors, a proceeding sometimes difficult,
the cornea lying directly upon the iris, there being no
anterior chamber in consequence of the escape of the
aqueous humor. The knife may have entered the
PERIPHERIC-LINEAR EXTRACTION.
223
cornea too far from its limbus, too near its centre.
In this event, it is necessary to cut out in the sclerot-
ica, and the wound will lie towards the inner canthus
of the eye. This may render tedious manipulations
necessary, after the opening of the capsule, in order
to force the lens inward to a point corresponding to
the opening of the wound.
Sometimes, after rupturing the capsule, instead of
the lens, we have a gush of vitreous humor from the
mouth of the wound. In this case, it is necessary
to remove the lens immediately from the eye, by
means of a curette, or small spoon.
Deep-seated hemorrhage may occur, especially if
the complication of glaucoma exist, and in such event
the prognosis is bad. Owing to sudden escape of the
aqueous humor the iris may be forced against the
knife, and wounded, in making the corneal flap. This
may render an iridectomy necessary.
The flap operation may be performed with or with-
out the etherization of the patient. I have seen it
performed oftener without, but I prefer myself to do
it aided by etherization.
PERIPHERIC-LINEAR EXTRACTION.
This operation, of Von Graefe, requires the ether-
ization of the patient, the recumbent position, and
the lids to be separated by a stop-speculum. The
224
THE CRYSTALLINE LENS.
eye being held in position by delicate forceps in the
left hand of the operator, it is entered with a long,
narrow knife (instead of the usual Sichel or Beer's
cataract-knife), the edge upwards, in the sclerotic,
about half a line from the corneal limbus, and near
its upper and outer portion so that the anterior cham-
ber will be opened across its extreme upper margin.
Some operators enter at the junction of the cornea,
and the sclerotic at a little lower point. The knife,
being entered at the temporal side, is pushed down-
ward and inward until it has entered the anterior
chamber to the extent of two or three lines, when
the handle is depressed and the point is carried hori-
zontally forward towards the nasal margin of the
cornea, so as to emerge in the sclerotic or limbus
corneæ, exactly opposite its place of entrance; the
edge of the blade is then turned sharply forwards,
the knife pushed horizontally onward, and the sec-
tion completed by drawing it backward from heel to
point. The next step, the eye being steadied by an
assistant, is to make an iridectomy by seizing the iris
which presents itself at the wound, and snipping it
off. The capsule is then lacerated, and, by gentle
pressure upon the eye, the cataract is forced through
the opening. If, as sometimes happens, the lens is
not readily evacuated, it should be drawn from the
eye by a small spoon-like tractor or curette.
LIEBREICH'S OPERATION.
LIEBREICH'S OPERATION
225
Is an important modification of the peripheric-linear,
and bids fair, I think, to supersede it. It is made.
with the same knife, but the incision is put back
again into the corneal tissue as in the flap operation.
The knife is "held with its back horizontal and
backwards, the plane of the blade making with the
horizontal meridian of the eye an angle of about
450" The knife should enter the eye just outside
the margin of the cornea, making a linear incision
across the latter, near the junction of its lower with
its middle third, or the opening may be above in the
same relative position. The other steps do not differ
materially from those mentioned in the two preceding
operations. Less skilful operators than Liebreich
may prudently abstain from following his suggestion
to operate without an assistant. The operation is
certainly easier than either of the two preceding; but
it is much facilitated, as I have found from experi-
ence, by etherization, fixation, and a good assistant.
SPOON EXTRACTION, OR THE TRACTION OPERATION.
The opening in this operation is usually made with
the lance-shaped iridectomy-knife at the upper border
of the cornea at its junction with the sclerotic, and
enlarged laterally, when thought necessary, with the
scissors. An iridectomy is then made, the capsule lac-
erated, and a scoop or miniature spoon is cautiously
introduced, carried between the lens and posterior
capsule, and the cataract slowly drawn from the eve.
226
THE CRYSTALLINE LENS.
EXTRACTION OF THE LENS WITH CAPSULE,
An opening is made in the sclerotic or at the
corneo-scleral junction, followed by an iridectomy; a
scoop is then introduced behind the lens and capsule,
and both are extracted together.
RECLINATION OR DEPRESSION
For senile cataract has justly fallen into disrepute,
and is seldom practised. It might sometimes be called
for in very aged persons, unwilling to undergo the
much severer operation of extraction. The eye is
entered through the sclerotica, about two lines from
the cornea at the temporal side, just below the hori-
zontal meridian. The needle at present in use is
delicate, flattened, and spear-shaped towards its point,
and double-edged. It is carried forward until its flat
surface is directly behind the pupil, and against the
anterior capsule. The lens is then pressed gently
backward and downward out of the field of vision.
It is pressed in this particular direction in order that,
if possible, it may lie isolated in the vitreous humor,
free from contact with the ciliary bodies and the
choroid, upon which it would otherwise act as a
foreign body, and cause irritation. In fact, the great
danger from the operation always is, that, sooner or
later, the lens will come in contact with the choroi-
dea and cause a choroiditis. Its effects are brilliant
AFTER TREATMENT IN EXTRACTION.
227
at first, but not permanent. Now and then there is
an exceptionally successful result. I saw, during the
semester of 1863, in Vienna, a man who had reclina-
tion performed for cataract in the year 1839, and
now, for the first time, was troubled by indistinct
vision from a shred of opaque capsule.
AFTER TREATMENT IN EXTRACTION.
After the operation both eyes should be gently
closed and a simple bandage applied, as described in
chapter second under Bandaging. The bandage and
charpie should be removed twice a day, the discharge
gently washed away with tepid water, and a soft moist
sponge drawn across the edges of the tarsi, which fre-
quently adhere to each other. Attentions of this
kind render the patient more comfortable, quiet, and
less nervous, and so facilitate healing and a fortunate
result. The patient should keep his bed about forty-
eight hours, and then if all goes well he may exchange
it for the sofa. The bandage may be continued for
ten or twelve days, and then be replaced by a broad
shade, and the sooner after this the patient can get
into the open air the better. The diet for the first
day or day and a half may consist of farinaceous
articles and beef-tea, but after this, should be gen-
erous, and nearly that to which he is accustomed.
I always administer aconite after the operation for
228
THE CRYSTALLINE LENS.
thirty-six hours or more. In case of constipation,
later, bry. and nux are better than the "mild purga-
tive" so often recommended by surgeons. If the
eye is quite hot and painful during the first few
hours after the extraction, cold compresses may be
used. For the first forty-eight hours when the pain
is severe, and the eyelids swollen with muco-puru-
lent discharge, we may expect more or less sup-
puration of the cornea. A compress bandage is
to be applied, and the case treated as described
under Suppurative Corneitis and Ophthalmitis. This
dangerous complication avoided, we may have an
acute iritis. Atropine should be instilled into the
eye at once, of the strength of four grains to the
ounce of water, not only for the purpose of securing
immobility to the iris, but to prevent if possible clos-
ure of the pupil. The advent of acute iritis may be
known by pain, photophobia, lachrymation, chemo-
sis, discoloration of the iris, turbid aqueous humor,
and contracted pupil. The treatment of iritis has
been already given. Simple iritis, of a serous char-
acter, may come on later from irritation of the iris,
and is much less dangerous than the more rare acute
suppurative or traumatic iritis, above mentioned.
Prolapse of the iris is liable to occur soon after
extraction, in which case atropine and the compress
bandage are to be immediately applied. Corneal
CAPSULAR OPACITIES AFTER EXTRACTION. 229
fistula from imperfect union of the lips of the wound
will require the same treatment. If after two or
three weeks no perfect union occurs, the edges of the
orifice may be touched cautiously with a solution of
arg. nit., which will probably effect the object
through the local inflammation set up by it. If this
fail, an iridectomy to relieve intraocular pressure
should be tried. Cystoid cicatrix, the name given by
Von Graefe to a healing of the wound in the sclera
or limbus cornea through the intervention of cicatri-
cial tissue, which finally becomes thin and bulging, is
noticed oftenest as a sequel of iridectomy for glaucoma.
It may occur also in glaucomatous eyes after extrac-
tion. We cannot change the nature of the cicatrix,
but we may perhaps prevent an increase of bulging,
sometimes, by operating to remove intraocular pres-
sure.
CAPSULAR OPACITIES AFTER EXTRACTION.
After fully dilating the pupil with atropine, the
wrinkled, semi-opaque capsule which sometimes re-
mains in the pupillary area, is to be torn open with
a fine needle which is passed into the eye through the
cornea. It may be necessary to use two needles,
one in each hand, entered at opposite sides of the
cornea; their points, meeting in the capsule can be
moved in opposite directions, which renders the
division of it easier and more certain.
In some
230
THE CRYSTALLINE LENS.
instances it cannot be torn by needles, and then it
may be advisable to attempt the withdrawal of the
tough capsule by means of the delicate canular for-
ceps. It is a very hazardous proceeding, and I have
often known it to fail. None of these operations
should be undertaken until all irritability of the iris
has passed away, and after the operation atropine
should be instilled, bell. and acon. administered, and
the patient kept for twenty-four hours in a subdued
light.
SECONDARY CATARACT
Is an opacity of the lens occurring in the course
of glaucoma and other deep-seated diseases of the
eye. As a rule, no operation for the removal of
the cataract is indicated, as the risk is very great,
without a prospect of corresponding benefit, if all
goes well. The operation of mine, following an
iridectomy for glaucoma, published in the "New
England Medical Gazette" for June, 1869, was
unusually successful, more so perhaps than could
have reasonably been hoped for. In that case, how-
ever, there were pretty certain indications that the
fundus of the eye had been restored to a tolerably
healthy condition. The patient could see a lighted
candle in a darkened room at a distance of fifteen
feet. There was evidence that the glaucoma had
ceased to progress, and there was a chance, that
SOFT CATARACT.
231
whatever improvement of sight might be gained by
the removal of the opaque lens, might be permanently
retained.
SOFT CATARACT
Occurs in younger subjects, those under thirty-five
or forty years of age. Its color and general ap-
pearance has already been noticed. One of the com-
monest forms of this lenticular opacity is the infantile
or congenital cataract. It is either congenital, or
develops during infancy. There are two varieties:
the lamellar, called by German writers schicht-
staar, is a central opacity surrounded by a more or
less transparent zone of lens substance, so that when
the pupil is fully dilated the sight is usually improved
to a remarkable degree. It seems to be connected in
some manner with infantile convulsions. The prog-
ress of the opacity is slow, sometimes almost imper-
ceptibly so. Children with this form of cataract are
often thought to be near-sighted. This idea
This idea may be
corrected at once by the test mentioned under Am-
blyopia, and the cataract diagnosed by lateral illumi-
nation or the ophthalmoscope. The other variety of
opacity, the cortical cataract, is much more rapid in
its course. This opacity is seen in the form of opaque
striæ running from the circumference to the centre,
the interstices at first being of transparent lens,
which after a time becomes mottled, hazy, and opaque.
232
THE CRYSTALLINE LENS.
When mature, the cataract is bluish-white, more
dense at the centre, the striae often presenting a
pearly aspect. In infantile cataract an early opera-
tion is indicated in order to prevent, as far as possible,
the amblyopia retina, which develops rapidly in
young eyes, when the visual rays of light are excluded
by opacities in the transparent media.
OPERATIONS FOR SOFT CATARACT.
The operations for soft cataract are those of discis-
sion, linear extraction, and suction. Discission, or
solution, consists in entering the eye through the cor-
nea with a fine needle, rupturing the capsule of the
lens centrally, and lacerating more or less the lens
substance, permitting its absorption by the aqueous
humor, which obtains access to it through the opened
capsule. Before the operation the pupil should be
dilated with atropine, and subsequent to it, should
be kept as widely dilated as possible, to avoid contact
with lens matter, which might occasion otherwise
irritation, possibly iritis. Several operations of
puncturing or lacerating with the needle will be re-
quired before the whole of the substance of the opaque
lens will be absorbed. The interval between each
operation will probably be three months or more, ac-
cording to the progress of absorption; whenever
progress ceases the operation is to be repeated. Too
•
LINEAR EXTRACTION.
233
much lens matter should not be broken up at once,
lest too much swelling of the lens substance ensue,
causing great irritation. If this should happen,
the lens may be immediately removed from the eye
by linear extraction. After the operation the patient.
should remain quiet for a day or two in a partially
darkened room.
Iridodesis, or iridectomy, for an artificial pupil,
is sometimes done for lamellar cataract, when it
appears to be stationary or non-progressive. This
affords very good vision if the circumference of the
lens is clear and the opacity pretty sharply defined.
It is, perhaps, the freest from danger of all opera-
tions, but if the cataract prove to be progressive and
the opacity extends, the eccentric pupil is no longer
serviceable, and the eye is perhaps not in quite so
favorable condition for the most successful results from
discission or linear extraction.
LINEAR EXTRACTION
Should be performed a few days subsequent to a
needle operation, in which the laceration of the cap-
sule and division of the substance of the lens, is more
thorough and extended than in the one advised for
discission and removal of the cataract by absorption.
When the lens matter has become softened and swol-
len by admixture with the aqueous humor, the pupil
234
THE CRYSTALLINE LENS.
being widely dilated by atropine, the cornea is opened
at its temporal margin with a broad needle in an oblique
direction. A curette is then introduced, the eye being
fixed in the most convenient position with the forceps,
and by gentle pressure upon the lips of the wound
the semi-fluid lens will flow gently down the groove
of the curette, and be brought out at the small
corneal aperture. Afterwards the simple bandage
should be applied, and the patient kept in bed for
twenty-four or forty-eight hours, the pupil being
dilated by atropine, applied daily, until all signs
of iritis have disappeared.
THE SUCTION OPERATION,
Like the linear, is probably more easily accom-
plished a few days after breaking up the lens with
the needle, although either operation may follow im-
mediately, if necessary. The operation is like the
last described, only in place of the ordinary curette,
is substituted a tubular one, attached to a second tube,
of glass, and this to a metal syringe, from which the
suction power is obtained. The syringe is constructed
so as to be worked by the right hand, which also guides
the curette, while the left keeps the eye in position
by the forceps.
Diabetic cataract, appearing in the course of a
diabetes, is generally soft, but harder in elderly per
sons.
MEDICAL TREATMENT OF CATARACT.
235
It is to be removed by linear extraction, if
the health of the patient is not too much impaired.
Fluid cataract is of rare occurrence. Generally
there is a nucleus more or less firm. Suction, or
linear extraction, is the suitable operation for it. In
appearance, it is milky-white, homogeneous, and
without opalescent stripes.
TREATMENT OF CATARACT BY PARACENTESIS.
Sperino's method consists in repeatedly tapping
the anterior chamber through the cornea, evacuating
the aqueous several times at one sitting, and repeat-
ing the operation at frequent intervals an indefinite
number of times; he operates twenty, fifty, a hun-
dred times or more, on the same eye before the lens
regains its transparency, and frequently this result is
not attained in the end. The idea is, to permit the
opaque fibres of the lens to regain their transparency
through the relief to the intraocular circulation
afforded by the paracentesis.
MEDICAL TREATMENT OF CATARACT.
It does not seem improbable to me that in the
course of time, we may find some reliable remedy,
the administration of which before the lens-fibre has
become degenerated, may restore its transparency.
Cataract is known to be a result of ergotism. It has
236
THE CRYSTALLINE LENS.
also been produced in frogs by administering sugar
in large quantities, or by injecting it under the skin.
Chloride of sodium and alcohol have produced similar
results. In our school, cures, or beneficial results, are
reported to have followed the use of cannab., còn.,
phosph., silex, sulph., and a few other of our
remedies.
CAPSULAR CATARACT.
Opacity of the substance of the capsule probably
never occurs by itself. There is always a previous
opacity of the lens.
Anterior capsular cataract, or false cataract, is
usually situated centrally, and is caused originally by
an inflammation of the iris or cornea. In young chil-
dren the anterior chamber is very shallow, and in the
new-born it scarcely exists at all, the cornea and
lens being nearly in contact, so that an ophthalmia
would be likely to extend to the capsule, or, if puru-
lent leave some deposit upon its anterior surface.
When this opacity is prominent, and extends some-
what into the pupil, it has been called pyramida.
cataract. An artificial pupil is usually indicated in
this form of opacity. In capsulo-lenticular cata-
ract, both capsule and lens are extracted either sepa-
rately or together.
DISLOCATION AND ITS DIAGNOSIS.
237
DISLOCATION OF THE LENS
May be spontaneous, the result of a blow on the
eye or head, or it may be congenital and hereditary.
It is either partial or complete. The lens may be
thrown backwards into the vitreous humor, forward
through the pupil into the anterior chamber, or by a
rupture of the sclerotic it may be forced beneath the
conjunctiva. In the latter case, and also when dislo-
cated into the anterior chamber, it should be extracted.
If lying in the vitreous it may be permitted to remain,
if its presence occasions no great irritation, if other-
wise, it should be extracted by the traction operation.
DIAGNOSIS.
There is generally pain, photophobia, lachrymation,
tremulousness of the iris, and the signs of absence
of the lens behind the pupil, mentioned under Apha-
kia. Lying in the anterior chamber the lens may be
plainly seen and recognized. Not long since, how-
ever, a case was sent me which had been called an
opacity of the cornea. It was in an eye otherwise
diseased, and the dislocation was occasioned by a
blow on the head. Under the conjunctiva, the dis-
placed lens may be seen as a small semi-transparent
swelling. In partial dislocations there will be mo-
nocular diplopia or polyopia. Lateral illumination
238
THE CRYSTALLINE LENS.
will enable us to determine the amount of displace-
ment. Direct examination with the ophthalmoscope
is still better. We may then see the free edge of
the lens as a dark crescentic line across the red pupil.
Partial displacement often causes great irritation, and
may lead to glaucomatous inflammation. In such
cases the lens is to be extracted. Sometimes the
great irritation experienced at first may be lessened
by the instillation of atropine, by warm soothing
fomentations of bell., cham., opium, and the internal
administrations of acon., bell., cham., or, when the
pain is deep seated, of spigel., macrot., or sanguin.
In congenital or other cases, where the dislocation
appears fixed, an operation for artificial pupil is indi-
cated.
TRAUMATIC CATARACT.
The opacity in the lens generally commences within
twenty-four hours after the injury to the capsule.
It is at first confined to the locality of the wound,
but soon involves the entire lens, spreading more
rapidly, the younger the subject. There may be con-
siderable pain and irritation resulting from the wound
in the cornea or laceration of the iris, or simply from
the pressure of the swollen lens upon the iris. Trau-
matic cataract may occur from a blow, which, with-
out the rupture of the external tunics of the eye,
may nevertheless rend the capsule of the lens. The
APHAKIA.
239
pupil should be kept dilated, and the medical treat-
ment be similar to that mentioned in dislocation of
the lens. After the irritation has subsided, if the
absorption of the lens is bound to be going on, there
should be no surgical interference; but if the pain
continues, tension of the globe is increased, the pink-
ish zone around the border is marked, and traumatic
glaucoma is feared, the lens should be extracted.
APHAKIA,
Or absence of the crystalline lens, occurs after ex-
traction, from complete dislocation, and after absorp-
tion of the lens. It may be recognized when the
history of the case is not known, by the blackness of
the pupil, diminished size of the anterior chamber,
and tremulousness of the iris in case the latter has
lost the support of the capsule also. The refraction.
of the eye is, of course, much changed. An emme-
tropic eye becomes hypermetropic, a hypermetropic eye
more hypermetropic, a myopic eye less myopic, and
the power of accommodation is gone. The spectacles
suited to this condition of the eye are spoken of in
the next chapter.
CHAPTER XIII.
SPECTACLES-ARTIFICIAL EYES.
SPECTACLES.
THE ordinary glasses for spectacles, in optical
defects, are convex or concave spherical, except in
astigmatism, when they are cylindrical, or a combi-
nation of both spherical and cylindrical. The nature
and use of these glasses have already been sufficiently
explained.
CATARACT GLASSES
Are thick convex lenses of great refractive power.
After extraction of the crystalline lens the accommo-
dative power of the eye is lost, and therefore two
pairs of spectacles will be necessary, one for reading
of about 21-inch focus, and the other 41-inch focus for
distance. These numbers will vary somewhat accord-
ing to the refractive state of the eye before operating,
whether emmetropic, myopic, or hypermetropic. It
is advisable also that the glasses should be small and
encircled by a black ring of ebony or shell a quarter of
an inch in width. Large glasses admit too much light
PRISMATIC AND DECENTRED GLASSES. 241
into the eye, and cause a dazzling sensation. Some-
times a combination of cylindrical with the spherical
glasses are requisite in order to afford sufficient acute-
ness of vision for the patient to read with comfort.
Cataract glasses should not be worn for some weeks
after the operation; while much irritation remains it
is better not to attempt the use of the eyes for near
objects.
PANTOSCOPIC GLASSES,
Verres à double foyer, are sometimes called
Franklin glasses from the fact that he wore such.
The upper and lower half of each glass have differ-
ent foci. If a myope becomes presbyopic the upper
half of his glasses would be concave for distance, and
the lower half convex to neutralize his presbyopia in
reading.
PRISMATIC AND DECENTRED GLASSES.
Prismatic glasses are useful in aiding or exercising
certain muscles of the eye, as explained under the
article on Strabismus. Decentred lenses are so con-
structed that the wearer looks through an eccentric
part instead of the centre. A convex lens, for
instance, is so arranged that its centre lies a little to
the inner side of the visual axis, in consequence of
which a slight prismatic effect is produced.
16
242
SPECTACLES ARTIFICIAL EYES.
EYE PROTECTORS.
Eye protectors made of curved blue glass are the
best. Goggles with wire, silk, or glass sides keep
the eye, as a general rule, too close and warm. For
photophobia, simple blue spectacles of plain glass are
generally sufficient, and may be darker or lighter in
shade, according to the amount of protection re-
quired. Brown or smoke-colored glasses may be used,
if preferred. The latter cut off all the rays of light,
and consequently render vision somewhat less dis-
tinct, while blue glasses, excluding the orange rays
only, interfere less with the clear definition of objects.
Green glasses protect the eye from the red rays alone;
but it is the orange rays which are most intolerable
to a sensitive retina.
Strong plate glass spectacles are worn by those
finding it necessary to protect the eyes against
chips and particles of stone or steel. It is proposed
to make them of curved mica. Such spectacles
would be cheap, durable, not likely to break, and
very light.
STENOPAIC SPECTACLES,
Composed of metallic plates with small central
apertures, are useful in opacities or cloudiness of the
cornea. They exclude the peripheral, and permit
only the central rays of light to enter the eye.
ARTIFICIAL EYES.
243
Acuteness of vision for near objects is increased, but
they are not serviceable for more distant views, as
they limit the field of vision too much.
ARTIFICIAL EYES.
After enucleation or excision of the eyeball, or
after excision of a staphyloma of the cornea, or in
case of a shrunken globe from any operative inter-
ference or disease, the deformity may be almost
completely removed by wearing a suitable artificial
eye. It should not be worn for a month or six
weeks after the removal of the eyeball, lest irritation
and inflammation of the conjunctiva ensue. To in-
sert it, the upper lid is to be raised, the upper border
of the artificial eye introduced beneath it, and the
lid allowed to fall; then the lower lid is to be de-
pressed and gently pulled forward when the artificial
eye will slip into place. To remove it, depress the
lower lid, and with a hook or bodkin force its lower
edge forward, and it will fall out. It should be
caught on something soft or yielding so as not to
break or scratch it. It should be removed and
cleansed every night, and, if worn every day, after
six months should be exchanged for a new one, as at
the end of this time it becomes roughened and may
occasion irritation and inflammation.
CHAPTER XIV.
THE MUSCLES OF THE EYE.
PARALYSIS.
}
THE nerves supplying the muscles of the eye are
the third, fourth, and sixth. The third supplies the
internal, superior and inferior recti, the inferior ob-
lique, the levator palpebræ superioris, the constrictor
pupillæ, and the ciliary muscle.
The fourth nerve supplies the superior oblique, and
the sixth the external rectus.
The rectus externus moves the eye outward.
"
""
internus moves the eye inward.
""
""
""
superior moves the eye upward and inward, and rolls
(inclines the vertical meridian) the eye inward.
inferior moves the eye downward and inward, and rolls
it outward.
,, superior oblique moves the eye downward and outward, and
rolls it inward.
inferior oblique moves the eye upward and outward, and rolls
it outward.
The third and sixth nerves are more often affect-
ed, the fourth very rarely. For convenience in de
PARALYSIS OF THE EXTERNAL RECTUS. 245
scribing the diagnostic symptoms, we will consider
the paralytic affection as occurring in the left eye.
PARALYSIS OF THE EXTERNAL RECTUS.
On moving an object before the eye from right
to left (a lighted candle is convenient), a convergent
squint is noticed. The movement of the eye to the
left is sluggish. There is diplopia as the object is
moved into the left half of the field of vision, the
images being homonymous (not crossed, the right
belonging to the right eye, the left to the left eye),
parallel, of the same height, the distance between
them increasing as the object is moved further to the
left. The position of the head is also characteristic,
the patient carrying it turned somewhat to the left, in
order to avoid the confusion of sight arising from the
double images. A prismatic glass may be worn to
correct the diplopia.
A prism bends the rays of light towards its base.
Applying it to the left eye, base towards the temple,
rays of light are bent outward, and the image is pro-
jected inward towards that of the other eye. The
prismatic glass should be just strong enough to fuse
the two images. If we wish to exercise the par-
alyzed rectus so as gradually to strengthen it, we
may prescribe a weaker prismatic glass which does
not quite fuse, but approximates very nearly the two
246
THE MUSCLES OF THE EYE.
images. The effort of the eye to fuse the images
will call the rectus externus into action to a limited
extent, and as it grows stronger we may weaken the
strength of the prism.
PARALYSIS OF THE INTERNAL RECTUS
Is rarely met with as an isolated affection. The
third nerve, supplying also the superior and inferior
recti, the inferior oblique and others, several muscles
are simultaneously affected. The symptoms would,
however, be the reverse of those just noticed, and
prismatic glasses would be worn with the base inward.
The patient would also incline his head slightly
towards the right. In
PARALYSIS OF THE SUPERIOR RECTUS,
The eye will not turn upwards readily. There
is also a slight divergent squint. The inferior
oblique drawing the eye outward, crossed double
images will occur in the upper half of the visual
field. The images are not parallel, diverge upwards,
and differ in height.
PARALYSIS OF THE INFERIOR RECTUS
Would occasion symptoms just the reverse of the
above. In
PARALYSIS OF THE THIRD NERVE.
247
PARALYSIS OF THE SUPERIOR OBLIQUE
The deviation of the visual axis is but very slight.
There is a want of mobility noticed in the attempt to
turn the eye downwards and inwards. Homonymous,
or corresponding double images are seen in the lower
half of the field of vision. The left image (that of
the affected eye) appears lower than he other. The
images will be oblique, converging towards the top.
The patient will be annoyed in descending stairs,
which appea double, and irregular in outline. He
will be apt to turn his head downward and to the
right, so as to bring objects into the upper and left
portion of the field of vision, avoiding the diplopia.
Prisms are worn base downward and outward.
PARALYSIS OF THE THIRD NERVE
May be complete, affecting all the muscles sup-
plied by it, or it may be partial, affecting only one or
more of the muscles. In complete paralysis, say, of
the left eye, there is first ptosis. On raising the up-
lid we
per find the eye restricted in its movements in
the upward, downward, and inward directions. The
rectus externus, being supplied by the sixth nerve, is
unaffected, and the eye can consequently move out-
ward. It can also move to a certain extent down
ward and outward, through the superior oblique
which is supplied by the fourth nerve.
248
THE MUSCLES OF THE EYE.
1
PROGNOSIS AND TREATMENT.
Whether a cure of paralysis of the muscles of the
eye can be prognosed, depends chiefly upon the cause
of the affection. If syphilitic, a not uncommon
cause, the prognosis is generally favorable. If of
rheumatic origin, the prognosis is highly favorable.
When due to intracranial causes, the prognosis is,
of course, often unfavorable. The more acute the
case, generally speaking, the better are the chances
for a cure. In syphilitic cases, I believe iodide of
potash, after merc., to be the best remedy. In rheu-
matic cases, where the seat of the disease is the sheath
of the nerve, my experience has been excellent with
bry. Gelsem., merc., macr.t., nux, ignat., and
other remedies, have appeared more or less beneficial.
The chances of cure are much increased if the par
alysis is partial and only one nerve affected, the gen-
eral nervous system being in good condition. In
case of paralysis of the sixth nerve (external rectus),
the condition of the abdominal viscera should receive
more than ordinary attention, as this nerve seems to
be particularly influenced by reflex action from the
sympathetic. When other means fail, paralysis of
the ocular muscles from peripheral or extracranial
causes may frequently be cured by electricity. Far-
adization does not appear to be as efficacious as the
1
TREATMENT OF PARALYSIS.
249
primary galvanic current. Benedict
Benedict had unusual
facilities for testing the value of electricity at the
clinics of Prof. Arlt, in Vienna. Of twenty-seven
cases, all but five were benefited, and seventeen of
them cured. Contrary to the generally received
opinion, which attributes the benefit to the direct
excitation of the paralyzed nerve, he found "that the
cure was dependent, generally speaking, upon reflex
irritation through the fifth pair of nerves." He found
further that "in most cases a curative action was only
produced when the excitation was relatively weak.”
He used from three to fifteen of Daniell's elements.
The excitation should only continue about half a
minute at each sitting, the improvement occurring
in most cases instantaneously. In operating, the
copper pole is generally placed on the forehead, while
the zinc pole is, in affection of the external rectus,
placed over the cheek-bone, in ptosis over the affect-
ed lid, in paralysis of the internal rectus or the inferior
oblique, over the side of the nose at the inner angle of
the eye, in case of the inferior rectus, over the lower
margin of the orbit, and in paralysis of the superior
oblique, on the nose at the internal angle of the eye.
In mydriasis, the zinc pole being on the cheek-bone,
* The interesting article on this subject from which my informa
tion is obtained, is in the "Ophthalmic Review," No. 6, page 143.
It is a translation from the "Archiv. für Ophthalmologie.”
250
THE MUSCLES OF THE EYE.
4
the copper pole should be applied over the closed
eyelid.
The prognosis, under any treatment, of cases
arising from intracranial lesions is unfavorable. Pain
in the head, dizziness, loss of intellectual power,
unsteady movements, and great difficulty in fusing the
double images by prisms, all indicate a cerebral cause.
Among the cerebral lesions may be mentioned tuber-
cular deposits, hydrocephalus, effusions of blood,
aneurisms, softening of the brain and tumors. Os-
titis, periostitis, exostosis, and tumors situated at the
base of the brain, sometimes occasion the paralysis
Similar orbital affections may also cause it.
In children, oftener than in adults, a local paralysis
may be the result of some nervous irritation in a dis-
tant part. Dentition is often the exciting cause, and
in such instances the prognosis is nearly always favor-
able.
In adults the annoyance of the constant double
vision is relieved by bandaging one eye, or by the
use of spectacles, one glass of which may be dark or
frosted.
SURGICAL TREATMENT.
When other remedial measures fail, or only partially
complete the cure, the abnormal direction of the eye
and the resulting diplopia may sometimes be remedied
by an operation to restore the equilibrium of the
SPASM OF THE CILIARY MUSCLE.
251
muscles. The description of operations on the
muscles of the eyeball is given under the article
Strabismus.
PARALYSIS OF THE CILIARY MUSCLE
Is not of common occurrence. It has been noticed
chiefly during convalescence from severe fevers and
debilitating diseases like diphtheria. It may be
produced temporarily by dropping a small quantity
of a solution of sulphate of atropine, four or six
grains to the ounce of water, into the eye. The
patient sees well at a distance, but is not able to
read fine print. Near objects appear indistinct. Suit-
able convex glasses will restore near vision.
Perfect rest of the eyes and frequent bathing in
cold water should be enjoined. The diet in these
cases ought to be generous and nutritious, and hy-
gienic conditions should be made as favorable as
possible. Remedies adapted to the impoverished
condition of the patient's system, like china, ferrum,
or hydras. will be indicated. Recovery is generally
satisfactory.
SPASM OF THE CILIARY MUSCLE
It
Is sometimes met with in hypermetropia.
occasions myopic refraction of the eye, so that the
patient sees better in the distance through concave
glasses. By paralyzing the ciliary muscle, however,
I
252
THE MUSCLES OF THE EYE.
we find that the eye is really hypermetropic; the
spasm appears to be the result of overworking the
ciliary muscle in accommodating (see article Asthe-
nopia and Hypermetropia). The affection may also
be diagnosed by the aid of the ophthalmoscope, which
shows a hypermetropic refraction notwithstanding
the existing myopia for distance. The simple device
of the card with the pinhole, mentioned under Am-
blyopia, may also be of use in diagnosis.
TREATMENT.
The eye should be allowed complete rest, and it
may be necessary to paralyze the ciliary muscle by
the daily instillation of atropine solution for some
weeks, so as to insure complete rest to the ciliary
muscle also. Internally, the general health of the
patient being good, I would use nux v. and gels.,
from having used these remedies with good results
in spasmodic affection of the orbicularis. The in-
ternal use of small doses of physostigma might also
prove serviceable. The spasmodic affection being
cured, the case should be treated as one of accommo-
dative asthenopia.
Nystagmus, or involuntary oscillation of the eye-
ball, is owing to spasmodic twitching of the muscles
which control the globe. It is most frequently seen
in congenital cataract in children, but may be brought
CONCOMITANT STRABISMUS.
253
on by any affection of the eye which causes indis-
tinctness of vision. Its cure can only be effected by
restoring acuteness of vision to the diseased eye.
STRABISMUS (CONCOMITANT STRABISMUS).
When the eye is turned inward it is termed con
vergent strabismus, if outward divergent strabis-
mus. If confined to one eye it is called monocular,
if the squint alternates between the two eyes, it is
binocular or alternating strabismus. In the latter
case, the acuteness of vision in the two eyes being
about the same, the patient fixes, sometimes one eye,
sometimes the other, on the object, the squinting
eye being the one not in use for the time being. In
monocular strabismus the sight of the squinting eye
is almost invariably impaired, and no attempt is
made by the patient to use it.
In treatment it is practical to divide strabismus
also into the periodic and the confirmed, although
the pathology of the two is usually identical, and the
first is but the precursor of the second. Occasionally,
however, we meet with a periodic squint, especially
in children, where the affection may be traced to some
nervous irritation in a distant part, or to the cerebral
irritation from dentition. No doubt that a squint of
this kind arises often from partial paralysis of one or
more of the ocular muscles, and is therefore not
254
THE MUSCLES OF THE EYE.
properly spoken of under the head of Concomitant
Strabismus. In the latter there is a tension or an
increased energy or shortening of a muscle, but the
eyeball can be moved outward or inward at will,
which is not the case in paralytic strabismus.
The commonest cause of concomitant strabismus is
hypermetropia. It is caused also by myopia, and
by amblypopia, corneal opacities, or any circum-
stance which renders vision of one eye defective.
CONVERGENT STRABISMUS
Is usually due to hypermetropia. Donders believes
this to be the cause in seventy-seven per cent, and
Wecker in eighty per cent. It will be remembered
that in the hypermetropic eye the antero-posterior
diameter is too short, and that parallel rays of light
reach the retina before being focussed, and vision is
therefore indistinct: that the refractive power of
such eyes requires to be aided by convex glasses in
order to prevent over-exertion in accommodating
or accommodative asthenopia. In regarding near
objects still greater exertions to accommodate are
necessary, and consentaneous with accommodation
comes the convergence of the visual axis in order to
fix both eyes on the same near point. Convergence
however in such eyes is greater, than under similar
circumstances, it would be in normally refractive (em-
DIVERGENT STRABISMUS.
255
metropic) eyes. A habit of turning the eyes inward
is formed, which results first in a periodic, then in a
permanent, squint. Such squint often makes its ap-
pearance in children at the age of four, five, or six
years, when they are learning to read, and is often
attributed to any cause but the right one. Some-
times its appearance is noticed a few years later, when
the first earnest study is begun. If one eye happen
to be more hypermetropic than the other, the tendency
to squint is still stronger, for this eye may then turn
inward without the annoyance which would otherwise
be occasioned by the production of distinct double
vision. The same would be true if in hypermetropia
one eye happens to be amblyopic or defective in vision
from opacity of any kind.
DIVERGENT STRABISMUS
Is very apt to be associated with myopia. Large
staphyloma posticum, or posterior bulging of the
globe, increases the tendency of the myopic eye to
turn outward, as does also the frequent insufficiency
of power in the internal recti met with in myopia.
On account of the elongated shape of the eyeball it is
almost impossible to turn both eyes inward so as to
make their axes converge to the near point requisite
for myopic vision. Therefore one eye is used and
the other rolls outward. One eye being more myopic
256
THE MUSCLES OF THE EYE.
;
than the other increases the tendency to divergent
strabismus. Great defects of sight in both eyes,
vision being almost absent, are apt to produce slight
divergent squint.
1
TO DETERMINE WHICH EYE IS AFFECTED.
Let the patient regard an object a few feet from
him, then cover one eye with the hand, and note
whether the uncovered eye has to make a lateral
movement in order to fix itself on the object. We
try each eye in this way, and the deviating eye is the
affected one. This determines the primary deviation.
The secondary deviation is the associated movement
which the sound covered eye makes while the squint-
ing eye is adjusting itself upon the object. The
primary and secondary movements are equal in ex-
tent. This is an important fact in the differential
diagnosis of ordinary or concomitant squint and
paralytic squint. In the latter, the secondary devia-
tion is the greater. Suppose the external rectus of
the right eye paralyzed, and the eye turned inward.
Hold an object before the eyes and covering the left,
the right will move slowly outward, perhaps the dis-
tance of a line, in order to fix itself, while the asso-
ciated movement of the covered eye, inward, will
probably equal two or three lines; the reason of this
is plain; the right externus is very weak, the left
售
​TREATMENT OF CONCOMITANT SQUINT. 257
internus healthy; the impulse necessary to turn the
right eye outward is much greater than is necessary
for the associated movement of the left eye inward,
hence the greater movement of the left eye.
The amount of the deviation of a squinting eye,
an important point to be considered in case of an
operation, is found by marking with a pen the point
on the lower lid directly beneath the centre of the
pupil of the affected eye, while it is turned inward or
outward, and then covering the sound eye permit the
former to fix itself on some convenient object when a
second mark beneath the centre of the pupil is again
made. The distance between the two marks gives
the extent of the strabismus. Several instruments
are in vogue also for the measurement of squint, but
the above method is simple, and generally sufficiently
exact.
TREATMENT.
The treatment, of course, will depend very much
upon the cause; also upon the history, duration, the
state of vision, amount of deviation, periodicity or
permanency, and whether monocular or binocular.
All these points are first to be investigated.
When the squint is recent, and the result of ner-
vous disturbance from ascarides, dentition, whooping-
cough, gastric or other visceral affection, the removal
of the primary disease by suitable medication may
17
258
THE MUSCLES OF THE EYE.
restore the eyes to their normal position. Many
cures of this kind are recorded in our literature.
Hirsch* publishes several cases dependent on hel-
minthiasis, cured with spig., cina, sepia, and sulph.
Cyclamen † cured a boy aged two and a half years,
of strabismus of six months' standing, following con-
vulsions. The same remedy also cured a child aged
two and a half months, of squint following measles,‡
and also a coachman of Vienna. The particulars
not given. Gallavardin § cured with hyos. a case
of eight years' standing, in a girl of twelve, but
failed in other cases. Afterwards, following the
treatment of Tavignot, he cured two cases with
phosph., it is said. The treatment with phosph. is
probably better suited to cases of paralytic than con-
comitant squint. Gallavardin recommends alumin.,
bell., hyos., stram., and tabac.
Recent cases dependent on hypermetropia may
often be cured by the use of convex glasses. The
following is a case in point: Mr. B. called, on April
19, 1869, in consequence of a convergent strabismus
* "British Journal of Homœopathy," July, 1857, from the "Neue
Zeitschrift für Homœopathische Klin."
t ↑ "American Homœopathic Review," Vol. II. p. 224.
"Marcy and Hunt's Practice," Vol. II. p. 560.
§ "British Journal of Homœopathy," Appendix, 1860, p. 240.
||Jahr says: For this defect (disposition to squint) I give chil
dren, with the best result, hyos. or bell., in the first place, and if
those do not help, alumin. — Ed. "Medical Investigator."
ORTHOPÆDIC TREATMENT OF SQUINT. 259
He had also se-
His
of the right eye, since two weeks.
vere asthenopia for a number of weeks, brought on
from overuse of his eyes in book-keeping.
general health was perfect. I found a hypermetropia
of about, and prescribed convex glasses, at the
same time cautioning him in regard to over-exertion
of the eyes
At the end of a week the squint, which
at first was more than a line in extent, had nearly
vanished, and in two weeks it was gone. The asthe-
nopia was cured also.
The periodic, divergent squint, seen often in
myopes, may frequently be cured by prescribing the
proper concave glasses, so that they may see distant
objects without effort.
Orthopaedic exercise of the internus or externus
muscle, when the deviation is not of great extent, is
sometimes curative. The exercise is best accom-
plished by means of prisms, and presupposes toler-
able sight in the affected eye. If this does not exist,
bandaging the sound eye systematically for a short
time every day, may, in a few weeks, restore suffi-
cient vision for our purpose.
To correct a convergent squint the prism should
be used with its base inward, thus inducing a correc-
tive squint outward. The eye is turned outward
through the involuntary effort to fuse the double
images, care being taken that the prism be of just
sufficient strength to nearly, but not quite, accomplish
260
THE MUSCLES OF THE EYE.
!
the fusion. In order to exercise the internal rectus
the base of the prism should be directed outward.
These orthopedic measures will generally be found
more efficacious in paralytic than in concomitant
squint. In the latter, however, they may be used to
advantage, when necessary, in perfecting the result
of an operation, and especially in aiding to fuse the
double images, which sometimes are very annoying
even after the most successful operations. Another
method of treatment favorably mentioned for conver-
gent strabismus dependent on hypermetropia, in chil-
dren, is to paralyze the ciliary muscle with atropine,
so as to prevent all attempts to accommodate up to
the time when suitable glasses can be worn. Com-
menced early, during periodic squint, this treatment
has proved successful.
SURGICAL TREATMENT OF STRABISMUS.
When the case is of long standing the operation
of tenotomy is indicated, the object being to divide
the shortened muscle at its insertion in the sclerotic,
and permit it to reattach itself farther back.
The operation which I usually perform, and which
The
I think most advisable, is that of Von Graefe.
eyelids having been separated by a speculum or an
assistant, supposing it a case of convergent strabis-
mus, the assistant turns the eye outward with a pair
of forceps. The operator then seizes with delicate
SURGICAL TREATMENT OF STRABISMUS. 261
forceps a fold of the conjunctiva near the cornea, just
below the middle line of the insertion of the internal
rectus. Snipping it through with the scissors, he
burrows underneath the conjunctiva somewhat, up-
ward, downward, and inward, separating, to a limited
extent, the subconjunctival tissue from the muscle.
The strabismus hook is now inserted beneath the ten-
don at its lower edge to raise it from the globe and
hold it, and the muscle is divided by a succession of
delicate snips with the scissors as near as possible to
its insertion in the sclerotic.
The operation is quite severe, but adults bear it
readily without etherization. Children should be
etherized. Very little after-treatment is required.
If the eye is hot and painful, a cold compress may be
applied over the closed lids, and a few doses of acon-
ite administered. The divided muscle will reunite
itself to the sclerotica within three or four days, and
while this process is being accomplished it is well to
bandage the sound eye so as to compel a central
position for the other, and insure the attachment of
the internus behind its former insertion. The daily
or occasional exercise of the squinting eye, by band-
aging the sound one, for some weeks before the opera-
tion, for the purpose of restoring acuteness of vision,
when the eye is amblyopic from want of use for
years, is commendable.
262
THE MUSCLES OF THE EYE.
If the squint is of considerable extent it is better
to operate on both eyes. For instance, if the stra-
bismus is three lines in extent, by one operation on
the affected eye we may reduce it to one line, then a
slighter operation on the sound eye will bring the
visual axes of both parallel. One operation will not
usually remove more than from two to two and a half
lines of deviation. The effect is increased by a free
separation of subconjunctival tissue from the muscle
when operating. The effect is decreased by avoiding
this. The effect may also be increased after the
operation by making the patient wear glasses, the
right half of each glass being blackened with court-
plaster (the left eye having been operated on), so
that the affected eye is turned far outward during the
process of healing; or, a thread may be inserted in
the conjunctiva and the eye turned outward and held
by attaching the thread to the cheek with adhesive
plaster. The effect may be lessened when, after an
operation, on testing the result we find that we have
done too much, by inserting a conjunctival suture,
bringing the edge of the wound, and with it the
muscle, farther towards the cornea.
The operation of Liebreich is similar to that
of Graefe, except that he separates the subconjunc-
* See " Archives of Ophthalmology and Otology," No. 1, Vol. I
p. 26.
SURGICAL TREATMENT OF STRABISMUS. 263
tival tissue back to the semi-lunar fold, and "divides
the latter, likewise, as well as the caruncle, from the
subadjacent parts," and "lengthens the vertical sec-
tion of the capsule, above and below," and always
closes the conjunctival wound with a suture. He
claims that the effect of the operation in this way
may be so increased that no more than one operation
on one eye is ever necessary; that the sinking in of
the caruncle, and the apparent bulging of the globe
occasionally noticed, is avoided.
Usually the sinking in of the caruncle, and the
accompanying undue prominence in the globe, for-
merly noticed after operations for strabismus, are to be
avoided by limiting the separation of the subconjunc-
tival fascia with the scissors, avoiding, also, all un-
necessarily large excursions with the hook, and,
above all, by being careful to divide the tendon of
the muscle at its insertion, rather than the muscle
itself farther back.
In rare instances, both in paralytic and concomi-
tant squint, it becomes necessary to advance the
insertion of a muscle so as to give it greater power.
The operations mostly practised are those of Crit-
chett, Graefe, and Liebreich, for the descriptions of
which I am obliged to refer the reader to the larger
works on Ophthalmology.
CHAPTER XV.
THE EYELIDS.
BLEPHARITIS, OR OPHTHALMIA TARSI,
Is a follicular inflammation of the edges of the lids,
which are red and swollen. Excessive secretion from
the follicles of the cilia produces a morning aggluti-
nation of the lids in the beginning, and later, in severe
cases, the discharge becomes purulent, there are
pustules and superficial ulceration, the cilia fall out,
the tarsal border becomes thickened and rounded, the
lids are crusted, the puncta lachrymalia no longer
catch the tears, and the excoriation and irritation of
the edge of the lids are kept up by their constant
overflow. The cause of the affection in mild cases
may be overuse of the eyes, especially in an unwhole-
some atmosphere, and such causes, generally, as tend
to produce a hyperæmia of the conjunctiva. Severe
cases occur mostly in ill-fed and ill-housed scrofulous
subjects, and often as a sequence of ophthalmia.
scrofulosa, or of exanthematous fever.
TREATMENT OF TARSAL OPHTHALMIA. 265
TREATMENT.
A
In mild cases, rest of the eyes, avoidance of impure
atmosphere, the application to the edge of the tarsi at
night of simple cerate, or of an unguent of one grain
of white precipitate to a drachm of simple cerate, and
the administration of merc., internally, will suffice to
cure. In severe cases, in bad subjects, we must rely
chiefly on the constitutional means mentioned under
Conjunctivitis Scrofulosa. The name of the unguents
recommended for these cases is legion, but I find one
better and simpler than the others, and generally as
effective as can be expected for an inflammation
which is to be regarded merely as a local manifesta-
tion of a constitutional disease. It is made of two
grains of the red precipitate to a drachm of simple
cerate; a small portion is rubbed between the cilia or
along the edge of the tarsi at night, and in conjunc-
tion with this the red oxide of mercury in the second.
or third trituration, is administered internally. As
an intercurrent remedy, an unguent of pot. iod. two
grains, to the drachm of cerate, with kali hydriod., in-
ternally, I have also used with more or less benefit.
Cleanliness must be rigidly insisted on, the crusts
must be soaked off with tepid water, or milk and
water, every morning, or no treatment will avail
much. For excoriated lids from overflow of the tears
266
THE EYELIDS.
or eczema, a lotion of ten grains of borax to the ounce
of water, to which a few drops of glycerine may be
added, or a solution of one grain of the acetate of
lead to an ounce of water, with the addition of a few
drops of glycerine, will be grateful to the exposed
surface, and prove useful at least, as a palliative.
In such cases slitting up the canaliculus, as directed
in the next chapter, will often aid the tears in finding
their proper channel. Other internal remedies are
those recommended in Scrofulous Ophthalmia.
ACNE CILIARIS
Is a similar, but much milder, inflammation of the
hair follicles at the edge of the lid. It appears
mostly in youthful persons in conjunction with acne
of the face, and is due to the same causes, and requires
the same internal and dietetic treatment. The lids
should be carefully cleansed every morning. I have
found sepia and sulph. the most efficient remedies.
HERPES ZOSTER FRONTALIS. (SEU OPHTHALMICUS.)
A number of affections of the eye have been
observed associated with herpes zoster frontalis.
Among them are conjunctivitis, corneitis, ulceration
of the cornea, iritis, paralysis of the third nerve, and
the ophthalmic branch of the fifth. It has been no-
ticed that unless the vesicles spread to the nose, the
ENTROPIUM, INVERSION OF THE LID. 267
eye usually escapes all complication in the disease;
and that the affection of the eye is generally most
severe when the vesicles extend downward to the tip
of the nose.
The treatment of the eye will be mostly
palliative, and such as has been given in this work
in its proper place. The cure will depend upon the re-
moval of the herpes zoster by the means and reme-
dies laid down in the works of our school on General
Practice. The prognosis in such cases is good, ex-
cept in old and feeble subjects.
MALPOSITION OF THE LIDS.
ECTROPIUM, EVERSION OF THE EYELIDS,
May be caused by the various ophthalmia, and by
cicatrices from injuries. Arlt, of Vienna, used to
advise us in these cases to bandage the eye, the indi-
cation being to shorten the lids and to protect the
exposed mucous surface from the air.
The pressure
is to be made by means of charpie and the bandage,
not upon the eyeball, but at the angles of the lid,
chiefly at the inner angle, so as to increase the ten-
sion of the orbicularis. After three or four days
the improvement will be decided, provided the band-
age has been readjusted whenever displaced.
ENTROPIUM, INVERSION OF THE LID,
Is due generally to old purulent or granular oph-
thalmia, in which, both from the disease, and the im-
268
THE EYELIDS.
proper use of caustics, structural changes of the
conjunctiva have resulted. It is sometimes due, in
the lower lid, to a spasmodic affection. Trichiasis,
the turning inward of the eyelashes, and the conse-
quent irritation of the surface of the cornea, is a usual
feature of this affection. Distichiasis, a double row
of cilia, more or less regularly placed, results also
from old ophthalmiæ. The cilia may be extracted in
these cases with the cilia forceps. The simple excision
of a fold of the skin beneath the lower lid will some-
times remove the entropium. In the treatment of
ectropium and entropium, the palliative measures
mentioned for ophthalmia tarsi and the medical and
hygienic treatment recommended for scrofulous oph-
thalmia will always be indicated. In severe cases
surgical means will be required also. For the mul-
titude of operations suited to the various phases of
these affections, I am reluctantly obliged to refer the
reader to the more comprehensive surgical works.
Syphilitic and cancerous ulcerations of the lid, the
latter being usually of the rodent or epithelial variety,
require the same medical treatment as if situated
elsewhere. I have no new experiences to offer. A
case of rodent cancer of the lid, now under my treat-
ment for about six weeks, and of several years'
standing, is improving under arsen., internally, and
Simpson's paste, externally.
TREATMENT OF TUMORS.
269
TUMORS OF THE EYELIDS.
CHALAZION, OR MEIBOMIAN CYST,
Is a morbid enlargement of a meibomian gland,
generally isolated and in the upper lid, but some-
times found in the lower lid, and sometimes a num-
ber are noticed in one lid at the same time. They
are recognized at first as small hard prominences
which, as they grow larger, gradually become softer.
The contents are gelatinous, or semi-fluid, occasionally
nearly fluid.
Such tumors are usually an indica-
tion of impaired health. Mothers are frequently
subject to them after confinement and nursing.
TREATMENT.
These tumors, in rare instances, disappear without
treatment. I have known several instances of the
kind. Occasionally I have succeeded in curing
them promptly by administering merc., internally,
and permitting the application night and morning,
to the external face of the tumor, of an unguent of
four or six grains of red precipitate to the ounce of
cerate. They may sometimes be cured by restoring
the general health of the patient by medical and
hygienic means, but oftener than otherwise, it will be
necessary to reverse the lid, make a small incision
over the inner surface of the tumor and squeeze out
270
THE EYELIDS.
the contents, or remove them with a small spoon or
curette. The operation may be performed without
etherization, and, by applying the eyelid tourniquet,
may be rendered almost bloodless. The tumor is
diable to recur, and constitutional remedies should be
used to prevent this.
1
OTHER TUMORS OF THE LIDS
Are the sebaceous, or dermoid, which appear at
the upper and outer margin of the orbit, but some-
times at the lower and inner, and when annoying are
to be dissected out. Probably no medical means
will suffice for their removal. Milium or molluscum,
small white tumors, are to be pricked or incised, and
their contents squeezed out. Navi, and aneurisms
by anastomosis, are to be treated as in other parts of
the body.
Warts may be ligatured or snipped off
with the scissors.
HORDEOLUM, OR STYE,
Is a small boil at or near the margin of the lid.
It is rarely necessary to lance it. At the commence-
ment if the fever and pain are considerable, cold
compresses and acon. are indicated, otherwise puls.,
followed by staph., is usually the best treatment. If
dependent on general debility of the patient the dis-
ease will be likely to recur unless the general health
PARALYSIS OF THE ORBICULARIS.
271
is restored. Abscess of the lid is generally the
result of injury. The treatment will be precisely
the same as for abscess in other parts of the body.
In case lancing is necessary the incision should be
made in a horizontal direction, so that the cicatrix
remaining will be scarcely noticeable.
EPICANTHUS
Is a crescentic fold of skin overlapping the in-
ner canthi of the eyes, giving the face in this region
an Asiatic aspect. Operations are undertaken solely
for cosmetic considerations, and although successful
up to the point perhaps of rendering the nationality
of the subject doubtful, cannot always be said to en-
hance the charms of such faces to the extent de-
sired by near relatives. I remember a case of
epicanthus at Sichel's Clinic, in Paris, in a girl six or
seven years of age. Sichel advised pinching up the
skin at the bridge of the nose with the fingers, "ten
or twenty times a day for five minutes." The de-
formity is congenital, and decreases as the child grows
older. The operation for it consists in excising verti-
cal folds of skin in the spaces between the eyes and
uniting the edges of the wound with sutures.
PARALYSIS OF THE ORBICULARIS,
LAGOPHTHALMOS,
After a
Prevents complete closure of the lids.
tine the eye becomes irritable from constant ex-
272
THE EYELIDS.
posure; lachrymation, conjunctivitis, corneitis, and
other evils follow. If the cause of the disease is
peripheral, from exposure to cold or dampness, bry.,
macrot., merc., colch., and similar remedies, will be
indicated. The eye should always be shaded, or light-
ly covered. For the treatment when due to central or
cerebral causes, see Treatment of Paralysis of Mus-
cles of the Eye.
SPASM OF THE ORBICULARIS, OR BLEPHAROSPASM,
Is met most frequently in scrofulous ophthalmia.
It is a spasmodic closure of the lids, associated with
affections of the eyes where considerable photophobia
is present. It is met with in purulent and granular
ophthalmias, corneitis, iritis, hyperæsthesia of the
retina, in supraorbital neuralgias, and in cases of
foreign body in the eye. With the removal of the
above affections, the nature and treatment of which
are spoken of elsewhere, the spasm of the orbicularis
ceases.
Sometimes the disposition to spasmodic closure of
the lids becomes chronic, and long and patient treat-
ment is necessary to effect a cure. I have a case
now under treatment of a year and a half standing.
It is caused by a hyperæmia and hyperesthesia of the
retina. The patient has been under treatment three
months, is now much improved, and will, I think,
eventually be cured. I began with the administration
BLEPHAROSPASM.
273
of nux v. rather than cactus, gelsem., macrot., and
spigel., remedies which I often found useful in similar
irritations of the nervous structure of the eye, chiefly
on account of some general nervous debility, a slight
frontal headache, and want of appetite. The nux v.
was followed by gels. internally and externally (ten
drops of the tincture to half a cup of water, for bath-
ing the lids), and this has proved even more useful
than the nux, relieving the photophobia remarkably.
The patient is now so much better that I am certain
that these two remedies will cure the case. Medium
smoke-colored glasses were prescribed for out-of-door
use. Occasionally, in severe neuralgia, when the
spasm can be relieved by pressure over a branch of
the fifth nerve, the branch has been divided by in-
cision, and the disease cured. Nictitation, a slight
convulsive twitching, or too frequent winking or
blinking of the lids, is often noticed in very nervous
or hysterical individuals. It often accompanies other
nervous debility, is greatly increased by mental agi-
tation, is sometimes under control through great
effort, and at other times quite involuntary. It is
often incurable, but may sometimes be removed by
improving the condition of the nervous system of the
patient. It is occasionally an indication of defective
refraction of the eye, and is then cured by supplying
the patient with the proper spectacles.
18
UorM
274
THE EYELIDS.
PTOSIS,
Or drooping of the upper lid, may be due to para-
lysis of the third nerve, or of the branch which sup-
plies the levator muscle. In such instances the
treatment should, in the main, be that laid down for
paralysis of the ocular muscles. Gels., spig., zinc.,
plumb., and nux, will of course be thought of as act-
ing specifically upon the levator palpebræ superioris.
The disease is sometimes congenital, and some-
times the result of injury. An operation may be
performed for its relief, but is not advisable unless
the ptosis is nearly or quite complete, and occasions
great inconvenience. The best operation is that for
the subcutaneous contraction of the upper lid. A
transverse incision is made along the margin of the
lid, about two and a half lines from its edge. The
lips of the wound being drawn apart, the integument
is dissected from the orbicularis until the latter is
sufficiently exposed. A horizontal strip of the mus-
cle three or four lines in width is then excised, and
the wound closed by sutures, which pass through the
skin and the cut edges of the orbicularis.
Cases of partial ptosis in feeble persons from tu-
mefaction of the lid due to effusion beneath the skin
are not unfrequent, and are to be relieved only by
such general measures as the impaired health de-
mands:
CHAPTER XVI.
THE LACHRYMAL APPARATUS.
EPIPHORA,
OR the excessive secretion of tears, is due to some
mechanical irritation of the eye like that of a foreign
body, an inverted eyelash, to a conjunctivitis or
ophthalmia, and to deep-seated inflammations of the
eye. It is frequently a reflex nervous symptom in
mental emotion and in various disorders of the gen-
eral nervous system. The treatment must, of course,
be directed to the removal of the irritation. It is
perhaps doubtful whether hypersecretion of tears, due
to functional disorder of the lachrymal gland, and inde-
pendent of affections of the eye, ever exists. Profuse
lachrymation is not a symptom of any of the recog-
nized diseases of this gland.
STILLICIDIUM LACHRYMARUM,
Or the ordinary "watery eye," is an entirely dif-
ferent affection, and may always be suspected when
one eye alone is affected, and no immediate cause of
1
276
THE LACHRYMAL APPARATUS.
irritation is present. It arises from an obstruction
to the flow of tears through the lachrymal passage.
Finding no exit, the tears collect along the margin of
the lower lid, and finally drop slowly over its edge
upon the cheek. The lid, after some time, becomes
red and swollen from this constant moisture, and we
have a monocular blepharitis or ophthalmia tarsi.
When the lower puncta have become everted or ob-
literated so as no longer to catch the tears, the punc-
tum and canaliculus are to be slit up, thus converting
the outlet into an open channel.
SLITTING THE CANALICULUS
Is a very simple operation, but by no means as
easy as simple. I generally dilate the orifice some-
what with a delicate probe, and then putting the lid
slightly upon the stretch, slit the canal with a pair
of fine sharp-pointed scissors. Many operators in-
sert a fine grooved director, and using it for a guide,
slit the canal with a cataract knife. Others use a
probe-pointed knife, or probe-pointed scissors, and
still others, the instrument of Giraud Teulon, com-
bining the grooved director and a spring knife. No
assistant is necessary unless the patient is unusually
timid or very young. If the lower punctum happen
to be obliterated, it may be necessary to pass a fine
probe around into its canal by the way of the upper
DACRYOCYSTITIS.
277
punctum in order to determine its exact position
before attempting to lay it open. Many surgeons in
France and Germany prefer opening the upper ca-
naliculus as affording a more direct way to the sac.
When the upper lid is drawn well back, the direction
of the canaliculus is almost in a line with the direc-
tion of the sac, and the abrupt change of the probe
from the horizontal to the vertical position, necessary
when passing it from the lower canaliculus, is avoided.
The upper canal is best slit with a delicate probe-
pointed knife like Weber's.
In rare instances the canaliculus may be obstructed
by a foreign body, such as an eyelash, or a minute
chalky concretion, the removal of which effects a cure
of the case.
ACUTE INFLAMMATION OF THE LACHRYMAL SAC
Comes on rapidly, and is often mistaken for erysip-
elas of the face. The region about the inner angle
of the eye is exquisitely sensitive to touch, the lids
are red and oedematous, and the inflammation and
pain over the sac are intense until it bursts, when
complete relief ensues. The cause of inflammations
and suppurations of this kind is very likely a pre-
vious obstruction to the flow of tears. Retention of
the lachrymal secretion in the sac gives rise to dila-
tation and hypertrophy, and favors the formation of
278
THE LACHRYMAL APPARATUS.
1
abscess. Repeated suppuration leads to complete
obstructions of the passage, to lachrymal fistula, and
to disease of the lachrymal or superior maxillary bone.
Nasal polypi sometimes obstruct the lachrymal pas-
sage. The treatment of these diseases of the lachry-
mal duct and sac will necessarily be mechanical as
well as medical and topical.
TREATMENT OF ACUTE INFLAMMATION OF THE SAC.
Acon. and bell., in this affection, will be required
internally, with cold, or perhaps ice-water, compresses
externally. By these means the formation of abscess
and bursting of the sac, or the necessity of lancing
the sac, are frequently averted. Another means of
averting perforation is to slit the upper canaliculus,
and passing down a narrow knife incise the neck of
the sac, which makes a free opening upward for the
exit of pus.
If the disease has progressed so far
that suppuration is inevitable, it is better to change
from cold to warm applications, and to change our
internal remedies for hepar, merc., or silex. If the
sac is very much swollen, and the skin over it has
become thin, so that bursting is imminent, it is advis-
able to lay it open in a downward and slightly out-
ward direction. If left to find its own way out,
the
matter may escape at some ulcerated portion of the
sac, which permits it to flow beneath the adjoining
TREATMENT OF DACRYOCYSTITIS.
279
cellular tissue, and thus create additional swellings,
and finally find its way through the skin at consider-
able distance from its original seat. Our object
should be to prevent complications of this kind, and
to give the freest and speediest exit to the pus. After
opening, the lips of the wound should be kept apart
by a bit of lint to permit of free discharge, and the
swelling poulticed if necessary. After a few days,
when the inflammation has subsided, the canaliculus
should be opened, and a probe passed into the sac to
afford a free entrance and exit for the tears. The
external opening of the sac may then be allowed to
close.
If a considerable discharge of muco-purulent matter
continues, the sac and duct may be syringed out with
cold water daily, or with a solution of two grains of
alum to the ounce of water. I have seen excellent
results from using a grain or two of sul. of zinc to
the ounce of water, administering at the same time
zinc, or sul. of zinc, internally. I have used also to
advantage a few drops to the ounce of water of tinct.
of sanguinaria in conjunction with the administration
of sang., internally. Generally speaking, however,
vegetable solutions are in these cases less useful than
mineral, in my experience. The solutions are to be
employed daily, or every other day. To syringe the
sac thoroughly, it is sometimes requisite to pass a
+
280
THE LACHRYMAL APPARATUS.
cannula quite into it, attaching the syringe to the
mouth of the cannula afterwards. If necessary to the
introduction of the cannula, which is perhaps as large
as a number four to six of the Bowman probe, the
neck of the sac and the internal palpebral ligament
may be incised with a probe-pointed knife.
The selection of internal remedies is very much
controlled by the general condition of the patient and
by the diathesis. In scrofulous subjects, for instance,
merc., hepar, and calc. seem to be especially suit-
able, and will be indicated sometimes by the general
symptoms. I have also used, with benefit, for such
cases, kalihydriod., injecting daily the same, of the
strength of one to three grains of the salt to an ounce
of water. In other instances, macrot., stilling., and
hydras., often selected for symptoms but remotely
connected with the disease in question, have been ser-
viceable. In acute and subacute cases, if the dis-
charge is copious and purulent, no remedy compares
for promptness and certainty of action with arg. nit.,
externally and internally, while in older or different
cases, when the discharge is scantier and thinner,
cup. sulph., externally and internally, is better. The
injections of these salts should be commenced very
cautiously, with a solution of not more than a grain
to the ounce of water, and then, if necessary, later,
the strength of the solution may be increased. The
FISTULA OF THE SAC.
281
alum and the sul. of zinc are better when the dis-
charge is more mucous in character, but very often in
these lighter cases injections of cold water will be
sufficient, in conjunction with internal remedies. In
chronic cases, unless very mild, and of periodical
recurrence, when internal remedies are curative
through the restoration of the general health, me-
chanical means will be necessary as auxiliaries.
DILATATION OF THE SAC FROM DISEASE.
Firm pressure upon the sac will hasten its reduc-
tion to the normal size and condition. This can be
made by a thick compress held in its place by a
bandage. In chronic dilatation of the sac, where it
is desired to apply the pressure for a considerable
period, it will be found more convenient to use a
small spring truss, attached to a narrow band pass-
ing around the head horizontally just over the eyes,
and kept in place by another band running over the
head at right angles to it.
FISTULA OF THE SAC.
In old cases where the bursting of the sac has
occurred, or repeate lly occurred, a fistulous opening
through the skin remains; and by this channel the
tears flow over the cheek. In these cases an exit for
the tears should be made by dilating the passage
:
2
282
THE LACHRYMAL APPARATUS.
from above. The fistula will then heal of itself, or
healing may be hastened by touching the edges of
the opening with a crayon of mild nitrate of silver, or
sulphate of copper. In cases of this kind, disease of
the bone is sometimes present, and treatment, if
undertaken at all, is often unsatisfactory.
CHRONIC CATARRH, OR BLENNORRHEA OF THE LACHRYMAL
PASSAGES,
May result from an acute inflammation of the sac;
it may be merely an extension of a nasal catarrh, a
catarrhal or granular ophthalmia, but much oftener,
in my experience, it appears to be an idiopathic dis-
ease which comes on slowly and insidiously. A
patient presents himself to be cured of "watering "
of an eye.
He will hardly be able to inform us
accurately of the date of the commencement of his
trouble. It was first noticed in cold weather, and
especially when out in cold winds. Afterwards, it
was annoying in-doors, occasionally, and now the
It
watering" of the eye is continuous.
We diagnose
the case at once by putting a finger over the lachry-
mal sac and pressing gently upwards, when a muco-
serous discharge wells out through the punctum.
may be possible at this stage of the affection to press
the contents downward through the nose. However
this may be, if the patient is willing to give himself
the trouble to press out the contents of the sac sev-
TREATMENT OF STRICTURE BY PROBING. 283
eral times a day, avoid cold winds, over-exertion of
the eyes, and pay proper attention to the condition
of his general health, the chances are that he may go
on for years, and perhaps for a lifetime, without any
increase of the disorder. In addition to these
hygienic regulations, mild collyria of zinc or alum
dropped into the inner corner of the eye with zincum
or aluminum, internally, will often prove greatly
beneficial. Furthermore, when the general health
is at fault, one may frequently remove the lachrymal
disorder by restoring the system to a healthy state.
TREATMENT BY PROBING.
Patients are frequently impatient under the above
treatment, and unwilling generally to follow such strict
hygienic rules; they desire a treatment of some defi-
nite duration, and which offers at the same time a
tolerable chance of permanent cure.
We then pro-
ceed to the removal of the stricture or strictures of
the duct by probing. The probes used are usually
of silver wire of uniform size throughout, like Bow-
man's, or they may be made with a bulb at the ex-
tremity, and flexible or elastic, like those called here
the Williams probe. The Bowman probes are num-
bered from one to six or eight, No. 1 being quite
fine, and No. 8 about of an inch in diameter. I
generally commence with No. 2, and rarely go beyond
16
=
284
THE LACHRYMAL APPARATUS.
1
No. 4 or 5, in size. The probes are flexible, and will
remain bent in any direction we may desire. Gener-
ally, the probe finds its way into the duct more readily
if bent slightly at the end before introducing. In
probing the left duct, we stand before the patient,
and keeping the concavity of the bent probe always
towards us, enter the canaliculus, which has pre-
viously been slit up, passing the probe in a horizontal
direction, inclined slightly upward, at the same time
stretching the integuments of the lower lid outward.
Having reached the sac, as determined by the firm
resistance of its inner wall to the end of the probe,
and by the observation that the integuments at the
inner angle of the eye do not appear to resist the
probe or move forward with it, we turn the instru-
ment in a vertical direction, and pass it down into the
sac. To find and enter the nasal duct readily, the
direction of the probe will now require to be slightly
changed, so that its extremity shall point a little
outward and forward, and, having entered the duct,
it is to be pressed gently downward to the floor of
the nose. If operating on the right lachrymal pas-
sage, we may hold the probe in the left hand, or,
stand behind the patient, and use the right hand.
•
Probes of whalebone, gutta-percha, or laminaria
digitata, a species of sea-weed, are sometimes used.
The latter imbibe the moisture of the parts, and swell
1
1
TREATMENT OF STRICTURE BY PROBING. 285
up to double, and sometimes treble, their original
size when introduced.
A stricture may be situated at any point of the
passage. Its most frequent seat is where the canalic-
uli join the sac, or below, where the latter is nar-
rowed into the nasal duct. It is to be overcome by
firm, but gradual and gentle, pressure downward.
Frequently a change from a larger to a smaller probe
will be successful. Generally, however, the larger
one is to be preferred if much pressure is necessary,
as less likely to lacerate the lining membrane. Tact,
gentleness, and sometimes a good deal of persever
ance, are necessary. One may sometimes try for two
or three weeks, at intervals of two or three days, be-
fore overcoming a stricture. When we find it im-
possible to enter the sac from the lower canaliculus,
we may succeed, perhaps, from the upper, or it may.
be necessary to divide the stricture before the probe
can be introduced, with a narrow bistoury. Weber's
delicate probe-pointed knife, or the narrow knife of
Stilling, are suitable. The conical probe of Weber,
which increases rapidly in size from the point, may
often be used as a dilator to advantage, and the use
of the knife be dispensed with. Occasionally, the
lining of the sac is so much thickened from inflam-
mation and swelling, that it seems impossible to find
the entrance of the nasal duct from the sac.
In
}
I
286
THE LACHRYMAL APPARATUS.
such instances, we may do better to relinquish all
attempts at probing until time and the employment
of local and constitutional remedies have reduced the
inflammation somewhat, when the probing may be
ngain attempted with better chances of success.
Having once succeeded, the operation should be
repeated on every second or third day, gradually
increasing the size of the probe, and gradually in-
creasing the length of the intervals between each op-
eration, until the flow of tears through the passage
is unimpeded, and the secretion becomes normal in
quantity and appearance.
THE USE OF THE STYLE.
Attempts have been made, and apparently with
considerable success, to obviate the necessity for re-
peated probing, by the use of styles. Unlike the
old-fashioned ones, these styles are introduced, like
the probes, from above, and are to be used for some
months. When the discharge is not great they may
be worn days or weeks without changing, and it is
claimed that the irritation set up when the style is
first attempted to be worn soon passes off, and the
patient finds it comfortable. They are made of silver
or lead of different sizes, and may be flattened at the
upper
end so as to be bent over the lower lid like a hook.
Where there is difficulty in keeping up the dilation of
GENERAL REMARKS.
287
the strictured portion of the passage, and frequent
relapses occur, it would seem that this method offers
.
24
a chance of a permanent cure. It is said also to be
available in cases where frequent visits to the surgeon
are impossible. The styles are of wire, from to
12 of an inch or more in diameter, and one and
three-quarters if for the lower, or two inches in
length, if intended for the upper canaliculus.
METHOD OF STILLING.
The new method of Stilling proposes to cure the
disease radically by a single operation. He first
finds the seat of the stricture by probing, and then
withdrawing the probe, introduces a small narrow
knife in its place, and incises the stricture in three or
four different directions. This, according to the
author, and others who have practised his method, is
sufficient for a permanent cure, even in very severe
The rationale of this treatment is not very
apparent. If it prove as successful as represénted, it
will be a welcome resource in obstinate cases, even
if too severe a procedure for ordinary practice.
cases.
GENERAL REMARKS.
The most frequent obstacle to the permanant cure of
catarrh or blennorrhea is the tendency of the lachry-.
mal passage to close again after it has been sucess-
288
THE LACHRYMAL APPARATUS.
fully dilated. I believe this tendency may be best
overcome by a moderate and gentle dilation of the
passages, and, when possible, avoiding all bruising,
lacerating, and even cutting, of the lining membrane,
and then by constitutional and local remedies, endeav-
oring to restore the diseased mucous surface to as
healthy a condition as possible. Professor Arlt, of
Vienna, rarely goes beyond the No. 4 Bowman probe,
in size. He prefers not to risk a rupture of the
epithelial lining of the passage, and remarks that at
its nasal portion its normal capacity is not much
greater than a No. 4 probe, and that where the cana-
liculi join the sac the diameter is less than that of
No. 5. The following is his measurement on the
cadavre of the sac and duct. A millimetre is equal
to about two-fifths of a line:
THE SAC.
Length, ten. Width, four. An-
tero-posterior diameter, two
millimetres.
THE NASAL DUCT.
Length, about ten. Width and
antero-pos. diam., each 1 to
2 millimetres.
In the zeal for dilating the duct as widely as possi-
ble, so as to prevent its reclosure, the catarrhal inflam-
mation of the lining membrane and the dilatation of
the sac are overlooked. The permeability of the
tear passage, although a necessary stage in the prog-
ress of cure, does not always complete it. The ab-
normally dilated sac is to be reduced by pressure, and
THE LACHRYMAL GLAND.
289
the catarrh treated by local and constitutional reme-
dies, otherwise the germs of fresh inflammations are
left behind, and the old obstruction reappears.
OTHER OPERATIVE MEASURES.
The operation for obliteration (so called) of the
lachrymal sac by incision, and the application of
caustics, or the actual cautery, has fallen nearly into
disuse. The sac is rarely obliterated by the opera-
tion, and the result is generally unsatisfactory.
Herzenstein's operation for rupturing portions of
the lachrymal passage does not seem to have met
with favor as yet. The removal of the lachrymal
gland, as practised by Mr. Laurence for severe cases
of stillicidium, appears to promise more, but will very
likely be found too severe an operation for private
practice, unless in very exceptional cases.
THE LACHRYMAL GLAND.
The lachrymal gland is subject, in rare instances,
to acute and chronic inflammations, hypertrophy,
fistula, and to cystic formations. The acute and
chronic inflammatory affections of this gland are
amenable to such treatment as would be suitable for
similar affections in other parts of the body. The
disease of the gland is so rare that details of symp-
toms and treatment may be left for larger treatises.
19
290
THE LACHRYMAL APPARATUS.
In more than one hundred thousand cases of disease
of the eye observed at the Ophthalmic Hospital in
London, less than twenty cases of affections of this
gland are recorded.
CHAPTER XVII.
AFFECTIONS OF THE WHOLE EYE AND OF THE
ORBIT.
HYDROPHTHALMIA, KERATO-GLOBUS.
DROPSY of the eye (so called) affects principally
the anterior half of the eyeball. The peculiar stare
which the prominence of the eyes gives the patient is
very striking. The cornea are increased in size, the
anterior chambers in depth, and the irides are trem-
ulous for lack of support. The pupils are dilated,
and sometimes pear-shaped, and ultimately vision is
more or less impaired. The sclerotica grows thin
and bluish as the disease progresses, and all parts of
the eye are finally involved. The progress of the
affection is usually slow. It is probably incurable.
Remedies like arsen., merc., and those suitable for
affections of the cornea generally, may be prescribed,
in the hope, at least, of retarding the progress of the
malady. Surgically, repeated paracentesis corneæ,
and iridectomy have been productive of benefit.
292
AFFECTIONS OF THE WHOLE EYE
EXOPHTHALMIC GOITRE, GRAVES' DISEASE,
As far as progressive bulging of the globe is con-
cerned, resembles dropsy of the eye. It is associated
with hypertrophy of the thyroid gland, palpitation
of the heart, and subsequent dilatation of its cavities,
anæmia, visceral derangements, and in females with
amenorrhoea. The disease is also accompanied by
great nervous excitement and a capricious temper. Its
progress is slow, and the prognosis is not as uniformly
unfavorable as in dropsy of the eye. The treatment
cannot be laid down on account of the almost num-
berless complications which the disease may present,
but I have no doubt that judicious homœopathic
treatment would afford encouraging results. Hydro-
pathic treatment is to be favorably mentioned as
having been serviceable in this affection.
MEDULLARY CANCER OF THE EYE
Has been spoken of under the name of glioma
retinæ. Melanotic cancer is probably the same
disease, with the addition of more or less black pig-
ment in its structure. Sarcoma is a recurrent growth,
requiring similar treatment to cancer, but exhibits
less tendency to secondary deposits. Before break-
ing through the anterior tunics of the eye, it has been
mistaken for glaucoma. It can only be distinguished
"
AND OF THE ORBIT.
293
from cancer by microscopic examination. Ophthal-
mitis, or suppuration of the whole eye, is noticed in
the chapter on the Choroid.
DISEASES OF THE ORBIT.
I have not the space to speak in detail of diseases
of the orbit, and must refer the reader to works on
general surgery. As regards diagnosis, tumors of
the orbit are accompanied by more or less protrusion of
the eye, and by diminished mobility of the globe, and
sooner or later there is impaired vision. In inflam-
mation and abscess of the cellular tissue there will be
added to these symptoms pain in and around the ball,
and tenderness on pressure of the globe backward.
Tumors will generally require to be removed together
with the eyeball, and inflammation and abscess will
demand the same general treatment as if located
elsewhere.
CHAPTER XVIII.
INJURIES OF THE EYE.
THE EYELIDS.
FOR contusions and ecchymoses of the eyelids we
have excellent remedies in our arnica, hamamelis, and
calendula. Lacerated or incised wounds are to be
treated as usual in other parts of the body, except
that especial care should be taken in accurately ap-
proximating the edges of such wounds in the lids, so
as to guard against deformity. In burns and scalds,
great care will be necessary during the cicatricial
period to prevent plastic union of the two lids at
the angles. This is to be prevented by inunction
with simple cerate, and by directing that the lids
be frequently opened. To prevent ectropium and a
contraction which might prevent the eye from closing
(lagophthalmos), the lids should be kept as much as
possible on the stretch, and be bandaged with ex-
treme care. For the same reasons it is always advisa-
ble, when possible, to bring the edges of wounds of
the lids together by fine interrupted suture, rather
THE TREATMENT OF CHEMICAL INJURIES. 295
than leave them to unite by granulation, and risk a
loss of substance and contraction.
INJURIES OF THE CONJUNCTIVA,
Of a chemical nature, are quite common. Those
from quick lime are of the most serious to which the
eye is subject. Complete destruction of the tissues
of the parts, with which the lime comes in contact,
may result. Slaked lime, mortar, and plaster are
not so rapidly destructive in their effect, but may in
the end prove nearly as fatal. The chief danger,
even in cases where the burn is not very extensive or
very deep, is in loss of sight from opacity of the cor-
nea. The whiteness of the corneal opacities in these
cases is very marked, and it has been demonstrated,
recently, that the cicatricial tissue reproduced after
these injuries contains lime.
THE TREATMENT.
It is wiser not to attempt to neutralize the alkali
by the use of weak acid. The eye is very intolerant
of acids in these cases, and they can hardly be of
service unless applied immediately after the accident.
It is better therefore to resort to olive oil at once, a
small quantity of which is to be dropped into the eye.
The lids are then to be everted, and the loose parti-
cles of lime removed with a delicate spatula. If the
296
INJURIES OF THE EYE.
epithelial layer of the cornea is destroyed it should
be removed, and, if possible, the cauterized portions.
of the corneal substance should also be taken off, so
that the reproduction of tissue may not only be
speedy, but that the new tissue may be free from
depositions of lime, and transparent. After the ap-
plication of a few drops more of sweet oil, the lids
should be closed, cold-water dressings used for the
first few days, and acon. and arn. administered.
In
In injuries from strong acids, a solution of carb. of
potash, or soda, five grains to an ounce of water, may
be used at first if the eye is seen soon after the injury.
When this is not convenient, warm water may be
substituted. Olive oil should then be used.
burns and scalds of the conjunctiva from hot fluids,
olive oil should also be applied, the lids closed, and
the eye lightly bandaged, as directed in chapter
second. Oil should be dropped into the eye two or
three times a day, the lids cleansed from all discharge,
and the bandage readjusted. Acon. and arn. will be
the remedies indicated for internal use.
Injuries from gunpowder are sometimes serious,
not only from the scorching and burning of the con-
junctiva from the explosion, but from the circum-
stance also, that unexploded grains of the powder are
deposited in and upon the conjunctiva, and are some-
times forced through it into the tissue of the sclerotic,
1
FOREIGN BODIES IN THE CONJUNCTIVA. 297
and often imbedded in the substance of the cornea.
The lids are to be everted and syringed so as to re-
move all loose powder, then all superficially imbedded
grains in the conjunctiva and cornea are to be removed
with the spatula or broad needle, and olive or castor
oil dropped into the eye two or three times a day,
and such general treatment resorted to as seems
necessary.
Mechanical injuries of the conjunctiva, from
foreign bodies such as cinders, dust, particles of iron,
steel, glass, and the like, generally occasion a good
deal of injection, and not unfrequently severe ciliary
neuralgia, photophobia, and lachrymation. In the
case of a single foreign body, like a cinder, it will
generally be found beneath the upper lid, and some-
times far back in the retrotarsal region. A small
spatula may be used to remove it. It is not worth
while however for a surgeon to attempt to do this
without everting the upper lid, nor by the introduc-
tion of other foreign bodies, like smooth pebbles
called eye-stones, or smooth round seeds. Leave
such proceedings as these to the foremen of establish-
ments, and to domestic practitioners. The method
of everting the upper lid is described elsewhere.
A
year or more ago a lady came to me for a conjunc-
tivitis of one eye, accompanied by severe ciliary irri-
tation, pain, and photophobia. She had been for
298
INJURIES OF THE EYE.
three weeks under the treatment of a colleague, and
during all this time she thought that she had not had
one comfortable night's rest. Her symptoms all
pointed to a foreign body, and on everting the upper
lid, there laid partially imbedded in the substance of
the conjunctiva, a minute bit of quartz with its sharp
edges and angles. Its removal cured her at once.
She had suffered for three weeks, when the exercise
of a little circumspection would have relieved her at
any time in three minutes. Splinters or other sub-
stances beneath the conjunctiva, if found impracti-
cable to remove with delicate forceps, may be cut
out with curved scissors. Impalpable particles of
dust or sand may be washed out with the syringe and
warm water.
In the "American Journal of the Medical Sciences,"
vol. 50, p. 561, among other cases of neglected foreign
bodies in the eye, is that of a German who was treated
some time for granulated lids, until finally the cause
of the affection was discovered in a neglected "eye-
stone" which he had put into his eye six months pre-
viously, and which he thought had dropped out while
he was asleep, as his wife said she had seen it in the
bed. The removal of the "eye-stone" cured the eye.
In the “Ophthalmic Review," vol. 1., p. 337, is re-
lated in full, the case of an old man who fell to the
bottom of the stairs, and applied to a surgeon for a
SYMBLEPHARON.
299
wound in the conjunctiva at the inner angle of the
After a week's treatment the presence of
right eye.
a foreign body was suspected, and the next day a cast-
iron hat-peg three and three-tenths inches in length
was drawn from the wound. The patient, wonderful
to relate, recovered without unfavorable symptoms.
Small particles, like gravel or dust, are to be removed
by everting the lids and syringing them, and also by
the use of the spatula or blunt probe, when necessary.
ANCHYLOBLEPHARON
Is the union of the margin of the lids with each
other, either directly or by membranous bands. It
is a result of injury, or ulceration from disease. The
union is to be severed with the scissors or the scalpel,
and reunion prevented by frequent separation, and
by anointing the cut surfaces with olive oil.
SYMBLEPHARON
Is the union of the inner surface of the lids with
the eyeball, and may also be direct and close, or by
membranous bands. In the latter case, the bands of
union may be divided, and daily dressing with olive
oil may possibly prevent a reunion. Generally
however, and especially when the adhesions are at all
extensive, reunion after separation cannot be pre-
vented, and all attempts of whatever nature are
300
INJURIES OF THE EYE.
fruitless. The condition is irremediable.
The cause
of the affection is an injury, usually a burn from hot
fluid, metal, lime, or mortar.
DIAGNOSIS AND TREATMENT OF FOREIGN BODIES WITHIN THE
GLOBE.
The diagnosis is sometimes quite difficult. When
the foreign body cannot be seen, with or without the
aid of lateral illumination and the ophthalmoscope,
we may suspect its presence;
If the pain does not yield to the usual palliative
treatment, and is apparently disproportionate to the
visible inflammation.
If the inflammation does not appear to be con-
trolled by the treatment, to the usual extent.
If symptoms of inflammation of the deeper struc-
tures of the eye are present.
If there is a circumscribed iritis with exudation,
limited to a given point, no foreign body being visi-
ble, the eye having been struck by a splinter of metal.
I recall a case like this in the clinic of Professor
Graefe, where he made an iridectomy, and then re-
moved the invisible bit of metal from behind the iris.
If there is non-union, or only partial union, of a
wound through which a foreign body may have
entered the eye.
In cases like the above, where the irritation or
eye.
FOREIGN BODIES WITHIN THE GLOBE. 301
inflammation is continuous, an attempt should be
made to find and remove the foreign body, and fail-
ing in this, the eye should be removed. Where the
foreign body can be seen, it should be removed in all
cases when it can be done without serious risk of loss
of the eye. It must be extracted at any hazard to
the eye, if irritation, pain, and inflammation, are
engendered by its presence, lest sympathetic inflam-
mation destroy the other eye. Inflammation recur-
ring in an eye which has lost all visual power from
former injury, whether the presence of a foreign
body be suspected or not, demands the removal of the
When a foreign body, like a bit of percussion
cap for instance, remains in the eye, but causes no
irritation, the sight of the eye being unimpaired by
it, and its extraction would be hazardous to the eye,
it may be left in its place; but the patient should be
enlightened as to the nature of the risk he is taking,
and be instructed to return to the surgeon the moment
symptoms of irritation come on in the injured eye.
The insertion of an artificial eye after the operation
of enucleation for sympathetic ophthalmia, should
be deferred for a number of months after all irrita-
tion in the remaining eye has disappeared. This
extreme caution is necessary, lest symptoms of irri-
tation be reawakened by the presence of the artificial
eye.
302
INJURIES OF THE EYE.
THE CORNEA.
Injuries of the cornea are more to be feared than
those of the conjunctiva, from the fact that opacities
upon its surface impair vision. Fragments of metals,
or splinters, in its substance, occasion great ciliary
irritation, pain, injection, photophobia, and lach-
rymation. If the foreign body, owing to its small size
or color, is difficult of detection, the pupil may be dilated
with atropine so as to enlarge the dark background,
and then oblique illumination and a magnifying glass
employed. A delicate spatula or broad needle may
be used for removing the foreign substance, and in
unruly or very nervous subjects, it may be necessary
to fix the eye with forceps. This is not usually neces-
sary; but the operation of removing substances im-
bedded in the cornea is one of considerable delicacy,
and sometimes requires a good deal of quickness and
dexterity. Chemical injuries of the cornea may be
treated as directed under Injuries of the Conjunctiva.
Clear cuts, or punctures of the cornea, heal readily,
and generally leave no scar behind. The danger in
these cases lies in the possibility that the iris or the
lens may have been wounded, and iritis or cataract su-
pervene. The treatment of wounds or injuries of the
cornea requires entire rest of the eyes, and the admin-
istration of acon. or arn. ; if the ciliary neuralgia be
THE IRIS AND LENS.
303
considerable, cham., spig., or macrot., warm fomen-
tations and the instillation of atropine, as palliatives,
may be required. Olive oil or castor oil is very grate-
ful to the eye after the removal of a foreign body,
and in abrasions of the epithelial surface of the cornea,
and the simple bandage described in the second chap-
ter of this work should be applied.
THE IRIS AND LENS.
If a wound of the iris is clean, with no laceration,
it may heal at once without iritis or suppuration. If
a bit of iris protrude through an opening in the cor-
nea, and cannot be readily replaced, either by careful
manipulation, or the employment of atropine or cal-
abar bean, it may be excised. Foreign bodies, such
as bits of percussion cap, or steel, remaining in the
substance of the iris, will almost invariably set up an
iritis, and should therefore be removed by an iridec-
tomy, excising that portion of the iris in which the
foreign body is situated. Injuries of the cornea and
iris, like other injuries, sometimes result much less
disastrously than we have reason to predict. I recall
the case of a child two years old, that had run a blade
of a pair of scissors into the right eye towards the
inner angle, penetrating the cornea and iris. I ex-
pected of course, traumatic cataract, but the direction
of the instrument was such that the capsule of the
304
INJURIES OF THE EYE.
lens was left intact. Iritis ensued, yet, the eye finally
recovered perfectly, leaving no corneal opacity behind,
and no deformity, except a slight displacement of the
pupil from a small synechia posterior, at the point of
perforation of the iris. In all wounds, when the
anterior or posterior chamber has been entered, the
eye should be bandaged immediately.
Hemorrhage into the anterior chamber may result
from a wound of the iris, or from a detachment of its
ciliary border. It may be so extensive as to com-
pletely hide the pupil and iris from view. I have
known it to occur to this extent in the operation of
iridectomy. It is the least dangerous form of intra-
ocular hemorrhage, and the blood is usually soon
absorbed. A fold of linen wet from time to time with
a lotion of ten drops of tinc. ham. to the ounce of
cold water, should be laid over the closed lids, and a
simple bandage applied.
When a wound of the anterior chamber is large,
and the iris bulges, forming a sac distended with
aqueous humor, it is not safe to excise it lest a further
prolapse occur. It should be pricked at intervals,
with a fine needle, so as to cause it to dwindle, and
permit the edges of the wound to approximate.
Later, it can be excised, if necessary. Traumatic
cataract has been already spoken of.
SYMPATHETIC OPHTHALMIA.
305
THE SCLEROTICA.
Incised wounds in the sclera are not usually dan-
gerous unless very extensive, but do not heal as
readily as wounds in the substance of the cornea.
Care must therefore be taken that the edges of the
cut approximate exactly, and, if necessary to this end,
a fine suture may be employed. Rupture of the
sclerotic is a far more dangerous accident, frequently
involving dislocation of the lens, prolapse of the iris,
great loss of vitreous and internal hemorrhage of the
eye. Soothing applications should be made, and if
after a few days no perception of light return, it is
better and safer to enucleate the injured globe.
Injuries in the ciliary region are chiefly dangerous
as giving rise to sympathetic ophthalmia.
SYMPATHETIC OPHTHALMIA
Is the name given to the inflammation set up in
the sound eye as a result of injury to its fellow eye.
Injuries in the ciliary region, with loss of vitreous
and wounding of the lens, are the most frequent cause.
Foreign bodies remaining within the eye are also a
frequent cause, and although such bodies may not
give rise to irritation in the wounded eye for many
years, where once the irritation occurs, sympathetic
ophthalmia in the other eye is often the result.
20
306
INJURIES OF THE EYE.
Sympathetic disease is never to be considered as im-
possible so long as there is tenderness of the injured
eye to touch in the ciliary region.
The nature of sympathetic ophthalmia is that of a
malignant and destructive iritis, which spreads rapidly
to the ciliary body and the choroid. In the beginning
there is irritation, some injection of the conjunctiva,
photophobia, lachrymation, increased tension, and
severe asthenopic symptoms quickly supervening
upon any attempt to use the eyes for reading, or for
any similar purpose. At this stage of the affection
there is no pain when the eyes are at rest; later,
there is some supraorbital neuralgia, iritis, great effu-
sion of lymph, adhesion between the iris and anterior
capsule, the choroid and vitreous become involved,
and atrophy of the latter is followed by softening of
the globe.
ENUCLEATION OF THE INJURED EYE.
The only justifiable course to pursue when sym-
pathetic ophthalmia is once begun in the uninjured
eye is to remove the injured one at once. Enuclea-
tion of the ball, under complete etherization of the
patient is not a formidable procedure. The lids are
to be well separated by a speculum: one or two as-
sistants with sponges should be near to remove the
blood during the operation, so that the view of the
ENUCLEATION OF THE INJURED EYE. 307
operator may be as little obstructed as possible.
Suppose the left eye to be removed. The operator
stands in front of the patient, who lies on a couch.
Seizing the conjunctiva at the outer side of the globe
near the insertion of the rectus externus, with the
forceps, he makes an incision, and carries his blunt-
pointed scissors quite around the circle of the cornea,
dividing the conjunctiva as near the corneal limbus
as possible. He then inserts a blade of the curved
scissors beneath the external rectus, and divides it
close to its sclerotic insertion. Relinquishing now
his first hold with the forceps, he seizes the globe at
the point of insertion of the rectus muscle, just
divided, in order to obtain a firmer hold, so as to
move the eyeball at will. The superior and inferior
recti and oblique muscles are successively divided
with the scissors close to the ball, and then with
larger scissors, the globe being pulled as far forward
and towards the nasal side as possible, the optic nerve
is cut a gush of blood follows from the ophthalmic
artery, the forceps are relinquished, the ball is grasped
with the fingers, the rectus internus divided, and the
enucleation is completed. The hemorrhage is trivial,
and readily controlled by cold water. In case of
encephaloid of the globe, or tumors of the orbit, and
like cases, the difficulties of the operation are much
increased, and the various steps in it will be different,
and other instruments may be necessary.
308
INJURIES OF THE EYE.
WHEN TO REMOVE THE INJURED EYE.
How soon, after the first symptoms of sympathetic
irritation manifest themselves in the sound eye, shall
the injured one be removed? Inasmuch as symptoms
of irritation do not always give rise to the disease,
and as the disease if it occur, is not absolutely cer-
tain to be of that fatal type which ends in de-
struction of the eye, and the total blindness of our
patient, how long may we wait with safety? This
question is sometimes difficult to answer; but in case
the injured eye is already blind, or all hope of resto-
ration of vision lost, we need not wait at all, for in
such an event its removal is in no respect contra-
indicated, and will in all instances guarantee the
integrity of the remaining eye, provided no symptoms
of sympathetic ophthalmia have yet made their
appearance. After sympathetic disease has once
commenced in the uninjured eye, the removal of the
other is not a certain, although the best, remedy
known, and succeeds in saving the remaining eye,
especially if done at an early stage of the disease, in a
vast majority of cases. Another means, that of divi-
sion of the ciliary muscle, has recently been practised
with some success. It might be worth while to try
this, provided tolerable sight in the injured eye were
still probable. An incision in the conjunctiva at that
A CASE OF INJURY OF THE EYE.
309
point in the ciliary region, which is sensitive to the
touch, is made with the forceps and scissors. The
eye being steadied, a puncture is made in the scle-
rotica over the ciliary muscle, with a cataract knife,
and the wound is closed with a suture.
The general treatment should enforce the strictest
hygienic regulations, absolute rest of the eyes, a sub-
dued light at home, and the protection of dark glasses
out of doors. The diet should be nutritious
be nutritious and
generous. The pupil should be kept dilated ad max-
imum, and internal and other remedies, such as
recommended for iritis, are to be used.
A CASE OF INJURY OF THE EYE.
I have a patient at the present time, a farmer, aged seventy, who
in chopping wood was struck on the eye by a chip. I saw him the
next day. He was suffering severely from ciliary neuralgia. No
wound or bruise of the cornea or sclerotic was observable. Vision
was so much impaired that only night from day could be distinguished.
The iris was completely paralyzed by the shock, the pupil dilated
and immovable. Ophthalmoscopic symptoms negative from cloudi-
ness of the vitreous humor. After a few days, under the internal
administration of bell. and spig., and the external use of arn., warm
fomentations, and atropine instillations, the pain subsided, and the
eye felt comparatively comfortable. Soreness of the ball remained,
and remains still. There was a mere perception of light in the eye,
and no more. At one time, about three weeks after the injury,
the sight improved so that large objects could be discerned; it then
gradually failed, and is now wholly gone. The eye has not been
removed for these reasons.
Although there is considerable pain, photophobia, and lachryma-
tion, at times, in the sound eye, as well as in the injured one, I find
310
INJURIES OF THE EYE.
that it never occurs spontaneously, but only after work in the fields,
or from other occupation requiring a stooping position.
The patient is seventy years old, and the probability of the oc-
currence of sympathetic ophthalmia is much less in aged than in
youthful subjects. He lives near, and can remain under my imme-
diate supervision. These circumstances determined me to wait and
operate only when the first threatening symptoms of sympathetic
disease in the sound eye should appear. A year has now elapsed,
the eyes are still irritable, permit of little use for near objects, but,
on the whole, there is a steady improvement.
SYMPATHETIC IRRITATION,
In the uninjured eye, may occur without giving rise
to ophthalmia. It may be recurrent, coming on
whenever there is an exacerbation of the inflammation
in the injured eye, but it is to be distinguished from
sympathetic ophthalmia by the important fact that no
iritis with.effusion of lymph is present. There is
some injection, lachrymation, ciliary neuralgia, and
severe asthenopic symptoms whenever use of the eye
is attempted. Removal of the injured eye cures
sympathetic irritation at once. When this operation,
or division of the ciliary muscle, is not resorted to,
measures directed to the improvement of the injured
eye, through internal medication, soothing applica-
tions, and strict hygienic precautions, may be tried.
CHAPTER XIX.
LIST OF A FEW INTERNAL REMEDIES WITH THE OPHTHALMIC
AFFECTIONS, OR THE SUBJECTIVE AND OBJECTIVE SYMPTOMS
OF THE EYES, FOR WHICH THEY HAVE BEEN FOUND USEFUL
IN MY PRACTICE.
THE list which follows comprises merely the
remedies which have been administered from indica-
tions furnished by the eye alone. Others have been
found useful also, but they have been selected on
account of symptoms apart from those of the eye,
and such as are familiar to all general practitioners.
Many remedies having a strong affinity for the eye,
judged by their pathogenesis, have not, in my ex-
perience, been found reliable. The diseases or symp-
toms given below have been repeatedly cured or
relieved by a single remedy, the name of which is
placed opposite each group. The dilutions or tritu-
rations used were the first, second, or third.
ACONITE. — In the early stage of inflammations of the conjunc-
tiva, cornea, and iris, and after surgical operations.
ALUMINA. In chronic blepharitis of adults, and in blennorrhoea
of the lachrymal passage, with thin discharge (ars.).
ARG. NIT. — In affections of the lining membrane of the lids, and
of the lachrymal duct and sac when there is a copious dis-
charge of pus.
1
ARNICA. — In injuries, and in hemorrhage beneath the conjunctiva.
3
312
INTERNAL REMEDIES.
ARSENICUM. In superficial and deep-seated ulceration of the
cornea, especially in scrofulous subjects. Catarrhal oph., with
thin secretion and irritation of the edges of the lids. Ulceration
of the tarsal edges, with thin secretion, and in ophthalmia
scrofulosa generally.
ATROPIA.
See the remarks at page 150 on the internal effects of
liquids dropped into the eye. Ophthalmia scrofulosa where
there is extreme intolerance of light. Iritis of all kinds.
Ciliary neuralgia. Neuralgia oculi. Internal congestions of
the eye where tension of the eyeball is increased.
BAPTISIA. — In mild purulent ophthalmia (puls.).
BELLADONNA. — In photophobia; injection of the ocular conjunc-
tiva: congestion of the retina and optic nerve; dilation of the
pupil; ciliary neuralgia and pain in the optic nerve, with con-
gestion. Neuritis optica (diagnosed with the ophthalmoscope).
Scrofulous ophthalmia with great congestion of the conjunctiva
and photophobia.
CONIUM. Photophobia in scrofulous subjects or in scrofulous
ophthalmia (tart. emet., bell., ars., merc., hepar, spig.).
BRYONIA. Scleritis or episcleritis. Conjunctivitis with soreness
of the eyeballs to the touch and on moving them (sang.).
CACTUS. Hyperæmia of retina and optic nerve; optic neuritis.
Asthenopic symptoms in conjunction with a tendency to con-
gestive headache or flushed face.
CHAMOMILLA. Ciliary neuralgia, especially in scrof. or purulent
ophthalmia of children (spigel. bell.).
CUPRUM AND CUP. SULPH. -In chronic ophthalmiæ, with rather
scanty mixed discharge of pus and mucus. Pannus.
EUPHRASIA.
Simple or catarrhal conjunctivitis, with copious
secretion or lachrymation (puls.).
GELSEMINUM, Accommodative asthenopia, with the usual sub-
jective symptoms. Diplopia (from functional disturbance of
accommodation in one eye). Ptosis from partial paralysis.
Chronic spasms of the orbicularis. Nictitation. Hyperæsthesia
retinæ, with photophobia (nux v.).
GLONOINE. Venous hyperæmia, or congestion of the retina and
optic nerve (cactus, phosph, sang., bell, zinc, zinc. phos.).
GRAPHITES. — Blepharitis, with pustular eruption along the tarsi
and loss of cilia (hepar).
INTERNAL REMEDIES.
313
HAMAMELIS. — Redness of the conjunctiva and asthenopic symp
toms. Hemorrhage into the ant. chamber. Bruises of the
lids. (To be used externally at the same time, in each of the
above.)
HEPAR. - Purulent ophthal. with merc. Inveterate blepharitis
with purulent secretion, in scrofulous subjects. Chronic cor-
C
neitis. Conjunctivitis herpetica (ars., bell., merc., tart. emet.).
HYDRASTIN. In acute catarrhal ophthalmiæ, with profuse dis-
charge, especially in scrofulous or ill-nourished subjects.
KALI HYD.
- Inflam. of lach. sac, with mucous discharge. Syph-
ilitic iritis, choroiditis, and corneitis
LEPTAND. Asthenopic symptoms, with yellow look of the scle-
rotica.
MACROTIN.
―
Accommodative, retinal, and muscular asthenopia.
Photophobia from asthenopia; hyperemia of conjunctiva, iris,
choroid, and retina, due to prolonged exertion of myopic or
hypermetropic eyes. Soreness of the eyeball to touch and on
moving it (bry.). Aching pain in the eye (spig. merc.).
MERC. - Blepharitis, chronic or otherwise; meibomian cysts;
purulent ophthal. with copious discharge; corneitis diffusa,
superficial and deep-seated ulceration of the cornea; pustular
ophthalmia; syphilitic disease of any or all the different struc-
tures of the eye; episcleritis; pain in the eyeball at night;
scrofulous ophthalmia, with photophobia.
Nux v. Asthenopic symptoms. Photophobia from retinal hyper-
æsthesia. Dilatation of the pupil from spinal irritation. Di-
plopia from muscular asthenopia, from paralytic strabismus.
Paralysis of sixth nerve (rectus externus). Homonymous
diplopia. Weakened power of accommodation in one eye from
over-exerting it. Severe pain in the eyes, and during the night,
with conjunctival injection, brought on by overuse of the
eyes, especially by artificial light (gels. merc.). Spasmodic or
involuntary closure of the eyes in adults (gels.).
OPIUM. Hyperæmia of the conjunctiva and borders of the tarsı,
with injection of the ocular conjunctiva in connection with con-
gestive headache.
PULS. Catarrhal ophthalmia with mucous secretion. Styes, es-
pecially in children and at the age of pubescence.
314
INTERNAL REMEDIES.
PHOSPH.
Retinal hyperæmia with congestion to the head. Flashes
of light, dazzling points, or rings of various colors, before the
eyes, indicating extreme sensitiveness of the retina.
SANG.Retinal congestions, with tendency to flushed face and
congestive headaches. Superficial injection of the eyeball,
with feeling of soreness.
SCUTEL.- Spasmodic twitchings of the lids (gels, nux.).
SECALE. — Asthenopia. Asthenopia with enlarged pupils, due to
nervous debility. Diplopia from derangement of accommo-
dation (gels., nux v.).
SEPIA. Acne ciliaris.
Severe
SPIGELIA. — Conjunctivitis and iritis in children, particularly in
those of scrofulous diathesis. Congestion of the ciliary vessels,
as indicated by the pinkish zone around the cornea.
pain in and around the eyes, and on moving them. Severe
photophobia from ciliary nervous irritation (bell., con.).
STAPHYSAGRIA. In hordeolum, to prevent recurrence.
STILLINGIN. — Asthenopia characterized by debility rather than
inflammation, or marked irritation of the accommodative ap-
paratus. Asthenopia from general debility (macrot., hydras.),
SULPHUR. — In chronic ophthalmia scrofulosa, with superficial
corneitis, the pinkish zone well marked around the edge of the
cornea, and photophobia (merc., spigel.).
TART. EMET.-- Photophobia in scrofulous ophthalmia of children.
Pustular conjunctivitis.
ZINCUM. - Retinal asthenopia.
Anæsthesia retinæ. Neuritis
optica. Acute retinitis albuminurica. Bright's disease (ars.).
ZINC. PHOSPH.·
Affections of the retina marked by great irrita-
tion. Hyperæsthesia retina, with photophobia, flashes of light
and luminous spectra (zinc., nux v., gels., phos.).
ZINC. SUL.
Conjunctivitis, simple, catarrhal, and mild purulent,
when the discharge is not very copious. Catarrh of the lach-
rymal passages.
CHAPTER XX.
TEST TYPE.
THE first series of test type is presented merely
as a convenience in noting the state of the vision,
with or without glasses, for reading or near objects.
The different sized print is numbered, so that a record
can be made from time to time, and the progressive
improvement or failure in visual power accurately
determined. The second series, made up of different
sized gothic letters, is intended for the more exact
measurement of the patient's acuteness of vision.
The numbers in this series indicate the distance at
which an emmetropic eye should distinguish the
letters. The letters of No. 6 should be named
readily, in a good light, at six feet, 10 at ten feet,
20 at twenty feet, and so on.
If No. 20 can be
V=10 or 1; if it
20
seen only as far as ten feet, then
can be seen at twenty feet, then V=1, and the eye
is emmetropic. Occasionally a person will be met
with who can read the letters at a much greater dis-
tance than the average. I have met those who could
read Snellen No. 6 quite easily at ten feet, but such
instances are not common. In experimenting, how-
ever, with a considerable number of persons, I have
found it desirable, practically, to place the standard
of normal vision considerably higher than Jaeger,
and somewhat higher than Snellen.
#
316
TEST TYPE.
FIRST SERIES.
No. 1.
I think it does not matter just when I first came to Venice. Yesterday and to-day are the same here.
arrived one winter morning about five o'clock, and was not so full of Soul as I might have been in warmer weather.
Yet I was resolved not to go to my hote in tre omnibus (the large, many-seated boat so-called), but to have a
gondola solely for myself and my luggage. The porter who seized my valise in the station, inferred from some
very polyglottic Italian of mine the nature of my wish, and ran out and threw that slender piece of luggage into
a gondola. I followed, lighted to my seat by a beggar in picturesque and desultory costume. He was one of a
class of mendicants whom I came, for my sins, to know better in Venice, and whom I dare say every traveller
No. 2.
recollects- the merciless tribe who hold your gondola to shore, and affect to do you a service
and not a displeasure, and pretend not to be abandoned swindlers. The Venetians call them
gransieri, or crab-catchers; but as yet I did not know the name or the purpose of this poverino,
at the station, but merely saw that he had the Venetian eye for color: in the distribution and
arrangement of his fragments of dress he had produced some miraculous effects of red, and
he was altogether as infamous a figure as any friend of brigands would like to meet in a lonely
place. He did not offer to stab me and sink my body in the Grand Canal, as, in all Venetian
No. 3.
keeping, I felt that he ought to have done; but he implored an alms, and I hardly
know now whether to exult or regret that I did not understand him, and left him
empty-handed. I suppose that he withdrew again the blessings which he advanced
me, as we pushed out into the canal: but I heard nothing, for the wonder of
Venice was already upon me. All my nether-spirit, so to speak, was dulled and
jaded with the long, cold, railway journey from Vienna, while every surface-sense
was taken and tangled in the bewildering brilliancy and novelty of Venice. For I
No. 4.
think there can be nothing else in the world so full of glittering and exquisite
surprise, as that first glimpse of Venice which the traveller catches as he issues
from the railway station by night, and looks upon her peerless strangeness. There
is something in the blessed breath of Italy (how quickly, coming south, you know
it, and how bland it is, after the harsh, transalpine air!) which prepares you for
your nocturnal advent into Venice; and O you! whoever you are, that journey
toward this enchanted city for the first time, let me tell you how happy I count
No. 5.
you! There lies before you for your pleasure, the spectacle of such
singular beauty as no picture can ever show you nor book tell you;
beauty which you shall feel perfectly but once, and regret for ever.
For my own part, as the gondola slipped away from the blaze and
bustle of the station down the gloom and silence of the broad canal, I
forgot that I had been freezing two days and nights; that I was at that
moment very cold and a little homesick. I could at first feel nothing
No. 6.
but that beautiful silence, broken only by the star-silvered dip of
the oars. Then on either hand I saw stately palaces rise gray and
lofty from the dark waters, holding here and there a lamp against
their faces, which brought balconies, and columns, and carven
arches into momentary relief, and threw long streams of crimson
into the canal. I could see by that uncertain glimmer how fair
TEST TYPE.
No. 7.
317
was all, but not how sad and old: and so unhaunted by any
pang for the decay that afterwards saddened me amid the for-
lorn beauty of Venice, I glided on. I have no doubt it was a
proper time to think all the fantastic things in the world, and
I thought them; but they passed vaguely through my mind,
without at all interrupting the sensations of sight and sound.
Indeed, the past and present mixed there, and the moral and
No. 8.
material were blent in the sentiment of utter novelty and
surprise. The quick boat slid through old troubles of
mine, and unlooked-for events gave it the impulse that
carried it beyond, and safely around sharp corners of life.
And all the while I knew that this was a progress through
narrow and crooked canals, and past marble angles of
palaces. But I did not know then that this fine confusion
No. 9.
of sense and spirit was the first faint perception of
the charm of life in Venice.
Dark, funereal barges like my own had flitted by,
and the gondoliers had warned each other at every
turning with hoarse, lugubrious cries; the lines of
balconied palaces had never ended; - here and
there at their doors larger craft were moored, with
No. 10.
dim figures of men moving uncertainly about
on them.
At last we had passed abruptly out
of the Grand Canal into one of the smaller
channels, and from comparative light into a
darkness only remotely affected by some far-
streaming corner lamp. But always the pallid,
stately palaces; always the dark heaven with
TEST TYPE.
No. 11.
319
its trembling stars above, and the dark
water with its trembling stars below;
but now innumerable bridges, and an
utter lonesomeness, and ceaseless sudden
turns and windings. One could not re-
sist a vague feeling of anxiety, in these
No. 12.
strait and solitary passa-
ges, which was part of the
strange enjoyment of the
time, and which was refer-
able to the novelty, the
hush, the darkness, and the
No. 13.
piratical appearance and
unaccountable pauses of
the gondoliers. Was not
this Venice, and is not
Venice for ever associ-
TEST TYPE.
321
No. 14.
ated with bra-
voes and unex-
pected dagger-
thrusts?


That
valise of mine
might represent
No. 15.

unbounded
wealth to
the uncul
tivated eye.





TEST TYPE.
323
No. 16.
Who, if I
made an out
cry, could
understand
the Facts of
the Situa
tion, as we
say in the
journals?
To move on











[HOWELLS' VENETIAN LIFE.
TEST TYPE.
SECOND SERIES.
No. 2.
LHDETFCIUO
No. 3.
EUCFO PGTHL
No. 5.
GTOHLE QFDI
No. 6.
HGFD PUOIE
No. 8.
I GOT CLEI U
No. 10.
UFTDHG POE
No. 12.
QEC PUFDIL
325
No. 14.
PDLFHOTGI
21
TEST TYPE.
327
No. 20.
FPLOH
No. 32.




FHGT
告
​No. 50.
UCP



!
TEST TYPE.
329
No. 70.


LD
No. 100.


TH
1
TEST TYPE.
331
No. 200.
C

INDE X.
INDEX.
Abscess, of cornea, 125, 126.
globe, 156.
lachrymal sac, 278, 279.
Accommodation, 33.
anomalies of, 33.
Asthenopia, accommodative, 59.
muscular, 52.
retinal, 213.
remedies in, 52, 65, 74, 213.
spectacles in, 52, 63, 213.
differs from refraction, 34. | Asthenopic eyes, to be used daily,
mechanism of, 34.
paralysis of, 251.
spasm of, 251.
Aconite, the use of, 111.
Acne ciliaris, 266.
Adhesions of the pupil, 139, 140.
Alumina, use of, 111.
Amaurosis, 198.
causes of, 200.
prognosis in, 201.
treatment of, 198, 202.
Amblyopia, 203.
causes of, 206, 208, 209.
diagnosis of, 203.
Anchyloblepharon, 299.
Anomalies of refraction, 35.
but with moderation and dis.
Astigmatism, 65.
cretion, 64.
compound, 66.
diagnosis of, 66.
irregular, 66.
mixed, 71.
regular, simple, 66.
spectacles for, 68.
test type and lines for, 70.
Atrophy of optic nerve, 198.
field of vision in, 199.
not uniformly fatal to sight,
208.
ophthalmoscopic
ance of, 198.
appear-
Anterior chamber, narrow in in- Atropine, action of, 149, 312.
fants, 236.
Aphakia, 239.
Apoplexy of retina, 185.
Aqua chlori, the use of, 105.
an aid to diagnosis, 9.
strength of solution, 149.
use in eye affections, 123,
140, 216, 221, 312.
Aqueous humor, evacuation of in Aut-ophthalmoscope, 21.
cataract, 235.
in iritis, 141.
Argen. nit., external use of, 79, 80,
88, 94, 101, 280, 282.
its homoeopathic action in
conjunctivitis, 91.
internal use of. 311.
Arnica, the use of, 311.
Arsenicum in corneal ulceration,
124.
the use of, 312.
Artificial eyes, 243.
pupil, 144.
Bandage, compress, 17.
simple, 17.
Baptisia, the use of, 312.
Belladonna, a substitute for atro-
pine, 128.
its internal use, 312.
Blepharitis, 264.
Blepharospasm, 272.
Blindness, simulation of, 210.
Bright's disease, 182.
Bryonia, use of. 312.
Burns and scalds, 295, 296.
336
INDEX.
F
Cactus, the use of, 312.
Calabar bean, its action, 150.
strength of solution, 150.
use of, 123, 148.
Canaliculus, obstructions of, 276,
277.
to slit up, 276.
Cancer of the eye, medullary,
292.
Capsular cataract, 236.
opacities, 229.
Capsule of lens, removal of, 229,
230.
wounds of, 238.
Case of convergent strabismus,
258.
dislocation of lens, 237.
foreign body in the con-
junctiva, 297.
gonorrhoeal ophthalmia, 92.
granular ophthalmia and
pannus, 103, 104.
infantile ophthalmia, 89.
loss of sight from a blow,
309.
neuro-retinitis, 195.
following pregnancy, 207.
retinitis pigmentosa, 186.
ulceration of the upper lid,
268.
wound of the cornea and
iris, 303.
Cataract, 216.
atropine in, 216, 221.
cause of, 219.
complications in, 218.
diagnosis of, 216.
by lateral illumination,
217.
by ophthalmoscope, 217.
objective symptoms of, 217.
prognosis in, 221.
paracentesis in, 235.
subjective symptoms of,
216.
when ripe or complete, 217,
218, 232.
black, 220.
capsular, 236.
capsulo-lenticular, 236.
congenital, 231.
cortical, 231.
diabetic, 234.
Cataract, fluid, 235.
hard, 219.
operations for, 220.
after treatment, 227.
lamellar, 231.
nuclear, 220.
pyramidal, 236.
secondary, 230.
senile, 219.
soft, 231.
operations for, 232.
striated, 220.
traumatic, 238.
treatment of cataract, medi-
cal, 235.
discission or absorption,
232.
extraction plus capsule,
225.
flap extraction, 222.
linear extraction, 233.
peripheric-linear extrac-
tion, 223.
reclination, 226.
spoon extraction, 225.
suction, 234.
Cataract-glasses,. 240.
Catarrhal ophthalmia, 77.
treatment of, 79.
Chalazion, 269.
Chamomilla, the use of, 312.
Choroid, hyperæmia of, 152.
sarcoma of, 292.
tubercles of, 156.
Choroiditis, 152.
disseminated, 152.
ophthalmoscopic
appear-
ance of, 153.
suppurative, 155.
Choroido-iritis, 142, 154, 159.
Chronic headache, need of ophthal-
moscopic examination in, 30.
Ciliary muscle, action of, 34.
action of atropine on, 149.
calabar bean on, 150.
reuralgia of, 74, 75, 171,
172.
paralysis of, 251.
spasm of, 251.
Circles of diffusion, 60.
Closure of pupil in iritis, 144, 145.
after cataract operations,
228.
INDEX.
337
:
Closure of pupil, operations for,
145, 146.
Collyria in conjunctivitis, 79, 80.
internal effect of, 150.
Color blindness, 212.
Concomitant strabismus, 253.
Congenital ophthalmia, severe
cases, 87.
Conical cornea, 130.
diagnosis of, 130.
artificial pupil in, 131.
Conium, the use of, 312.
Conjunctiva, affections
cysts of, 118.
of, 73.
foreign bodies in, 297.
injuries of, 295.
warts of, 117.
Conjunctivitis, 75.
catarrhal, 77.
congenital, 86.
diphtheritic, 97.
Egyptian, 85.
eruptive, 113.
exanthematous, 116.
gonorrhoeal, 92.
granular, 98.
phlyctenular, 113.
purulent, 83.
pustular, 113.
scrofulous, 106.
simple, 77.
Contagiousness of ophthalmia, 82,
85, 92, 98.
Convergent strabismus, 254.
Corelysis, 142.
Corydialysis, 146.
Cornea, affections of, 119.
abscess of, 125, 126.
abrasions of, 303.
conical, 130.
fistula of, 229.
haziness of, 106, 125, 132.
injuries of, 302.
[171.
opacities of, 99, 132.
paracentesis of, 122, 123,
perforation of, 121, 122.
staphyloma of, 128.
ulcers of, 120.
crescentic, 95, 121.
deep, 121.
superficial, 120.
transparent, 121.
treatment of, 122
Corneitis, 125.
indolent, 126.
diffuse, 125.
extent to be limited by
pressure, 126.
phlyctenular, 119.
scrofulous, 125.
suppurative, 125.
treatment of, 126.
Cortical cataract, 231.
Crossed diplopia, 246.
Cuprum, the use of, 312.
Cyclitis, 143.
Cysticerci, 159.
Cysts of iris, 151.
of lids, 269.
Dacryo-cystitis, 277.
Detachment of retina, 187.
causes of, 189.
Diabetic cataract, 234.
Dilated pupil in disease of eye,
147, 162, 198.
Dilated pupil necessary in iritis,
140.
Diplopia, 14.
crossed, 246.
homonymous, 245, 247.
Diphtheritic conjunctivitis, 97.
Dislocation of lens, 237.
Direct examination with ophthal
moscope, 22, 23.
Diseases of the eye coexist with
disease of the brain, 28.
coexist with insanity, 30.
myopia, 40,
41, 42.
impossible to diagnose for-
merly, 27.
made a specialty by the
Egyptians, 1.
necessary instruments in,
for general practitioners,
16, 17.
not always indicated in
imperfect vision, 38, 55,
59, 67, 203.
progress in the knowledge
of, 4.
to distinguish from optical
defects, 203.
use of certain internal
remedies in, that have
338
INDEX.
proved reliable in the Field
practice of the writer,
311, 312, 313, 314.
Divergent strabismus, 255.
Division of ciliary muscle, 176.
Double vision, 14, 245, 246, 247,
of vision, to ascertain the
extent, 13.
in amaurosis, 199, 200, 201.
in cataract, 218.
important to determine,
199.
Fistula corneæ, 229.
lachrymalis, 278, 281.
260.
Dropsy of the eye, 291.
Ectropium, 267.
Flap extraction, 222.
accidents in, 222.
Embolism of central artery of re- Fluid cataract, 235.
tina, 192.
Encephaloid disease, 191.
Encysted tumors of lids, 269.
Entropium, 267.
Enucleation of the eye, 306.
Epicanthus, 271.
Epiphora, 275.
Euphrasia, use of, 312.
Examination of the eye, 7.
by lateral illumination, 26.
ophthalmoscopic, 22.
Excision of the eye, 306.
of staphyloma, 129,
Excoriation of the lids, 264, 265,
266.
Exophthalmos, 292
Episcleritis, 134.
Epithelial, cancer of lid, 268.
Extraction. See Cataract.
of foreign bodies from the
eye, 297, 300.
Eyelashes, removal of, 268.
Eye protectors, 242.
Eyeball. See Globe.
Eyelids, affections of, 264.
blepharospasm, 272.
distichiasis, 268.
ectropion of, 267.
entropion of, 267.
epicanthus, 271.
hordeolum, 270.
paralysis of, 274.
ptosis of, 274.
spasm of orbicularis, 272.
tinea tarsi, 264.
trichiasis, 268.
tumors of, 269, 270.
wounds of, 294.
Eyes, artificial, 243.
Foreign bodies in the conjunc-
tiva, 297.
in the cornea, 302.
within the eyeball, 300.
Fourth nerve, paralysis of, 247.
Gelseminum, the use of, 312.
Glaucoma, acute inflammatory,
162, 163.
cause of, 167.
chronic, 166.
danger of delay in oper-
ating for, 173.
early symptoms of, 162.
excavation of nerve in, 165.
fulminans of Graefe, 167.
iridectomy in, 172.
medical treatment of, 168.
neuralgic pain in, 163.
non-inflammatory, 166.
ophthalmoscopic diagnosis
of, 165.
operations for, 172, 176.
pathology of, 167.
premonitory symptoms of,
162.
prognosis in, 174.
secondary, 177.
treatment, 168.
surgical, 172.
rationale
176.
of iridectomy,
when to operate in, 173.
Glioma retinæ, 191.
treatment of, 191.
Globe affections of the whole, 291.
foreign bodies within, 300.
tension of, to determine, 10.
Glonoine, the use of, 312.
to insert and remove, 243. Glossary, viii.
Far-sight. See Presbyopia.
Goitre, exophthalmic, 292.
Gonorrhoeal ophthalmia, 92.
Granular ophthalmia, 98.
INDEX.
treatment of chronic, 100.
Graphites, the use of, 312.
Grave's disease, 292.
Hamamelis, the use of, 312.
Hard cataract, 219.
Hardness of globe, to determine,
10.
in glaucoma, 163, 164.
relief by atropine, 141.
division of ciliary
muscle, 177, 308.
iridectomy, 172.
paracentesis, 123,
171.
Headache, need of ophthalmo-
scopic examination in, 30.
Hemeralopia, 211.
Hemorrhage in the ant. chamber,
304.
into the vitreous, 158.
of retina, 185.
Hepar sulph., the use of, 312.
Herpes frontalis (seu ophthal-
micus), 266.
Herpetic ophthalmia, 113, 119.
Homonymous diplopia, 245, 247.
Hordeolum, 270.
Hyalitis, 157.
Hydrastin, the use of, 313.
Hydrophthalmia, 291.
Hyperæmia of choroid, 152.
of conjunctiva, 75.
iris, 136.
optic nerve, 194.
retina, 178.
Hyperæsthesia retinæ, 213.
Hypermetropia, 54.
asthenopia in, 59.
diagnosis of, 55.
spectacles for distance in,
not to be prescribed
unless absolutely neces-
sary, 58.
treatment of, 62.
Hypopion, 126.
Implements and instruments, 15.
Inflammation of choroid, 152.
conjunctiva, 75.
ciliary body, 143.
cornea, 119.
Inflammation of iris, 136.
339
lachrymal appa-
ratus, 275.
lids, 264.
optic nerve, 193.
retina, 179.
sclerotica, 134.
vitreous humor,
157.
whole eye, 155.
Injections of conjunctiva, 77, 78.
significance of different red-
ness of the eye, 75, 76.
Injuries of conjunctiva, 295.
cornea, 302.
globe from gunpowder, 296.
percussion caps,
300.
of iris and lens, 303.
lids, 294.
sclerotic, 305.
sympathetic
from, 305.
ophthalmia
Inoculation, for granulated lids,
105.
Internal recti, division of, 260.
insufficiency of, 52.
Intolerance of light, the remedies
for, 312, 313, 314.
Involuntary oscillations of globe,
252.
Iridectomy, the operation, 144,
172.
in cataract, 233.
choroiditis, 154.
conical cornea, 131.
glaucoma, 172.
Iridodesis, the operation, 145.
in cataract, 233.
conical cornea, 131.
Iridodonesis, or tremulous iris,
150.
Iris, adhesions of, 139, 140, 154,
155.
cysts of, 151.
diseases of, 136.
foreign bodies in, 303.
hernia of, 143.
injuries of, 303.
prolapse of, 143.
tremulous, 150.
Iritis, acute, 136.
cause of, 139.
3.
i
340
Iritis, chronic, 142.
serous, 138.
suppurative, 137.
syphilitic, 137.
traumatic, 228.
treatment of, 140.
Ischemia retinæ, 192.
Kali hydriod, the use of, 313.
Keratitis, 125.
Kerato-globus, 291.
INDEX.
Lachrymal apparatus, affectious
of, 275.
epiphora, 275.
gland, diseases of, 289.
passage, obstruction of, 285.
canaliculi, 276.
duct, 285.
1244.
Muscæ volitantes, 158.
Muscles of eyeball, affections of,
paralysis of, 244.
Mydriasis, 147.
Myopia, 35.
cause, 36, 37.
correction by glasses, 46.
complications in, 40, 41, 42.
senilis, 72.
Myopia, diagnosis of, 38.
ophthalmoscopic
ance in, 39, 40.
progress of, 43.
treatment of, 42.
hygienic, 51.
appear.
preventive, 44, 49.
by remedies, 45.
Myosis, 148.
sac, 277.
Neuralgia oculi, 215.
blennorrhoea of sac, 282.
ciliaris, 74, 75, 171, 172.
fistula of sac, 281.
Neuritis descendens, 197.
stricture of, 285, 286, Neuro-retinitis, 193.
287.
treatment of, 283, 284,
285, 286.
case of, 195.
diagnosis of, 194.
treatment of, 198.
Stilling's operation, 287. Nictitation, 273.
Lagophthalmos, 271.
Lateral illumination, 26.
in cataract, 217.
corneal opacities, 8, 9.
dislocation of the lens,
237.
Lens, affections of, 216.
dislocations of, 237.
wounds of, 238.
[274.
Leptandria, the use of. 313.
Leucoma of cornea, 133.
Levator palpebræ, paralysis of,
Liebreich's op. for cat., 225.
Lime, injuries from, 295.
treatment for, 295.
Linear extraction, 233.
Macrotin, the use of, 313.
Mal-position of the lids, 267.
Meibomian cysts, 269.
Melanosis of the eye, 292.
Mercury, in disease of eye, 313.
externally, 114, 120, 265.
Micropsia, 181.
Mortar, injuries from, 295.
treatment of, 295.
Night blindness, 186, 211.
Nitrate of silver, use of mild
crayon of, 101, 282.
homœopathicity of, 91.
in granulations, 101.
purulent ophthalmia, 85,
88.
internal use of, 311.
Nuclear cataract, 220.
Nux vomica, internal use of, 314.
Nystagmus, 252.
Objective examination of eye, 7.
Obstruction of lach. passages,
284, 285, 286.
Obliteration of lach. sac, 289.
Onyx, 125.
Opacities of cornea, 99, 132.
lens and capsule, 216.
vitreous, 159.
Ophthalmia catarrhal, 77.
diphtheritic, 97.
Egyptian, 85.
gonorrhoeal, 92.
granular, 98.
herpetic, 113, 119.
INDEX.
341
Ophthalmia neonatorum, 86.
phlyctenular, 113, 119.
purulent, 83.
pustular, 113.
scrofulous, 106.
sympathetic, 305.
tarsi, 264.
Ophthalmitis, treatment of, 156.
Ophthalmoscope, 18.
appearance of fundus with,
24.
retinal vessels with, 25.
binocular, 20.
direct examination with, 23.
fixed, 21.
how to use, 21.
importance to general prac-
titioners, 28.
indirect exam. with, 22.
inverted image with, 22,
23.
Liebreich's, 20.
principles of, 18, 19.
upright image with, 22,
23.
Ophthalmoscopic exam. necessary
in chronic headaches, and in all
suspected disease of the brain,
30, 194.
Optic axes, convergence of in ac-
commodation, 34.
disc, how to find it, 22.
nerve, atrophy of, 198.
diseases of, 193.
oval appearance of,
24.
neuritis, 193.
Orbicularis, paralysis of, 271.
spasm of, 272.
Orbit, diseases of, 293.
diagnosis of, 293.
Oscillations of the eyeball, 252.
Pain, diagnostic value of, 11.
remedies for external, 74,
75, 140, 141, 171, 172.
internal, 172, 311, 312,
313.
Panophthalmitis, 156.
treatment of, 156.
Pannus, 99.
171, 176.
Paralysis of ciliary muscle, 251,
levator palpebræ,
247.
nerve fourth, 247.
sixth, 245.
third, 247.
orbicularis, 271.
rectus, externus, 245.
inferior, 246.
internus, 246.
superior, 246.
superior oblique, 247.
Paralytic affections, causes of, 248.
treatment of, 248.
surgical of, 250.
by electricity, 248, 249.
Passavant's operation, 142.
Perforation of cornea, 121, 122.
lach. sac, 278, 279.
Phosphorus, the use of, 313.
Photophobia in corneitis, 109, 110,
123.
in iritis, 137, 142.
retinal asthenopia, 213.
scrofulous ophthal., 106,
107, 110.
not a symptom of retinitis,
12, 180.
remedies for, 110, 142, 312,
313, 314.
Physiological excavation of optic
nerve, 199.
Physostigmatis faba, 150.
Pinguecula, 117.
Plaster, injuries from, 295.
treatment of, 295.
Posterior staphyloma, 40, 41.
Powder, injuries from explosion
of, 296.
Presbyopia, 71.
treatment of, 71.
Prisms, action of, 245, 259, 260.
for double vision, 245, 246,
247, 259, 260.
for testing strength of mus
cles, 53.
Prolapse of iris, 143.
Pterygium, 116.
treatment of, 116.
Ptosis, treatment of, 274.
Pulsatilla, use of, 313.
Paracentesis of cornea, 122, 123, Pupil, abnormal dilation of, 147,
162, 198.
22
342
INDEX.
Pupil, abnormal contraction of, | Sclerotico-choroiditis posterior, 40.
148.
artificial dilation of, 149.
contraction of, 150.
closure of, 144, 145, 228.
Purulent ophthalmia, 83.
of infants, 86.
Pustular ophthalmia, 113, 119.
Rapidly increasing presbyopia, 72.
Refraction, anomalies of, 33-35.
Refraction in amblyopia, 203, 204.
astigmatism, 65.
hypermetropia, 54.
myopia, 35.
normally refractive eye,
33-35.
differs from accommoda-
tion, 34.
Remedies, internal, 311, 312, 314.
local, palliative, 74, 75, 140,
141, 171, 172.
Retina, apoplexy of, 185.
cancer of, 191.
detachment of, 187.
diagnosis, 188.
embolism, central artery of,
192.
glioma of, 191.
hyperæmia of, 178.
|
diagnosis of, 40.
progressive, 40, 41, 43, 51.
treatment of, 45, 49, 50, 51.
Scleritis or epi-scleritis, 134.
Scrofulous ophthalmia, 106, 119.
treatment, 108, &c.
hygienic, 109.
local, not serviceable,
108.
remedies in, 112, 113.
Scutellarin, the use of, 313.
Senile cataract, 219.
Sepia, the use of, 314.
Short sight, 35.
Simulation of blindness, 210.
Sixth nerve, paralysis of, 245.
Sketch of rise and progress of
ophthalmic surgery, 1.
Snow blindness, 214.
Soft cataract, 231.
treatment of, 232.
Sparkling synchysis, 159.
Spasm of ciliary muscle, 201.
orbicularis muscle, 272.
Spectacles, 240.
cataract, 240.
cylindrical, 68.
hyperæsthesia of, 213.
inflammation of, 179.
ophthalmoscopic appear. of,
180.
paralysis of, 192.
Retinitis, 179.
albuminurica, 182.
apoplectica, 185.
pigmentosa, 186.
syphilitica, 184, 185.
diagnosis of, 180, 181, 183,
184, &c.
treatment of, 182, 184, &c.
Rheumatic iritis, 136.
treatment, 140.
Sanguinaria, the use of, 313.
Second-sight, 72.
Secale, the use of, 314.
Sclerotic, anterior staphylom. of,
128, 135.
[41.
posterior staphylom. of, 40,
rupture of, 305.
wounds of, 305.
decentred, 241.
kinds of, 240.
pantoscopic, 241.
prismatic, 241.
stenopaic, 242.
Spigelia, use of, 314.
Statistics of optical defects, 37, 38.
Staphyloma anterior, 128.
posterior, 40, 41.
Staphysagria, use of, 314.
Stillingin, use of, 314.
[258.
alternating or binocular,
Strabismus, 258.
causes of, 244, 254.
concomitant, 253.
convergent, 254.
divergent, 255.
measurement of, 257.
operations for, 260.
paralytic, 243.
periodic or confirmed, 253.
primary and secondary de-
viation in, 256.
remedies for, 258.
surgical treatment of, 260.
INDEX.
343
Strabismus, treatment by elec- | Traumatic cataract, 238.
tricity, 249.
hygienic, 259.
Strictures of lach. passages, 285.
treatment, 284, 285, 286.
by probing, 283.
styles, 286.
Stilling method, 287.
Strumous ophthalmia, 106.
corneitis, 119.
iritis, 228.
Tremulous iris, 150.
Trichiasis, 268.
Tumors of choroid, 292.
conjunctiva, 117.
eyelids, 269, 270.
iris, 151.
retina, 191.
Suction operation for cataract, Ulcers of cornea, 120.
234.
Subjective examination of the
eye, 11.
Sulphate of copper, locally, 101,
280, 282.
internally, 312.
Suppurative corneitis, 125.
choroiditis, 156.
iritis, 137.
Sulphur, internal use of, 314.
Symblepharon, 299.
Sympathetic irritation, 310.
ophthalmia, 305.
cause, 305.
treatment general, 309.
by operation, 203.
when to operate, 308.
Syndectomy, or peritomy, 105.
Syphilitic disease of iris, 137.
cornea, 125.
retina, 184, 185.
Tarsal tumors, 269, 270.
Tartar emetic, use of, 314.
Tattooing the cornea, 133.
Tears, overflow of, 275.
Tension of globe, to determine, 10.
in glaucoma, 163, 164.
operations for increased,
123, 171, 172, 177, 308.
Test type, in astigmatism, 70.
for reading, 316.
to determine distant vision,
319.
Third nerve, paralysis of, 274.
Tinea tarsi, 264.
Traction operation for cataract,
225.
eyelids, 268.
case of, 268.
Upper lid, how to reverse it, 8.
Use of the eyes during the morn
ing hours preferable, 83.
Vision, acuteness of, 12.
double, 14, 245, 246, 247.
state of, its diagnostic
value, 12, 204.
weakness of, 52, 59, 213.
Vitreous, affections of, 157.
cholesterine in, 159.
cysticerci in, 159, 160.
fluidity of, 159.
foreign bodies in, 300.
hemorrhage into, 158.
inflammation of, 157.
opacities of, 157.
Warts of conjunctiva, 117.
eyelids, 270.
Weak sight, 52, 59, 213.
Wounds of eyeball, 304, 305.
eyelids, 294.
iris, 303.
sclerotic, 305.
sympathetic inflammation
from, 305.
Yellow spot, appearance of, 23.
how to find it with the
ophthalmoscope, 22.
Zinc, use of, 314.
Zinc. phosph., use of, 314.
Zinc. sulph., internal use of, 314.
local use of, 79, 279, 283.
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