REST FOR PAINFUL EYES, IS THIS ADVICE ALWAYS GOOD? -By- JULIAN J. CHISOLM, M.D., Professor of Eye and Ear Diseases in the Fniversity of Maryland, Surgeon in Charge of the Presby- terian Eye and Ear Charity Hospital of Baltimoro City, Etc., Etc. (Read before the Baltimore Academy of Medicine, December 21st, 1886.) (Reprint from the Maryland Medical Journal, of Jannar'f let, 1887.) BALTIMORE: Journal Publishing Company Print, 209 Park Avenue, 188 7 . REST FOR PAINFUL EYES, IS THIS ADVICE ALWAYS GOOD? When the eyes tire under much and long continued use relief naturally comes with rest,and we voluntarily desist from work so that the eyes may regain their normal condition of comfort; and this they rapidly do. This eye weari- ness, which comes on simultaneously with a tired feeling in the whole body, is not a painful condition. That it is a general discomfort which rest relieves, is familiar to us all as individuals, and hence we are ever ready to acquiesce in the proposal to rest our painful eyes, when such advice comes from the physi- cian to whom we have appealed for treatment. But is this advice always goodf To answer correctly this very impor- tant question eye troubles must be classi- fied into two great divisions. First—We have diseased states of the eyes, inflammatory in their nature, ac- companied by pain with other evidences of congestion, and often associated with blurred vision. Second—This great division comprises faults in eye construction, defects in the 2 focusing po ver, errors in refraction, un- accompanied by visible congestions ex- cept on abusive use of the organ. Jn one or the other of these two great classes most eye troubles can be placed. When we see an eye that is red, water- ing, painful, and in many instances ac- companied with blurred vision, whether this trouble be in one or in both eyes, we naturally and properly advise rest from eye work, while the inflammatory symp- toms arc being relieved by judicious medication. We even shut out the nor- mal retinal stimulus, light, by smoked glasses or darkened rooms, and thereby add to the comfort of the patient. All eyes, painful under use, are not necessarily inflamed ones. On the contrary, a very large number of the most annoying eye troubles are not de- pendent upon diseased conditions. The discomfort induced by the use of such eyes is occasioned by faults in the focus- ing power, necessitating over use of the eye muscles, and subsequent pain in the eyes and head. Any disturbance of the system, which causes temporarily general muscular debility, will diminish the force of the eye muscles and increase the tendency to head and eye pains. As these eye faults are most frequently congenital, starting with our very being, they often commence to show 3 their injurious effects when young growing and not necessarily over strong eyes, are taxed in the acquisition of knowledge, and when the advice to rest these painful eyes tor months at a time is a serious interference with school life and with education. Jn this classifica- tion is brought a very large number of young persons, whose eyes are badly shaped, and hence pain in them on use. A well shaped eye should be nearly a sphere. In such a round eye the inner or retinal coat will receive the focused image, sharply defined, of distant ob- jects, without aid from the muscles of accommodation. These important mus- cles, within such an eye-ball, are called into use when the eye is viewing near objects. Writing, reading and sewing are properly called eye work, because they require the need of the accommodat- ing eye muscles. All other uses to which the eyes are put, except the view- ing of near objects, mean rest. This of course is not rest from retinal work, which is going on actively as long as our eyes are opened, for as a rule the retina does not seem to tire. It means rest from intra-ocular muscular work. Such a round eye is called emmetropic, and is the type of a good one. This is the kind of eye that nature should always supply to the human race. 4 Unfortunately from this standard, de- viations, detrimental to the comfortable uses of the organ, are found in numbers. Many children are born with eyes flat- tened from before backwards, so that the retina is brought too near the lens and therefore in front of its normal focus plane. This flat eye is called over-sight- ed or hyperopic. Such a flat eye, when at rest, does not see even a distant object sharply. It needs muscular work for all purposes, to enable it to focus light from far as well as from near objects. Such an eye is never at rest during waking hours. As nature abhors a vacuum, so badly shaped eyes may be said to abhor badly defined pictures on the retina. An effort, is made involuntarily by the flat eye to sharpen outlines and perfect the focus. This is always a muscular effort. When required for distant vision, as is always the case with flat eyes, some of the muscular force of the eye is used up, leaving less for the accommodating power in viewing small near objects. If the eye be very flat and the demand upon the muscular apparatus necessarily very great for even distant objects, then the moderate use of the eyes for reading soon exhausts the remaining muscular power. After reading for a short time the natural relaxation of the over-worked and tired muscles changes the focus of 5 the lens, blurs the image upon the re- tina, and causes the letters of a page to run together. A little rest enables the muscles to resume work and the printed page to be again clearly seen, but a very few more minutes use of the tired muscles again blurs the page. If the ef- fort to read be persisted in, pain in the eyes and in the head ensues. If the muscular force be weakened by any acute disease then the eyes give out the sooner. We experience this in children after measles, diphtheria, etc. Children who could study with comfort before the attack find themselves unable to read for any length of time afterwards. Often months are required before the eye mus- cles again become strong. An eye may be so very short in its antero-posterior diameter that all the intra ocular muscular power is required for viewing distant ob- jects, leaving none for near work. Children with such badly shaped eyes can not 6tudy, because from de- ficiency in the focusing power of the crystaline lensthey can not distinguish the shape of the small letters. The nervous apparatus of such an eye is good. The retina and optic nerve are perfect, but the picture thrown upon this retinal screen is blurred, solely for want of accurate focusing power. Add to the lens power 6 and perfect vision for small objects is at once obtained. The accidental use of their grandmother’s glasses to aid the crystaline lens to focus a sharply denned image is a marvellous revelation to such an eye, and shows just what it requires to make it a strong useful organ; viz, a pair of properly adjusted magnifying spectacles. With such scientific aid the child is in condition to undertake hard study, and seeing clearly becomes easy. Because over exertion of the eye muscles is no longer required,when the chi Id wears properly selected glasses, no more pain in eyes and head is experienced during study hours. Although rest from near work will always bring about relief from the pain consequent to over muscular exertion, the advice so often given to parents by the family physician, to take hyper- opic children from school, and let them rest their eyes from study, for months at a time, is bad, because it is founded on ignorance of the cause producing the trouble. At the end of six or twelve months the eye is,just as misshaped as it was before the rest was taken, and ap- plication for near work will surely bring back the former painful discomfort. This is a matter of every day observation. Adjust proper glasses, correct the error of refraction, give the eye muscles less 7 work to do by allowing the eye to do its work with spectacles on, and conse- quently without effort, is surely the rational course to be pursued. With the aid of magnifying glasses for all uses a fat eye will need no rest. To rest such eyes with the expectation that they will become strong is delusive, and is there- fore bad advice. Again an eye may be misshaped from the round standard by being longer than it ought to be. An eye long in its antero- dosterior diameter is more oval than round and is called near-sighted or my- opic, because it only sees near objects clearly. The retina is so far from the lens in long eyes that a focus of light from distant objects is made before the retinal screen is reached. When the picture is finally thrown upon the nerve layer it is illy defined and consequently blurred. Distant objects for such eyes are always befogged, unless the strength of the crys- taline lens is weakened and its focus lengthened by the use of concave or near-sighted glasses. As fiat eyes were always congenital, so long eyes may be found at birtli. As a rule, however, eyes acquire this condition and become misshaped by too much study in early school life. When an ej’e, previously good for seeing distant objects, changes shape and becomes near-sighted, the 8 change indicates a yielding of the sclerotic or outer tough coat which is the sustaining wall of the eye-ball. This is a weakening and diseased condition of the organ, which will eventually be a serious injury if it becomes excessive. When progressive near-sightedness is found in school children, in order to check the rapid deterioration in this very valuable organ, rest from eye work be- comes a very important factor in the treatment. When the eye-ball is elongated, the cornea retaining its regu- lar outlines concave spherical glasses correct the defect in the focusing power of the lens and makes vision better; but this aid for distant vision does not make such young and still growing eyes strong or capable of standing abusive work. There is still a very important class of misshaped eyes, also starting usually with the very beginning of life. It is to call attention to the headaches and eye pains caused by many such eyes that this paper is written. In this large class of painful eyes the cause of trouble lies in irregularities of curvature of the surface ot the cornea. The curvatures of the various meridians differ, as if the eye-ball had been flattened from its sides. In such eyes the misshaped cornea may be represented by the crystal of a watch, which has lost its 9 true spherical form, from irregular pres- sure upon its edges when the substance of the glass was btill soft. The curva- tures of the short diameter, correspond- ing to the direction of pressure must be greater than those of the longer ones, and this must necessarily vary the focus of light passing through these different convex surfaces. In some meridians light may pass through and focus cor- rectly upon the retina; in other direc- tions the focus of transmitted light will be made too rapidly or too tardily, in either case blurring the retinal image, and causing defective vision. Whether the cornea border be compressed verti- cally, horizontally, or obliquely it so changes the surfaces of the cornea for that direction, that however perfectly the other surfaces of the cornea may focus, the faulty curvature acts as if it were a distinct lens of different focal power, and it will cast shadows over the sharply defined picture made by the cor- rect portions of the cornea. This error of refraction is called astigmatism, and may be found in long, short, or round eyes; hence we find simple or mixed, hyperopic or myopic astigmatism. Such irregular corneas are frequently met with. In all such eyes an effort is made automatically to correct this fault by changing the shape of the erystaline 10 lens to correspond with the irregularities in the cornea. Fortunately the lens in young persons is so soft and jelly-like, that very little action on the part of the eye muscles corrects the faulty lines of refraction, and a perfect focus is secured. For a time this succeeds well, and com- fortable clear vision is enjoyed, provided the application of the eyes for near work is not too long continued. But unfor- tunately the lens is hardening steadily with advancing age, and the muscular ef- fort has to be continually increased till it becomes irksome and finally painful. The discomfort produced does not re- strict itself to the eyes alone, but diffuses itself over the brow, forehead, and temples, causing headache more or less persistent. In some cases the pain in- vades the whole head, back of neck, and even spine. These headaches can al- ways be brought on by eye use. To some very sensitive astigmatic patients eye use refers to their whole waking life. They arise in the morning with comfort- able heads, but before they are dressed the headache has been started by the necessary toilet preparations, and it in- creases in severity with the advancing day. Sun rise and all day headaches they are, with some of these very susceptible persons, whose eyes see differently for the different curvatures of their cornea. 11 Every object in nature will radiate light from every exposed surface, and the eye catches some of these rays. Where the cornea is regularly curved light from any and all directions is accurately focus- ed on the retina, and while we see every thing perfectly we are not aware that we have eyes, so painlessly do they func- tion. To the abnormally sensitive as- tigmatic eye this varied direction of light beams, transmitted through and ir- regularly refracted by the varied curva- tures of the cornea, necessitates nearly a choreic action of the ciliary muscles. From this perpetual changing of focus, now for one part of the cornea and then for an other, fatigue of the muscles and pain in the eyes must soon be induced,even to the extent of making sunlight annoy- ing. This irregular shape of the cornea can be detected if the eye views a draw- ing similar to a clock dial, traversed by groups of black radiating lines of equal size and distinctness. By a well formed eye these groups ot lines are seen with equal sharpness of outline and of the same degree of blackness. By an astig- matic eye some of these groups of lines are brought out much more boldly than others. While some remain black oth- ers of these black lines may appear gray and at times even red or blue; and in- 12 stead of standing out boldly in the group they run together as if they were one solid line. The faulty lines are al- ways at right angles to those most clearly seen. With the clock dial card if the lines running from 12 to 6 o’clock are brightest those from 3 to 9 o’clock will be most blurred. If those from 10 to 4 are the most clearly defined the blurred lines will be in the direction of 1 to 7 o’clock, and so on for any other series of lines. If a cylinder lens be selected, which will make the dull lines as bright as the clear ones, this peculiar eye-glass, when carefully set at the prop- er angle, will equalize vision, and will remove the discomfort which the use of the eyes had formerly produced. The ordinary spectacles, worn by the masses, are called spherical lenses, being sections of a sphere or ball. Such are the glasses worn by near-sighted and by old persons. The peculiar glasses which correct irregularities of corneal refraction are called cylinder lenses, because they represent a slice of glass taken from the length of a round bar or cylinder. The spherical and cylinder glasses bear the same relation to each other as would an open umbrella to a wagon top. The cylinder lens has, as it were, a ridge pole over which the curvatures of the lens are made, while the spherical lens curves in all directions from a central point. In the use of cylinder glasses the ridge pole or plain surface is always set in the direction corresponding to the clearest lines of the clock dial, and the curved surfaces of the lens are put neces- sarily in the direction of the blurred or discolored lines of the dial. Such cylin- der glasses alone can give rest to the weary muscles in astigmatic eyes, for without them these irregularly curved eyes can not secure rest except during sleep. A very useful law can be laid down for the guidance of physicians in the treatment of their eye complaining pa- tients, viz. that headaches which come on with the use of the eyes and which disappear during the rest which a night’s sleep brings to the weary eyes, do not usu- ally depend upon gastric, hepatic,cerebral, or uterine troubles, as is so commonly believed. When school girls troin 12 to 18 years of age complain of eyes and head aching, after hours of close appli- cation, and are not annoyed in this wray during vacations or times of eye rest, inquiry is yet made by the family phy- sician concerning the menstrual func- tions. Any tardiness in the appearance of this discharge, or any deviation in its amount or frequency from what 13 14 the physician has established in his own mind as the normal, is deemed too often a sufficient and satisfactory explanation for all the head and eye discomforts. According to their theory when the monthly discharge becomes regular the head and eye troubles will disappear; but permanent relief does not come as was expected. When young men complain of these identical symptoms of eye pains and headache after hours of study I some- times wonder why from professional habit, their menstrual functions should not be also inquired about, for the same explanation might as truthfully be ac- cepted for them. In this connection I will also say that these eye-headaches disappearing after sleep have their origin neither in malaria nor in a bilious derange- ment, notwithstanding the fact that these terms are used every day in connection with them by patients and physicians. Neither quinine, calo- mel, morphine nor pessaries will prevent this kind of eye headache, although building up the system in feeble persons will help the eye muscles and relieve them. The careful adjust- ment of proper glasses, by correct- ing the painful muscular effort, alone will cure them. Ilest is a very frequent prescription with physicians for such 15 painful eyes. It will quiet temporarily the pain, but what permanent good can it possibly secure ? When upon the use of the eyes the headaches, and when painless heads are made painful by read- ing, with very few exceptions, it is the abnormal curvatures of the cornea which causes the eye and heal pains. IIow can rest bring about a correction in these faulty curvatures. Might as well expect rest from walking to make a shortened leg grow to the length of the other, as to expect a shorter curve in one direction of the cornea to grow out to the dimen- sions of the other longer meridians by rest- ing the eyes from reading or sewing. We can readily see the absurdity in the leg suggestion, and yet many physicians do not see that the expectations from the eye rest is equally preposterous. How many thousands in this country to- day are impatiently and uselessly resting eyes that pain when put to near work, when a pair of properly adjusted specta- cles will correct the evil ? Nearly every day I restore some restless patient to his work who had sought in vain relief from eye pains in rest: or 1 assist some am- bitious person, who having acquired an enviable start in life, feels that his pain- ful eyes have become barriers to further study and prospective promotion. Daily 16 by the use of properly selected glasses I cure headache often of years duration, and which have resisted every species of medication. In so doing I have often been able to satisfy anxious patients that their brains,stomachs, livers, kidneys, or uteri, have been accused wrongfully of pro- ducing the headaches, and that these have ever been innocent and healthy or- gans. The following remarks I have frequently heard from patients to whom I had recently prescribed astigmatic glasses. “For one week, ever since I put on the spectacles, I have been free from headache, and it is a freedom that I have not had before for years.” Although most astigmatic eyes cause headache and eye pains, if the eyes are much used in fine work, especially by arti- ficial light, I find cases of faulty refraction from astigmatism in which headache is not and has never been an annoying symptom. In some astigmatic persons a strong muscular development enables them to conceal the corneal irregularity. Should any disturbance of the system tempo- rarily weaken this muscular power, the eye muscles, along with the other muscles of the body are weakened and unable to keep up their work, then are pains induced. If it be a bilious or gastric disturbance its temporary in- 17 fluenee over the muscles is mistaken for the actual cause of the headache, when it is only the indirect cause, permitting the latent trouble to become manifest. If the astigmatism did not exist in a con- cealed form there would be no headache on use of the eyes during these general disturbances. Again in nervous persons, especially in females, I have found great suffering about the head and eyes, clearly traceable to a small degree of irregular refraction, and promptly corrected by the constant use of carefully adjusted cylinder lenses The report of a case with which I will close this paper is one of unusual sever- ity in effects, although a high degree of astigmatism did not exist.' Such extreme discomfort as this lady suffered is fortunately not often found. The case is also peculiar from the length of time that she suffered before her eyes were sus- pected of being the source of the trouble. In this age of diffusion of medical knowledge by means of many medical journals, physicians are on the alert to distinguish eye headaches from the head- aches caused by other organic disturb- ances, and usually at an early day, invoke the aid of the specialist in eye diseases to remedy theevil. In her own case several years elapsed in testing newspaper reme- dies for headache, having lost faith in 18 physicians from her earlier medical ex- periences. The case, however, will illus- trate the efficacy of proper glasses in re- lieving even years of suffering. Mrs. F., aged 38, the mother of several children, has been a martyr to headaches since childhood; and during the past 13 years, since her married life, has been often nearly crazy from them. Any close eye work, continued for even a short time, would send her to bed with a raging headache. On an average she has spent one day out of every week in a dark room, and that has been kept up for months at a time. If she felt bright and applied herself to complete any piece of needlework, so necessary with a growing family, she never failed to pay the penalty in severe head and ejTe suffering. When she came first to my office, she frankly told me that she had come because she had been advised, not that she expected any benefit,for she had no faith in any curative agent whatever having years since exhausted them all without finding any relief. She gave me this very clear history of her case. “Dr. A , has always been my family physician and in him I have every confi- dence. Having in my early married life exhausted his skill in vain attempts at relieving me of suffering, he gave up treating me for these headaches many 19 years ago. Under his ad vice I had con- sulted Prof. 13 , you know him to he one of our leading practitioners. lie aeknowleged that I had a good family doctor, but thought that something might have been overlooked, and that lie hoped to find me a remedy. He varied his medicines, as one after another failed to procure me relief, and finally head- vised a visit to the Sea Shore. I spent six weeks at Cape May, and while there rested my eyes from all work, eschewing both reading and sewing. I returned home with body invigorated by the salt baths and was free from pain. As soon as I commenced using my eyes in sewing all the old distressing symptoms return- ed. My family physician and friend, seeing me in some of these terrible at- tacks, advised me to consult another phy- sician Prof. C , who you know has the reputation of being a very skilfull physician. Ho had me under his pro- fessional care all Winter and Spring. Summer found me no better. Any use of the eyes in sewing or reading sent me to bed with twenty-four hours of suffering before me. He finally advised a course of mineral waters and sent me to the White Sulphur Springs of Virginia. There I spent two months which improved me much in health. In the Fall I returned to Baltimore looking and feeling well. 20 A very few days of housekeeping show- ed me that the long rest at the springs and the drinking of sulphur waters had brought me no permanent good. My head at times ached as badly as ever.” “I now despaired of ever getting relief, because I had sought the best medical ad- vice at my command and all to no pur- pose. Some of my friends,in their anxiety to see me cured of the daily suffering, advised me to try Homoeopathy. 1 ac- cepted the suggestion and sent for Dr. D . He examined carefully into my case and said that he could cure me. With these assurances from the new phy- sician, my feeling barometer at once went up,and my future prospects bright- ened. I entered actively into the course of medication mapped out by him. I took his mixtures hour by hour, for days and weeks,my faith growing unfortunate- ly less and less with the monoto- ny of the dosing. Finally as my headaches were not mitigated even by the long continued treat- ment, I gave up all hope and dismissed the homoeopathic physician.” “I felt that my case was now beyond medical cure, and I became despondent and rash. In my anxiety to secure relief I have tried anything that any one would suggest. I believe that during the last six years I have taken every quack remedy warranted to cure headaches that I could hear of, as pub- lished in the newspapers, and my many friends have kept me well supplied with this kind of information. Recently I have heard how Miss E has been cured of constant headaches by wearing glasses, and my friends have suggested that I have my eyes examined. On the principle that, in my desire to escape this bodily torment, I have been willing to try every treatment that has been brought to my notice I have come to have you examine my painful eyes, but I must tell you candidly that I expect no benefit, and have given up all hope of obtaining relief.” Upon examination I found that she could read the finest print, but only for a few lines. Her distant vision was also acute. Fixing the eyes upon the clock dial trial card for a short time caused pain in the head and eyes and also induced a feeling of nausea. I found that she could clearly see the vertical lines of the test card, but only dimly those which were horizontally placed. I selected from the trial case a magnifying lens which would make these blurred lines perfectly clear, for each eye, and finding the corresponding cylinders adjusted them at the proper angle in a trial frame. These I placed before her eyes. To her 21 22 surprise not only did all the lines come out with equal boldness of colorand of definition, but she found herself able to stare at them without inconvenience. After she had worn the glasses for some, minutes, feeling great comfort from them I removed the frames when immediately the nausea previously experienced came on. The restoration of the glasses brought back strength of vision and comfort. I prescribed for her the proper cylinder lenses set at an angle of 180°, in spectacle frames to be constantly worn. So anxious was she to test these spectacles that on her way home from my office she called at the opticians and remained in the store while the glasses were being fitted to the frames which she had selected. When they were ready she put them on at once and sallied forth. Before getting home she found herself walking with a degree of comfort which she had not known for months. The rapid improvement commenced from that hour. Her headache disap- peared within three weeks by the rest which her eyes enjoyed from the con- stant wearing of the spetacles. Now she makes her eyes do just what she pleases. Her constant headaches are bygones, and are only remem- bered from the years of torture through which she had passed. Her face has 23 become bright and free from care as her bead is free from pains. Her relief by such apparently simple means, and with- out medicines, is called a miracle by her self, and is a marvel to her friends. No amount of rest without these cylinder glasses could have effected this cure from suffering. It had been thoroughly tested, and had been found as useless, as the many prescriptions with which during many years her body had beer drugged. Cylinder glasses alone could, and they have cured her.