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JANUARY, 1893 
THE MYDRIATICS IN OPHTHALMOLOGY. 
By S. D. Risley, M.D., 
Professor of Ophthalmology, Philadelphia Polyclinic and College for Graduates in Medicine ; 
Lecturer on Ophthalmology in the University of Pennsylvania ; Attending 
Surgeon Wills Eye Hospital, Philadelphia. THE MYDRIATICS IN OPHTHALMOLOGY.1 
By S. D. Risley, M.D., 
Professor of Ophthalmology, Philadelphia Polyclinic and College for Graduates in Medicine ; 
Lecturer on Ophthalmology in the University of Pennsylvania ; Attending 
Surgeon Wills Eye Hospital, Philadelphia. 
I call your attention to-day to the mydriatics and their employ- 
ment in ophthalmic practice. 
The use of this interesting group of drugs furnishes probably the 
most important chapter in the local therapeutics of ophthalmology. 
The promptness and unformity with which they display the physio- 
logical property from w'hence they derive their name, never cease to 
command the attention and excite the interest of the careful observer. 
It should be anticipated however, that any family of drugs possessing 
such decided potency, would not only be of great value as therapeutic 
agents, but must possess also great power for harm if unwisely admin- 
istered. Indeed, I might very properly entitle these remarks " the use 
and abuse of the dilators of the pupil." 
The five members of the group to which your attention is called 
are those only which experience has proved to be of greatest value in 
ophthalmological practice, viz.: The salts of atropine, hyoscyamine, 
duboisine, homatropine and cocaine. These do not comprise all the 
alkaloids extracted from the solanaceae but are those which are habit- 
ually in use, and are therefore sufficient for the purposes of this lecture. 
The mydriatic alkaloids extracted from this curiously interesting- 
family of plants-the solanaceae-are, chemically considered, very com- 
plex. Although has been devoted to their study in the 
laboratory, there remains much confusion, and on the whole they fur- 
nish a promising field for skilful and patient chemical work. When 
subjected to the methods of manipulation now in vogue, they yield 
a group of alkaloids differing more or less widely in their physiologi- 
cal properties, although obtained from a common source. It seems, 
moreover, that the methods employed for extraction determine in large 
measure the nature of the product. For example, the alkaloid derived 
from the atropa belladonna will be atropine if extracted in the presence 
of an alkali, as soda or potassa, whereas without these the product will 
be hyoscyamine. The only means by which the chemist is able to dif- 
ferentiate the product'isjjy the fact that hyoscyamine has the property 
of rotating a beam of light to the left, while atropine possesses no polar- 
izing power, and chemically they are isomeric, having the common for- 
1 A lecture delivered at the Philadelphia Polyclinic Hospital and College for Graduates in 
Medicine, November iS, 1892. V. D. Risley. 
2 
mula Ci7H23NO3. This has led to the impression that atropine and 
hyoscyamine are identical. 
As found in the market the alkaloids may be placed in two classes,1 
the first of which would properly include those with a simple homo- 
genious base and having the above formula. To this class belong atro- 
pine, crystalline hyoscyamine and hyoscine. In the second class are 
included those having mixed bases, comprising the simple alkaloids of 
the first class, as they are found mixed in the plants of the natural 
order of the salanaceae, viz.:-the atropa belladonna, duboisia myopo- 
roides, datura stramonium, scopolio japonica, etc. To this class belong 
the commercial daturine, duboisine, amorphous hyoscyamine and scopo- 
lein. I shall endeavor to show you to-day that at least three members 
of this class possess, in some respects, essentially different physiological 
properties when used as mydriatics, notwithstanding their common 
parentage, chemical similarity and possible identity; therefore that in 
their employment as therapeutic agents we should be careful to secure 
a carefully isolated product as represented in the crystalline salts as 
against the mixed bases as represented in the amorphous commercial 
product. Very much of the confusion regarding their physiological 
properties and relative therapeutic value, doubtless, has grown out of 
the employment of these mixed bases. The immediate harm resulting 
from the use of an impure product displays itself first of all in the 
irritation of the conjunctiva and cornea, and second, by the variable 
duration of the resulting dilatation of the pupil and paralysis of the 
accommodation. It is, first of all, important that the solutions of the 
salts of these alkaloids should be bland, since any irritation of the 
tissues is especially harmful and directly opposed to the purposes for 
which the drug is usually employed. 
The mydriatics are employed by the ophthalmic surgeon- 
(1) As simple dilators of the pupil for the purpose of better exam- 
ination of the structures lying behind the iris. 
(2) In the treatment of a large group of inflammations of the ocular 
tunics. 
(3) For the paralysis of the accommodation. 
In each of these it is obvious that any irritation of the external 
tunics should be avoided, since the excessive lachrymation washes the 
solution away in the tears, and probably the resulting congestion pre- 
vents absorption. To this end, only neutral solutions of the crystalline 
salts in distilled water should be employed. It is probable that much 
of the atropine conjunctivitis, of which we formerly heard so much, was 
due to the neglect by the pharmacist of this precaution. In dispens- 
1 Vide. Trans. Am. Oph. Soc., December 1891, page 203. A Note on Hyoscyamine by S. D. 
Risley, M.D. The Mydriatics in Ophthalmology. 
3 
ing them the pharmacist should use mortars or other implements used 
only for this purpose, since it is very difficult to cleanse thoroughly an 
ordinary mortar in which some acid mixture has been previously com- 
pounded. Such precaution will avoid, in many cases, the irritating 
properties of many eye-washes from which our patients so often suffer. 
As Dilators of the Pupil.-In the thorough examination of the eye 
it often becomes necessary to enlarge the pupil. This is especially 
necessary for the careful inspection of the crystalline lens and vitreous 
body. It not infrequently happens that opacities of the lens, com- 
mencing in the extreme periphery, may be overlooked if the examina- 
tion is made through the narrow pupil, since the iris then lies in front 
of that part of the lens involved in the pathological process. 
In disease of the choroid and ciliary body, web-like or fine granu- 
lar opacities frequently occur in the vitreous, and veil or obscure more 
or less any image of the eye ground, giving a foggy appearance to the 
tissues under inspection, and are therefore liable to lead to erroneous 
opinions as to the cause of the obscuration, the condition of the vitreous 
being difficult to detect through a narrow pupil. With the dilated 
pupil, however, and a magnifying glass, the cause of the blurred 
image, if due to want of transparency in the vitreous, can readily be 
detected. For this purpose cocaine or homatropine should be selected, 
or the two may be used in combination. The latter course is ordinarily 
preferable, since a wider dilatation is secured than where either is used 
alone. They are desirable, furthermore, because of the shorter duration 
of the mydriasis than when atropine is employed. In many cases the 
cocaine, in two per cent, solution, is quite sufficient, and to be preferred, 
since the accommodation is very slightly disturbed, and in from one and 
a half to three hours the pupil is quite restored. The patient is thus 
saved the great annoyance arising from the blurred vision due to paral- 
ysis of the accommodation, and also the prolonged mydriasis produced 
by the other mydriatics. The annoyance will last about twenty-four 
hours if homatropine is used, between three and four days from solu- 
tions of duboisine, while hyoscyamine will last one week and atropine 
from ten to fifteen days. The great saving of time and annoyance to 
the patient, therefore, most forcibly commends the employment of cocaine 
or homatropine where the purpose designed is simply the advantage 
gained by a temporary dilatation of the pupil. 
If there are adhesions between the iris and lens capsule the use of 
the mydriatic will reveal their presence for diagnostic purposes, as in 
cases of iritis, but where used to detach these adhesions, one of the 
stronger mydriatics should be selected. 
The Treatment of Inflammations.-The mydriatics are used as 
therapeutic agents in the treatment of a large number of inflammations 4 
5. D. Risley. 
of the eye, both for their local anesthetic properties, and their me- 
chanical effects as dilators of the pupil. 
In abrasions of the cornea, in severe traumatisms, both by accidents 
or after many operations, in keratitis, phlyctenular disease, iritis, etc., 
they are of great value, and for this purpose the salts of atropine are 
usually employed. The drug is first of all cheaper than the others of 
the group, and I have a suspicion that it possesses local anesthetic 
properties in greater degree than hyoscyamine or duboisine. In the 
milder forms of inflammation, or in minor injuries, as superficial abra- 
sions of the cornea, which usually make a speedy recovery, homatro- 
pine either alone or combined with cocaine is to be preferred. 
The method of employment is often of much importance. In the 
treatment of inflammations you will find solutions of sulphate of atro- 
pine, gr. iv-f§i a useful standard strength to employ. In the case of 
children with phlyctenular disease of the cornea, so many examples of 
which you have seen under treatment at the clinic, it has long been 
my habit to detain them, making frequent instillations of the standard 
atropine solution until full dilatation of the pupil is secured. When 
this is reached you will often have the satisfaction of seeing the pho- 
tophobia and lachrymation disappear, and the little sufferer open the 
eyes and look about, possibly the first time for many days or weeks. 
Not infrequently the cure will date from such a treatment, but oftener 
it may have td be repeated day after day, each succeeding day the 
child returning with contracted pupils. The parents should have a 
solution at home, and be instructed in the method and frequency of 
its use. In young children the head should be firmly held between 
the knees of the surgeon and the parents instructed to use the same 
method. The excessive flow of tears in such cases not only dilutes the 
solution, but makes it difficult to have the drug retained sufficiently 
long for absorbtion. In these cases you need have little fear of poison- 
ing the child, partly because of the overflow of tears, but also for the 
reason that the nose and lachrymal passages are involved in the 
pathological process, and the latter partially or entirely closed by 
the turgid mucus membrane. While a single drop of the standard 
atropia solution dropped into the healthy conjunctival sac of a child 
may cause constitutional symptoms, by entering the stomach, through 
the tear ducts it may in these cases of phlyctenular disease be used with 
the most lavish freedom without general disturbance. 
In the treatment of acute iritis we wntness, however, in the highest 
degree the value of this important medicine. The permanent damage 
resulting from this serious disease is in a large measure due to 
adhesions of the iris to the anterior capsule of the lens. The soft 
and elastic iris, in health, lies in contact with the lens and moves The Mydriatics in Ophthalmology. 
5 
to and fro over its surface with every change of light and shade, but 
when the plastic forms of iritis occur, the small beads of lymph 
poured out from its surface glue it, very speedily to the lens capsule, 
and very firmly too, if the attachment is not disturbed at an early 
stage of the disease. It is not my purpose here to detail the unfor- 
tunate sequelae of these attachments, or posterior synechia, as they 
are called. They are however, often the Jons et origo of some of the 
most destructive pathological processes, which we are called upon to 
treat. This is particularly true in cases of recurrent iritis. It is therefore 
of the greatest importance to recognize the disease at the beginning 
and prevent the formation of these attachments by securing a wide 
dilatation of the pupil. By this means you draw the iris back from 
its contact with the anterior capsule of the lens and prevent the plastic 
adhesions. This disease is usually a painful affection so that the 
anesthetic properties of the mydriatics are important in securing your 
patient's comfort. If seen early, in the stage of hyperemia, it is usu- 
ally not difficult to dilate the pupil, but later when synechia have 
formed, or the tissues of the iris are not only turgid with blood but 
infiltrated with the products of inflammation, the task is more difficult 
and often impossible until other measures for its relief have been 
adopted, e. g., local, blood-letting, the use of mercurials, etc. Here 
also as in phlyctenular disease it is often necessary at the first sitting 
to make frequent instillations of atropine solutions gr. iv, or even gr. 
viii-fji, at intervals of fifteen minutes. If after an hour or more 
there is no result, I have often seen the pupil rapidly dilate, and the 
pains relieved by the abstraction of blood from the temple. Caution 
should be observed, lest the unpleasant constitutional effects of the drug 
are produced by its entrance into the stomach by the way of the tear 
ducts. This can be avoided by placing the finger, armed with a napkin 
or absorbing cotton, between the lids at the inner canthus, allowing 
it to absorb the tears for a moment after the instillation. The use of 2 
per cent, or 4 per cent, solutions of cocaine with the atropine adds 
greatly to the anesthetic effect of .the drug, but must be used with cau- 
tion, lest it disturb the nutrition of the cornea. It is probable that the 
anesthetic properties of the cocaine depend upon its power to deprive 
the tissues of their blood supply. If this is true, it is not prudent to 
keep the tissues too continuously under its influence. 
I cannot pass the use of the mydriatics in inflammatory diseases of 
the eye without a caution. There is one form of disease in which 
they certainly do harm. A form of disease moreover which possesess 
many symptoms in common with iritis in which as we have seen it is 
so important that these drugs should be used early and vigorously. I 
allude to glaucoma. A brief analysis of the symptoms of each will 
serve to set forth the danger of mistake. 6 
S. D. Risley. 
Iritis, acute. 
Redness. 
Pain. 
Dim vision. 
Photophobia. 
Lack lustre to iris from in- 
filtration. 
Glaucoma, acute. 
Redness. 
Pain. 
Dim vision. 
Photophobia. 
Lack lustre in iris from 
steamy cornea. 
Differ 
Small pupil. 
Cornea transparent. 
Cornea sensitive. 
Tension normal. 
Field normal. 
Anterior chamber normal depth. 
Bright zone of ciliary redness. 
Pupil moderately dilated. 
Cornea steamy. 
Cornea insensitive. 
Tension increased. 
Field abnormal. 
Anterior chamber shallow. 
Dark or purplish dilatation 
of blood vessels. 
Thus it will be seen that while these severe forms of eye disease 
possess many features in common, there is also a large group of 
symptoms which in typical forms of the disease definitely separate 
them. It leads me beyond the purpose of this lecture to discuss fully 
why this family of drugs do harm in glaucoma, since it involves the 
theories regarding the cause and nature of this disease. 
It is sufficient for my present purpose to state, that our present 
knowledge of glaucoma seems to teach that at least one important 
element in its etiology is the closure of the angle of the anterior 
chamber, so that the exit of the intra-ocular fluids by the way of 
Schlemm's canal is retarded or entirely prevented. It is obvious that 
crowding the iris into the angle by dilating the pupil would render its 
closure more complete, and thus in cases of glaucoma imminens, be 
liable to precipitate an acute glaucoma. The obvious lesson taught 
both by experience and these theoretical considerations is to avoid the 
use of these drugs in doubtful cases. The wise surgeon will avoid their 
use except with the greatest caution in all cases where there is increased 
tension of the eyeball, with diminished range of accommodation not 
accounted for by other recognized conditions, or with characteristic 
abnormalities in the field of vision. z 
Before entering upon the use of mydriatics for the'purpose of 
paralyzing the accommodation, in the correction of errors of refraction, 
I call your attention to their employment during and after middle 
life. There is a wide-spread opposition to their employment after the 
age of forty, since it is during the middle period of life that glaucoma 
■usually occurs. I am sure that the fears upon which the opposition is 
based are not well founded if due caution is exercised on the lines I 
have already pointed out. It is quite as important between forty and 
fifty years of age to use these drugs for the satisfactory correction of 
many eyes as before this period of life. The cases of retino-choroidal irri- The Mydriatics in Ophthalmology. 
7 
tation, and accommodation cramp with tonic contraction of the iris and 
ciliary muscle, are quite as frequent as before the age of forty, and the 
therapeutic value of the mydriatics is just as marked. A wide experi- 
ence fully justifies this statement. I have used these drugs with 
impunity, both in private and public practice in many thousands of 
eyes, after the time of life specified. If harm comes from them it is 
because a sufficiently careful study of the case has not preceded their 
use. I have yet to meet the first instance of an acute glaucoma, 
precipitated by the employment of a mydriatic, but I have always 
exercised the caution which I have pointed out and again emphasize as 
the duty of every person essaying their use. 
In Philadelphia, probably more universally than elsewhere, the use 
of these drugs has been insisted upon as necessary to the accurate 
correction of errors of refraction. This has largely grown out of the 
claim that the emmetropic eye is not only the model, but the normal 
eye, and that all departures from this simple standard of refraction 
are defects, and in the presence of asthenopia apparently due to their 
existence, should be carefully, accurately and fully corrected by 
glasses. I accepted this view very early in my practice, and a steadily 
widening experience has served only to strengthen the conviction then 
formed. In the endeavor to correct the manifest error of refraction we 
are dealing with an unknown, because an ever changing quantity, 
which constantly vitiates results, and the work done is unsatisfactory 
because it does not secure perfect relief. 
There is a wide-spread notion among the laity that the avoidance 
of reading glasses as long as possible is to save their eyes; that the 
necessity for a glass to read or work with is a sign of failing vision. 
They should be taught that the diminishing range of accommodation 
is physiological not pathological, and it is not only useless but harm- 
ful to resist it. This working without a glass to correct the presbyopia 
is a source of much harm to the eyes, and the cause of much suffering. 
I have, in a very large number of persons, seen violent headache and 
other reflex symptoms disappear as soon as a proper reading glass was 
secured. I recall the case of a celebrated clergyman, in charge of a 
large parish, and doing a large amount of literary work besides, who 
suffered from occipital pain, which had been ascribed to cerebral hyper- 
emia. He was advised to relinquish his work and travel abroad to 
secure relaxation and thus avoid a nervous breakdown. He was fifty 
years of age and prided himself upon his excellent eyes, since he had 
not required a glass to aid him at his work. His pupils were the size 
of a pin's head; the conjunctiva was hyperemic; the caruncles swollen; 
V he read easily D = o.5o, at 3octm-, but had no range of 
accommodation. 8 
A. D. Risley. 
A few days' use of a solution of homatropine, gr. dilated 
the pupils to large medium. The headache promptly disappeared and 
H = i. D was revealed. He received + 2.75 for reading, increased in 
six months to -j- 3.25. He was no longer able to read even large type 
without his glasses, but he had no return of his trouble and abandoned 
all idea of relinquishing his work. 
The headache of old people is very frequently due to the eye strain 
brought about by the use of too weak glasses, or from the neglect of 
astigmatic corrections. It is true, they have lost the power of adjust- 
ment through the hardening of the lenses, but they have not lost the 
ciliary muscle, and the fruitless strain to see with an improper glass is 
quite as painful and often as harmful to the eyes as earlier in life. It 
is in these cases you will find the solutions of homatropine of signal 
service. It should be used in from iv to viii gr. solution three times 
daily until the ocular irritation subsides and then the proper glasses 
chosen. 
It is in young eyes, however, that the use of these drugs is most 
frequently needful. I wish to impress upon you, however, that they 
are not to be employed for the sole purpose of paralyzing the power of 
accommodation. This is of great importance, and in most cases a 
necessity if you are not to be satisfied with more or less close approxi- 
mations in ordering the correcting glasses. My purpose has always been 
to determine with the greatest possible accuracy the static refraction of 
each eye. Having ascertained this it may be used in any way the 
judgment of the surgeon may dictate, but until this knowledge has been 
gained all subsequent action must be based upon unknown factors, and 
this knowledge cannot be had except through measurements made 
after thorough paralysis of the accommodation. 
You will not use these drugs for this alone, however. A very 
large percentage of refraction cases suffer from irritation and patho- 
logical changes in the intraocular tunics, the result of neglected eye- 
strain. The wooly choiroid, hyperemic retina and optic disc you will 
find to rapidly disappear under the sedative and restful influence of the 
mydriatics. I am sure you will soon learn to prize them for their 
therapeutic value as well as for the paralysis of the ciliary muscle. 
How shall you employ them ? 
The method of their employment and the member of the group 
you select will depend in large measure upon the condition of the eyes 
in any individual case. In eyes which are nearly or quite free from 
retino-choroidal irritation, homatropine hydrobromate will prove suffi- 
cient and the most desirable agent to employ. The property which 
most commends it, in comparision with the other members of the 
group, viz., its evanescent control over the power of accommodation, The Mydriatics in Ophthalmology. 
9 
makes it necessary to keep your patient at hand so that the determina- 
tion of the refraction can be made before the subsidence of its effect. 
I employ an viii gr. solution of the drug, instilling one or two drops in 
each eye every fifteen minutes for an hour or more, and often associate 
its use with a four per cent, solution of cocaine. They are not used at 
the same moment, however, since the cocaine solutions cause much 
temporary irritation. After the smarting has subsided the homatropine 
is instilled. In many cases you will be able to save your patients 
much time and annoyance by this method, since in from twenty-four 
to thirty-six hours its influence over the pupil and accommodation will 
have disappeared. It may also be selected in cases where retino- 
choroidal irritation is present, but must then be used for many days, or 
long enough to secure the needed rest and therapeutic effects already 
noticed. When employed for this purpose, it should be used at home, 
one or two drops being instilled in each eye four times daily. When 
used in this way, however, it proves of but little if any advantage in point 
of time over duboisine or hyoscyamine, since what is lost by the longer 
time required to recover from these drugs is gained by the shorter 
period required to accomplish the result wished for. All things con- 
sidered, I prefer the hyoscyamine to either of the other mydriatics in the 
average case of asthenopia, and employ habitually a ii gr. solution. 
One drop in each eye three times daily. It has the advantage of being 
less liable to cause constitutional symptoms than a iv gr. solution of 
atropine or a ii gr. solution of duboisine. Furthermore, the accommo- 
dation is recovered several days sooner than when atropine is employed 
-the average duration of the paralysis with hyoscyamine being seven or 
eight days while that of atropine is from ten to fifteen days. In order to 
secure this result, however, you must be sure that the preparation used 
is hyoscyamine. Some recent investigations, still in progress at the 
Wills Hospital, seem to show that the atropine of commerce is in fact 
hyoscyamine, while, on the other hand, much of the hyoscyamine is 
really atropine. This grows out of the fact that the product secured in 
the laboratory depends upon the manipulation used in its extraction. 
If too great heat and alkalies are avoided the product is hyoscyamine, 
which, by either heat or alkalies, is converted into atropine. There- 
fore, the manufacturer may furnish your druggist unwittingly with 
bottles labled, the one atropine the other hyoscyamine, when they may 
be the same drug. I have recently been impressed by the very wide 
variations in the returning range of accommodation when compared 
with the most carefully conducted observations made twelve years ago 
with the same drugs. Later studies show that some of the specimens 
of atropine give the same results as hyoscyamine, while certain samples 
of hyoscyamine have the same effect as those observed from atropine in 
my earlier investigations.